Inspection on 15/08/06 for Churchfields

This inspection was carried out on 15th August 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Churchfields 16/05/07

Churchfields 12/10/05

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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 Jane Offord Final Key Unannounced Inspection 15th August 2006 10:30 Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 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.V305945.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 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.V305945.R01.S.doc Version 5.2 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.V305945.R01.S.doc Version 5.2 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 12th October 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 1999 and consists of 11 separate selfcontained 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. The gardens provide an attractive setting with some areas secure but all allowing for wheelchair access. Fees for care in the home range between £518.84 and £1385.15 and are dependent on the accommodation offered, the source of funding and the dependency of the resident. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that looked at all the core standards for care of adults. It took place on a weekday between 10.30 and 16.30. The manager was off site at a meeting during the morning but returned at lunchtime. The senior team leader on duty helped with the inspection process during the morning. A tour of parts of the site was undertaken and some staff and residents were spoken with. Two new residents’ files, care plans and daily records were seen as were two new staff files, the policy folder, the duty rotas, some menus and some maintenance certificates. The staff training records, some supervision notes and the induction programme were looked at. Observation of care and activity around the site was made. Medication practice was not inspected this time as it had been the subject of a follow up visit by the pharmacy inspector a week earlier and their findings are recorded in a separate report. Residents were being supported to do things they had chosen, so some residents were having a lie-in, some were having a late breakfast, some were preparing to go on a trip out and others were relaxing watching television or sitting in the gardens. Interactions between staff and residents were friendly and appropriate. Residents clearly had the freedom of the site and were confident as they moved around. What the service does well: What has improved since the last inspection? A big programme of redecoration and refurbishment of the separate units has been commenced. Some units have had new refrigerators, freezers and dryers as well as new lounge furniture. Some rooms have new carpet or laminate flooring. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 6 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.V305945.R01.S.doc Version 5.2 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.V305945.R01.S.doc Version 5.2 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): 2. Quality for this outcome area is good. People who use this service can expect to have a full assessment prior to entering the home. This judgement was made using information available including a visit to the home. EVIDENCE: Two residents’ files were seen. One contained a pre-admission assessment the other did not. The second resident was from another part of the country so a pre-admission assessment was difficult. The file contained a lot of information from the previous care team and social worker. There was also information from the speech and language therapist and an occupational therapist assessment. The first file contained a full assessment that covered personal care, physical and health needs, communication, mobility, special equipment required, religion, diet, likes and dislikes, behaviour and social contacts. It was noted that a ‘high/low bed with bed rails’ was needed for the security of this resident. There was also a record that the family were Jehovah’s witnesses so the resident would be unable to have a blood transfusion. There was additional information about medication, the resident’s income and aspirations i.e. education, training and vocational wishes. The assessment was not signed or dated although the manager said they had seen the resident prior to admission. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 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, 7, 9. Quality for this outcome area was good. People who use this service can expect to have a care plan to help meet their needs and be encouraged to make decisions about their chosen lifestyle. This judgement was made using information available including a visit to the home. EVIDENCE: Both residents’ files seen had comprehensive care plans to meet their individual needs. Some of the areas covered related to personal care and daily living but there were additional interventions for psychological needs and mental health issues. Independence was encouraged where possible. ‘Encourage and praise XXXX. Can make their own choice for food but does not assist with preparation. Can take their own plate to the sink’. One care plan had an intervention to help the resident manage their forms, letters and appointments. It was noted for a resident whose cultural background was from a Mediterranean country that they enjoyed the food of their country of origin and some dishes should be included in the menus. Both residents’ files had risk assessments for daily activities such as cooking, using knives, unsteady gait and going out into the community. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 10 Observation of interactions between staff and residents showed that residents are given choices about what they want to do or eat and allowed to make their own decisions about their clothing. This inspection took place during the summer holidays and some residents had opted to have a lie-in as their usual activities were not available. Staff willingly prepared late breakfasts when residents did get up. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 11 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): 12,13, 15, 16, 17. Quality for this outcome area was good. People who use this service can expect to be encouraged to take part in appropriate activities and maintain contact with family and friends. They can also expect to receive a well balanced diet. This judgement was made using information available including a visit to the home. EVIDENCE: In the files of the two residents seen there were individual weekly activity programmes that included swimming, horse riding, bowling, computers, art and communications. The day care centre based in the home is run by dedicated staff five days a week. Residents’ activity plans show that they access different sessions at the centre during the week but also participate in activities arranged in the community as well. One record showed that the resident had been to Great Yarmouth, out on a boat trip, been shopping and spent some time in the sunshine in the garden. Another record showed that the resident attended a social club one evening a week, enjoyed the cinema, a music group, a barbeque and bowling. On the day of inspection a number of residents went with staff to visit the Tiptree jam factory. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 12 One resident enjoyed showing off their single bed roomed bungalow unit. They said they did not cook their meals but the staff cooked them curries when they asked for them. They were looking forward to the new football season and had had their bedroom decorated in the colours of their favourite team. They had been out that morning to meet a relative and gone to the local café for breakfast with them. They said they had enjoyed bacon, two eggs and hash browns. A resident from another unit talked about a recent holiday they had taken with staff in Lowestoft. They had had such a good time, they said, that they were already planning next year’s holiday and wanted to go for two weeks not just one. A recent pastime introduced to the home has been the cultivation of flowers and vegetables from seed. There were sunflowers in bloom around the site and the remnants of cherry tomatoes in a hanging basket. One resident talked about the potatoes and radishes they had grown and eaten. The administrator had a number of photographs of residents with the different produce they had grown. The manager has plans for a raised vegetable bed next year to allow easier access for some residents with mobility problems and to deter the rabbit population. The day care centre had colourful displays of work completed by the residents. One wall was completely taken up by work done on a pirate theme following the recent film that some residents had seen. There were also a selection of photographs of residents enjoying a garden party and fete. Each unit is responsible for the laundry, cooking and shopping for their residents. Residents participate according to their abilities and inclination. Menus are compiled with input from residents. The main meal is in the evening as residents are usually busy during the day. The menus seen showed meals such as shepherd’s pie and chicken casserole with vegetables and desserts of ice cream, fresh fruit or yoghurts. Sometimes there was a ‘takeaway’ on a Saturday and usually a roast dinner on Sunday. Lunch offered a light cooked snack such as scrambled eggs, sardines on toast or a selection of sandwiches and salad. In The Croft, a unit that offers accommodation to six people with high dependency needs, lunch on the day of inspection was chicken sandwiches and crisps. Residents were being helped with their meal sensitively and in a social group. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 13 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, 20. Quality for this outcome area was adequate. People who use this service can expect to have their health needs met and be supported to meet their personal care needs but they cannot be assured that the medication administration practice will protect them. This judgement was made using information available including visits to the home by a regulation inspector and a pharmacy inspector. EVIDENCE: There was evidence of visits to or from health professionals such as the GP, dentist, optician, occupational therapist (OT) and speech and language therapist (SALT). The manager said that one of the residents had recently become incontinent of urine and they were in the process of assessing the resident with the continence advisor. They wanted to identify if the problem was acute due to an infection or if it was more long term and would need a management plan. The pharmacy inspector had done a follow up inspection of the medication administration practice the week before this inspection and their findings form a separate report. The requirements from that report are repeated at the end of this report. The medication policy was seen during this inspection and did not contain any guidance on covert administration of medicines. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 14 The management plan for one resident with diabetes was seen. The manager and senior carer said the carers had been over anxious about looking after this person and had communicated their anxiety inadvertently to the resident. The help of the community nurse had been sought and together a plan had been formulated that would manage the resident’s condition with the minimum of input. The resident gives their own insulin under the guidance of the carers who have had instruction and a competency assessment from the community nurse. The resident is sometimes reluctant to eat, which can be a problem if they have had their insulin, but the carers know how to tempt the resident with their favourite meals of cheese on toast or hot dogs. The community nurse visits weekly and the resident has foot and eye care regularly. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 15 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, 23. Quality for this outcome area was good. People who use this service can expect complaints to be taken seriously and be protected from abuse. This judgement was made using information available including a visit to the home. EVIDENCE: The Commission for Social Care Inspection (CSCI) has not received any complaints about this service since before the last inspection. The complaints log was seen and showed two complaints had been recorded this year. One from a relative who complained that the carpet in the resident’s room had an unpleasant odour. The manager said the carpet had since been replaced with new floor covering that was easier to keep clean. The other was from a resident complaining about aggressive behaviour from another resident. The manager said both residents were being monitored by staff to prevent a recurrence of the situation. The complaints policy was seen and offered a robust investigation of any complaint but did not have the details of the local CSCI contact. The home also has the policy in a pictorial format so residents can be helped to understand the complaints process. The home has a copy of the guidelines issued by the Thurrock Adult Protection Committee and the home’s own policy on Protection of Vulnerable Adults (POVA) is cross-referenced to the Thurrock policy. The staff induction record covers training about POVA issues and the staff database of training shows that staff have further POVA updates. There is a Whistle blowing policy for the home and staff spoken with were quite clear about their responsibilities in relation to their duty of care. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 16 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, 30. Quality for this outcome area was adequate. People who use this service can expect to live in a homely environment but cannot be assured that the décor in all areas will be fresh or that some units will not have unpleasant odours. This judgement was made using available information including a visit to the home. EVIDENCE: The home consists of eleven units each with its own front door on a site in a residential area of Witham. Four bungalows have single occupancy, there are two four bed roomed bungalows and a two bed roomed one. In addition there are two first floor flats accommodating five residents each and a ground floor flat with four bedrooms. The Croft is the largest unit and caters for six residents with complex needs and high dependency. The manager said that there has been a large scale refurbishment and redecoration over a period of several months that had covered some thirty rooms on the site. Two four bed roomed bungalows were seen and both had been redecorated. They looked fresh and had new furniture in the lounges and new equipment in the kitchens. One of the upstairs flats was seen and that had not yet been decorated. The décor looked very ‘tired’ and shabby. The manager said they had to wait for a further budget to be available to continue the programme of decoration. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 17 A number of the residents were happy to show their individual rooms and they were all personalised with posters, soft toys and photographs. Some residents had chosen the colour for their room and soft furnishings that matched. A visit was made to The Croft and it was noted that the furniture there was minimal as five of the six residents are wheelchair users and need the space to manoeuvre their chairs. There was a smell of urine in the unit. The manager said they were aware of the problem and were trying to manage a particular resident’s behaviour with the assessment of the continence advisor. They would then address the floor covering issue. The home has a policy on managing infection control and there was evidence that aprons and gloves were available if required for some tasks. Liquid soap and paper towels were seen at all hand washing facilities. The staff in each unit are responsible for the laundry of the residents living there and all the units had washing machines with sluicing programmes and tumble dryers. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 18 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, 34, 35. Quality for this outcome area was good. People who use this service can expect to be supported by adequate numbers of well-trained and correctly recruited staff. This judgement has been made using information available including a visit to the home. EVIDENCE: The files of two recently appointed staff members were seen and both contained evidence of proof of identification and two references. Both files contained evidence that a check on the Protection of Vulnerable Adults list (POVA 1st) had been carried out before the member of staff commenced work and a Criminal Records Bureau (CRB) had also been completed. The job application and work history were retained in each file, together with a copy of the interview questions and responses. Staff spoken with said they had worked through the induction training pack after appointment. The pack uses discussion with a mentor, videos and question sessions to ensure the member of staff has understood the training. It covers areas of care including promoting independence, dignity, choice and respect. It also includes fire awareness, infection control, recognising abuse and what to do about it, health and safety, communication, confidentiality and the importance of following the home’s policies and procedures. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 19 The duty rotas were explained by the manager and show that there is flexibility in the staffing to enable residents’ needs to be met. One four bedded unit is funded for one carer but the manager said as one resident has been unwell recently they are rostering two carers each day. The day centre is staffed by three additional carers from 9:00 to 16: 30 each weekday. The manager or deputy (at present that post is vacant) are on call 24/7. The home also employs an administrator, a receptionist, a maintenance/gardener person and a part time cleaner for the communal areas of the building. The training records were seen and showed all staff receive regular updates on mandatory training such as moving and handling, food hygiene, first aid, infection control, POVA, fire awareness and health and safety. In addition senior staff have instruction in safe handling of medication. Some staff have attended training about managing epilepsy. In discussion with some staff they confirmed the training they had done and added that a lot of the training was covered in the NVQ courses they had attended. The home has a complement of fifty five care staff of which twenty three have achieved NVQ level 2 or higher, with a further six commencing the course this autumn and five more commencing NVQ level 3. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 20 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, 39, 42. Quality for this outcome area was adequate. People who use this service can expect to be consulted about the service and have their welfare protected by the policies in place but they cannot be assured that all safety checks will be up to date. This judgement was made using information available including a visit to the home. EVIDENCE: The registered manager has worked in care with adults with learning disabilities for over ten year and has been manager at Churchfields since 2005. She has achieved a B.A.(Hons) in Applied Community and Youth Studies and an NVQ level 4 in care. She has also achieved the Registered Managers Award and is a qualified Moving and Handling trainer. Interactions between residents and the manager were friendly and showed trust and confidence. Staff spoken with said the manager gave clear directions and was approachable. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 21 Observation was made of residents’ opinions and choices being made during the day but staff said more formal opinion surveys were generally not possible due to the level of understanding. Relatives’ opinions were sought and the results were made available. Overall people were happy with the service. The most recent survey was done in June 2006 and eighteen responses were returned. The areas that were covered by the questions included care, activities, food, safety and privacy. Two relatives marked that they did not know who to speak to if they had a concern about the care their relative was receiving. CSCI received eleven relatives’ responses to their comment card sent out prior to this inspection. Most of them expressed satisfaction with the care offered at the home but six of them said they did not know about the home’s complaints procedure. This information was fed back to the manager who said they would be considering ways to ensure that the complaints policy was readily available to all relatives. Some maintenance certificates were seen. Certificates for fire alarms, the call system, lift maintenance and gas safety were all recent and in date. There was a recommendation from the fire inspection that self-closure devices be fitted to fire doors. Some fire doors were wedged open on the day of inspection. The Loler test for hoists was overdue and the manager said they would follow it up with the firm. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X 1 X Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) (a) Requirement Pre-admission assessments must be signed and dated to evidence the day it was done and that the person who undertook it was a competent person. The registered person must ensure that records of the prescribing and administration of medication are accurate and up to date. This is a repeat requirement, previous timescale 01/07/06 not met. 3. YA20 13(2) 01/09/06 The registered person must ensure that the stock of medication prescribed for service users is kept to a minimum, must not be retained for stock use or beyond its usual shelf life and must be not be removed from the original labelled container. This is a repeat requirement, previous timescale 01/07/06 not met. Timescale for action 15/08/06 2. YA20 13(2) 17(1)(a) 01/09/06 Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 24 4. YA20 13(6) The registered person must ensure that staff authorised to administer medicines have been trained and assessed as competent to do so. This is a repeat requirement, previous timescale 01/07/06 not met. 01/09/06 5. YA20 12(1)(b) 13(2) The registered manager must ensure that medication is only administered in accordance with the prescriber’s instructions. The registered person must ensure that staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines. The registered person must ensure that medicines are stored in accordance with the manufacturer’s instructions. The registered person must ensure that a written care plans and protocol is completed for the resident who self-administers his own insulin injection. The complaints policy must be amended to contain the contact details of the local CSCI office. The programme of refurbishment must continue to ensure all units are up to a good level of decoration and pleasant to be in. Steps must be taken to eradicate unpleasant odours from the units. Fire doors that remain open during the day must be fitted with self-closure devices. DS0000063439.V305945.R01.S.doc 01/09/06 6. YA20 13(2) 01/09/06 7. YA20 13(2) 01/09/06 8. YA20 15(1) 01/09/06 9. 10. YA22 22 (7) (a) 23 (2) (b) 30/08/06 31/12/06 YA24 11. 12. YA30 YA42 16 (2) (k) 23 (4) (c) (i) 31/08/06 30/09/06 Churchfields Version 5.2 Page 25 13. YA42 23 (2) (c) 13 (4) (c) The Loler test on the hoists must be undertaken urgently to ensure the equipment is safe to use. 31/08/06 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 YA20 Good Practice Recommendations The medication administration policy should contain guidance on the covert administration of medicines. Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Churchfields DS0000063439.V305945.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!