Inspection on 16/05/07 for Churchfields

This inspection was carried out on 16th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Churchfields 15/08/06

Churchfields 12/10/05

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Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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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 Brian Bailey Key Unannounced Inspection 16th May 2007 10:00 Churchfields DS0000063439.V339959.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.V339959.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.V339959.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 churchfields@schealthcare.co.uk 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.V339959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 34 persons) 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 Minimum 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 15th August 2006 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. Active Care Partnerships Ltd owns the home and the registered manager is Stella Harrington-Keeton. Churchfields is situated in a residential area of Witham, 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 £875.35 and £1385.15 and are dependent on the accommodation offered, the source of funding and the dependency of the resident. Extras to the fees include hairdressing, papers, chiropody and toiletries. Inspection reports may be obtained from the home and from the CSCI website www.csci.org.uk Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection looking at the core standards for the care of adults. This report is based on a range of information that has been accumulated from our inspection records, a site visit to the home that took place on 16th May 2007 at 10:00am, a tour of four of the properties, discussions with the registered manager, deputy, staff, visitors and people that live at the home, questionnaires issued by CSCI and the records kept at the home. It is evident that a number of improvements have been made over the past few months to ensure the home meets the National Minimum Standards. The homes own Quality Assurance system has obtained good feedback from relatives and people at the home. A CSCI survey carried out in April/May 07 also indicated satisfaction with the service. During 2006, CSCI expressed concerns about errors in the administration of medication but the manager has since implemented changes that have now addressed these problems. The refurbishment programme continues and has already significantly improved the appearance of several units. What the service does well: What has improved since the last inspection? What they could do better: The manager should continue with the programme to upgrade the units through redecoration and buying new furniture where necessary. The manager Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 6 and deputy should continue to explore how and when more information and records can be made more meaningful to people at the home and to encourage their involvement in the process. 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. The summary of this inspection report can be made available in other formats on request. Churchfields DS0000063439.V339959.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.V339959.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. People who use this service can expect to have a care plan that is sufficiently detailed to enable staff to help meet their needs and be encouraged to make decisions about their chosen lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Up to date statements of purpose and service user guides were available. These contain a good range of information about the home, including its aims and objectives, the facilities offered and the staffing structure, which has been strengthened over the past year to take into account changes within the units. An informative brochure is also now available. Care records were sampled and these showed that the home obtains assessments for all prospective people and senior staff undertake their own assessments. Discussions with manager and deputy indicated that all prospective people are encouraged to visit the home prior to admission to see for themselves the facilities available and to meet other people and staff. The manager stated that the assessment period could take several visits before a placement is confirmed as suitable and acceptable. Churchfields DS0000063439.V339959.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. 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 that enable staff to help meet their needs and be encouraged to make decisions about their chosen lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care files seen contained comprehensive care plans to meet their individual needs. Areas covered were wide ranging and provided information regarding personal care; daily living and specific needs of the individual. Reviews of care plans are carried out at regular intervals and from those checked, all were up to date. The files included risk assessments for daily activities such as cooking, using knives and going out into the community. Daily records seen were clear and well written. A new style of care planning is being introduced. Observation of interactions between staff and residents showed that people are given choices about what they want to do or eat and allowed to make their own decisions about their clothing. Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 10 Churchfields DS0000063439.V339959.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. 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 has been made using available evidence including a visit to this service. EVIDENCE: From observation and discussion with the manager, staff and people at the home it was evident that a wide range of activities are available. Three files were looked at, which showed that there were individual weekly activity programmes organised. The day care centre based in the home is run by dedicated staff five days a week. Peoples’ 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. On the day of inspection a number of people were in the day room enjoying a musical session in the morning, a communication session in the afternoon and in the early evening many people returned to the room for a surprise birthday party. Other people were observed being supported by Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 12 staff to attend appointments or to go shopping in the community. Plans were underway for the summer holidays. One person spoken with had moved from flat at the home to another where there was more company. They said they were enjoying living at the new house and was looking forward to that evening’s party. Staff and visitors spoke of how people have been enabled to attend various functions such a family wedding and another person was now going home more frequently, which the relative appreciated. One person had been provided with an electric wheelchair, which from observation now provided the person with a greater degree of independence around the house than previously. The day care centre had colourful displays of work completed and there were also a selection of photographs of people on days out. Each unit is responsible for the laundry, cooking and shopping for their people. People participate according to their abilities and inclination. Menus are compiled with input from people. The main meal is in the evening as people are usually busy during the day. Evidence was available to show that meals are varied and that there were good stocks of food available in each of the units. One person spoken with said how much the meals were enjoyed and that they had sufficient. Churchfields DS0000063439.V339959.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. People who use this service can expect to have their health needs met and be well supported to meet their personal care needs. People can be assured that the medication administration practice will protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation and discussion with staff and people at the home, it was evident that they 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 to maximise their independence. A key worker system was in place. Minutes of staff meetings showed that staff regularly discuss and make recommendations that benefit people at the home, for example, some recent issues relate to a healthier diet, personal hygiene and exercise. There was evidence of visits to or from health care professionals such as the GP, dentist, optician, occupational therapist (OT) and speech and language therapist. All such visits were logged and were up to date. Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 14 Following the inspection by a CSCI pharmacist in 2006, the manager had taken the necessary steps to implement the requirements made. New arrangements have been introduced for the storage of medicines in each unit and staff have been assessed as to their competency to carry out the duties of administering medication. Medicine Administration Record (MAR) sheets were checked and seen to be accurate and up to date. One questionnaire returned to us by a relative felt it would be helpful if they had up to date information about any changes made their relatives medication. Churchfields DS0000063439.V339959.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. People who use this service can expect complaints to be taken seriously and to be protected from abuse. This judgement was made using information available including a visit to the home. EVIDENCE: The complaints policy was seen and offered a robust investigation of any complaint. Details of the local CSCI were also available. The home also has the policy in a pictorial format so that people can be helped to understand the complaints process. Eighteen questionnaires returned us showed that people do know how to make a complaint and were aware of the procedure. The home has a policy and guidelines on the Protection of Vulnerable Adults (POVA). 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. A POVA alert was raised in March 2007 regarding the care of a person at the home. This was investigated by Safe Guarding adult’s team and found to be not substantiated. Churchfields DS0000063439.V339959.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 and 30. Quality in this outcome area is good. People who use this service can expect to live in a homely environment and be assured that the décor in all areas will be bright and cheerful and odour control will be good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home consists of eleven units each with its own front door on a large 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 people each and a ground floor flat with four bedrooms. The Croft is the largest unit and caters for six people with complex needs and are assessed as high dependency. The refurbishment and redecoration programme has continued. The four units visited were attractively decorated and appeared bright and cheerful. The bedrooms were individual in style and clearly designed and equipped to suit and meet of the people. All areas looked fresh and had new furniture in the lounges and new equipment in the kitchens. The manager said that the programme of redecoration would continue. Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 17 A number of the people were happy to show their rooms and they commented that they liked them. Some people had chosen the colour for their room and soft furnishings that matched. The Croft was visited, which had also been refurbished. Odour control was good. Staff were interacting well with people and a visitor commented on how pleased they were with the home. The home has a policy on managing infection control and there was evidence that apron 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. The grounds were well maintained and improvements had been made the garden. Churchfields DS0000063439.V339959.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is 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 available evidence including a visit to this service. EVIDENCE: The files of three staff members were seen and each contained evidence of proof of identification and two references. The 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 files had been reorganised and with a checklist made it easy for information to be retrieved. Information provided by the manager shows that procedures are in place and that the manager takes the necessary action to implement disciplinary procedures when necessary. Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 19 All staff are required to work through an induction training pack after their appointment. The pack uses a variety of ways including the use of 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. The duty rotas were explained by the manager and show that there is flexibility in the staffing to enable peoples’ needs to be met. The day centre is staffed by three additional carers from 9:00 to 16: 30 each weekday. The manager or deputy is 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. A training needs analysis was available that showed the training that each member of staff had attended. 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, autism, managing behaviour and person centred planning. Of the care staff twenty-one have achieved a National Vocational Qualification (NVQ) level 2 and three a NVQ at level 3, with a further nine in the process of taking a level 2 and eight taking level 3. The home has made good progress towards having a large majority of staff with a qualification. Churchfields DS0000063439.V339959.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. People who use this service can expect to be consulted about the service and have their welfare protected by the policies in place and be assured that all safety checks will be up to date. This judgement has been made using available evidence including a visit to this service. 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. External managers are undertaking monthly visits to the home and reports were available for inspection. Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 21 The home’s Quality Assurance system includes issuing surveys to relatives and people at the home to obtain their views about the service. A pictorial questionnaire was issued to people in March 07 and the last one sent to relatives was in June 06. Overall the view was of satisfaction with the service. Responses received from people at the home raised some issues about decoration and furniture and the home has addressed these. CSCI also sent out questionnaires of which eighteen responses were received from relatives, health care professionals and from people living at the home. The majority of people expressed satisfaction with the care offered at the home although there are still a few people that say they do not know about the home’s complaints procedure. The home was able demonstrate good compliance with health and safety matters. Evidence was available to show that services and equipment were serviced at the appropriate intervals and staff training is provided. In 2006 the fire inspection that self-closure devices be fitted to fire doors. Since the last inspection self-closure devices had been fitted to the fire doors following a recommendation by a fire officer. Churchfields DS0000063439.V339959.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 3 2 3 3 3 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 3 25 3 26 X 27 X 28 3 29 3 30 3 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 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 23 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 YA24 Regulation 23 (2) (b) Requirement The programme of refurbishment must continue to ensure all units are up to a good level of decoration and pleasant to live in. Timescale for action 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Churchfields DS0000063439.V339959.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V339959.R01.S.doc Version 5.2 Page 25 - 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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