Inspection on 10/11/05 for Churchfields Nursing Home

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Churchfields Nursing Home 24/04/06

Churchfields Nursing Home 20/04/05

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE Churchfields Nursing Home 37 Churchfields South Woodford London E18 2RB Lead Inspector Julie Legg Announced Inspection 10 November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Churchfields Nursing Home DS0000062553.V258451.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Churchfields Nursing Home Address 37 Churchfields South Woodford London E18 2RB 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) 0208 559 2995 0208 554 6982 Yewtree Care Ltd. Elizabeth Matenga Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2005 Brief Description of the Service: Churchfields Nursing Home is a privately owned 25 place care home with nursing. The home is situated in a residential part of South Woodford, a short walk from local bus routes and about 15 minutes walk from the tube station. The building is a two storey house, with a large, three storey, purpose built, extension. There is a lift to the first and second floor, as well as a staircase. The home is similar in nature to other properties in the street, as they are a combination of traditional and new build. There is a large dining room, three lounges, and five bedrooms on the ground floor, with the remaining bedroom’s being on the upper floors. Offices, the utility room, treatment room, kitchen and stores are also on the ground floor. Twenty one bedrooms are single and two are double. All of the bedrooms have washbasins, but do not have ensuite toilet or bath/shower. There are bathrooms and toilets on each floor. The doors from one of the lounges leads to a pleasant patio area and garden. Nursing and personal care is provided on a 24hr basis. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a weekday from morning to late evening. Residents were asked about their experience of living at the home, and the inspector spoke to four relatives during the inspection. Staff were spoken to about care practices and their employment at the home. They were also observed directly and indirectly providing care to the residents. Discussions were held with the manager and the owners. Policies and procedures, records, residents and staff files were also examined. What the service does well: What has improved since the last inspection? What they could do better: Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 6 The Statement of Purpose is still in draft form and requires some amendments. The manager is currently using two pre-admission assessment forms and these need to be unified. All care plans need to be reviewed regularly or when there is a change in a resident’s needs. The manager also needs to unify the home’s risk assessments, as there are currently different formats being used, this could be confusing for the staff. The activities programme needs to be more extensive and to take into account residents who have dementia or cognitive impairment. The Statement of Purpose and the resident’s handbook needs to state that ‘sharing a double bedroom is the resident’s choice’. All staff should receive regular formal supervision. 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 Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Residents and their relatives/representatives have sufficient information they need to make an informed choice about moving into the home, and know the terms and conditions attached to them living at the home. A pre-admission assessment is undertaken for all prospective residents, and care plans are drawn up using this assessment. However, there are currently two pre-admission assessments, these need to be unified. This will ensure that the needs of a prospective resident can be appropriately identified. Prospective residents and their relatives/representatives are able to visit the home prior to their admission. EVIDENCE: The Statement of Purpose has been revised and the inspector gave feedback on areas that still need to be developed further. Comments on some parts of the Statement of Purpose are included in the sections on environment, complaints and protection. This was a previous requirement and a new timescale has been set. Residents’ files that were examined showed a copy of the home’s contract/statement of terms and conditions. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 9 The home had a previous requirement regarding the pre-admission assessment and that they must seek to obtain all the relevant information from relatives and professionals. To achieve this requirement the home has introduced another assessment form as well as the existing one. On examination of residents’ files, records showed that some information is being gathered on both assessment forms. These forms need to be unified to ensure that all appropriate information is obtained. This is requirement 2. Where appropriate, further information had been provided by the local authority and health professionals including GP and hospitals. Residents where capable, and relatives were involved in the assessment and admission process. Residents and relatives/representatives are able to visit the home prior to admission. Though in practice it tends to be the relatives, as the majority of the prospective residents are being admitted from hospital. One relative stated that he had visited a number of homes and he felt that he was made to feel very welcome and they were very patient in answering his questions and helped to alleviate his anxieties. Two other relatives that were spoken to stated that they had moved their mother from another home, as they were not satisfied with the care, also their mother did not like the previous home. They had heard good reports about Churchfields and after visiting and discussion with the manager, their mother decided to move. They are all very happy with the care she receives. The home does not provide intermediate care. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10, 11 Residents health, personal and social care needs are set out in individual care plans and provide staff with the information they need to satisfactorily identify and meet residents, needs. Care plans are evaluated monthly but these evaluations need to be meaningful. Residents’ placements are not formally reviewed. Residents are treated with respect and the arrangements for their personal care ensures their right to privacy is upheld. Residents’ wishes in relation to dying and death are clearly identified on residents’ care plans. EVIDENCE: Individual care plans were available for each of the residents. The records of four residents were examined and five residents and four relatives gave their views. Considerable work has taken place in ensuring that the care plans truly reflect all of the residents’ needs and that these needs are being met. The issues raised in the previous inspection regarding accurate recording and recommendations from health professionals being included in the care plan, have now been addressed. There is involvement of the continence advisor and Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 11 the tissue viability nurse and this is now evidenced in residents’ care plans. This requirement has now been met. There was evidence that care plans are being evaluated monthly, but these evaluations need to be meaningful and reflect residents’ changing needs. This is requirement 3. Residents are seen by other health professionals including dentists, opticians, doctors, chiropodists and specialist nurses. One resident told the inspector that since her admission (March 2005) she has been seen by the dentist, the chiropodist and the optician. The inspector was not able to evidence these visits from the daily living profile as these are not being completed regularly. This is requirement 4. The specialist continence advisor is visiting the home on a regular basis to carry out assessments on residents, and are also providing in house training for staff. There was also evidence that continence promotion and management programmes are in place for each resident. This was a previous requirement which is now met. The policies and procedures in regard to continence promotion and management have also been reviewed. This was a previous requirement which has now been met. The inspector examined residents’ risk assessments. There was evidence that the risk assessments are being reviewed monthly or when a change in need is identified. The risk assessments are fairly detailed and cover areas such as manual handling, the use of cot sides and footrests on wheelchairs. Every resident who uses cot sides has undergone an individual risk assessment which details the risks associated with using and not using them. Residents where possible, relatives and health professionals have been consulted and the use has been reviewed on a regular basis. This was a previous requirement which has now been met. Each resident that uses a wheelchair has been risk assessed and where residents have stated they do not wish to use the footrests, this has also been risk assessed. This was a previous requirement which has now been met. The registered manager has different formats of risk assessments, these need to unified to ensure uniformity in completion. This is requirement 5. One relative advised the inspector that their mother had a problem with her leg which staff dealt with quickly, her G.P was called and the leg had healed within a couple of days. This had not been the case in the previous home, when the leg had taken months to heal. Residents’ wishes in relation to dying and death are clearly identified in care plans. There was no evidence from residents’ files that 6 monthly reviews were taking place. The registered manager needs to ensure that the home completes reviews on each resident where all interested parties such as the resident, relatives/representative, social worker, can give an opinion as to whether the home is continuing to meet the resident’s needs. This is requirement 6. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 12 Residents and relatives that were spoken to all said that the staff respected their privacy and were treated with dignity. One relative stated “they are always patient with mum”. One resident stated that “ that the staff are very nice and respectful”. Staff were observed talking to residents respectfully and were observed knocking on bedroom and bathroom doors before entering. Care plans also stated how residents preferred to be addressed. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Although there is an activities programme available, more consideration needs to be given to planning activities which are suitable for those residents with specialist needs such as dementia. Visiting times are flexible and people are made to feel welcome, this ensures residents are able to maintain contact with relatives and friends as they wish. Residents are helped to exercise choice and control over their lives. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to the residents. EVIDENCE: There is a general programme of activities such as classical films, monthly entertainment, monthly church service, visits to the park and local shops. Staff were observed sitting and talking to residents and one care worker was sitting reading with a resident. There are two members of staff that have time allocated to organise activities, these hours are supernumerary to the care staff on shift. These activity hours need to be meaningful and stimulating Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 14 for all residents. A more extensive programme of activities, taking into account residents’ specialist needs such as dementia and cognitive impairment needs to be arranged. This is requirement 7. A regular church service has recently commenced at the home which has been very successful, and the day prior to the inspection the Bishop had visited. There are two residents whose first language is not English. One resident is Chinese and she has a volunteer who visits regularly, and the home has just employed a care worker who speaks the same dialect as the resident. Another resident is Polish and there are three carers who speak Polish. The home has recently carried out a residents’ survey, the main aims of the survey were to find out the level of satisfaction on the services provided, were residents’ choice/rights being observed and if the home’s aims and objectives were being met. The home has developed a plan in response to the survey, and areas have been identified that the residents are wanting the home improve on. Visiting times within the home are very flexible and visitors commented “staff make us feel very welcome, we can visit at any time”, and “We are always offered a cup of tea/coffee”. Visitors were seen to visit at various times during the inspection. Residents are able to receive visitors in one of the lounges or their own bedrooms. Relatives are encouraged to attend any of the social activities and on the day of the inspection a number of visitors were sitting with the residents, watching a film on the large screen television. Meals are served in the dining room and on the day of the inspection, meals were seen to be balanced in nutrition and of generous portions. There is a choice of meals and the chef said she would prepare something different if either of the choices were not to a resident’s liking. Residents and visitors spoke highly of the food and one resident stated that at times the meals were too big. Many of the residents require assistance with feeding, and staff were seen to carry out this task appropriately, talking to residents and not rushing them. A few of the residents lost interest in their food, and again staff acted appropriately offering words of encouragement to eat. The home has to cater for a wide range of diets including diabetic, soft and pureed diets as well as residents’ likes and dislikes. In visiting the kitchen this information was available to the cook, who kept a book of daily choices for each resident. She also advised the inspector that she met with all new residents and their relatives to discuss their dietary needs and likes and dislikes. There was a choice of meals for lunch and tea time. Residents were also seen having tea and toast later in the evening. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a satisfactory complaints procedure in place and residents and relatives/representatives feel confident that their complaints and concerns are listened to and acted upon. The home has a satisfactory policy and procedure regarding allegations of abuse. The staff have undertaken training in adult protection/abuse awareness to ensure that there is an appropriate response to any allegations of abuse. EVIDENCE: At the previous inspection, correspondence relating to complaints was stored in the residents’ files, this has been resolved. Residents’ files that were examined did not have any correspondence relating to complaints The inspector examined the complaints file where all appropriate correspondence is filed. This requirement is now met. The registered manager has changed the system for logging complaints and this is now in a central complaints log. The complaints procedure has also been redrafted which states that the complainant can contact the Commission at any stage of their complaint. This was a requirement from the previous inspection, which has now been met. Since the last inspection, the home has received two complaints. Both of these complaints were substantiated and the complainants were satisfied with the outcome. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. The home also has a copy of the Department of Health’s document ‘No Secrets’ and copies of the local authority (Redbridge) Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 16 documentation on abuse. Training on adult protection/abuse awareness is an ongoing programme that is attended by all staff including ancillary. The home also carries out in-house training as part of all new staff’s induction programme. The inspector spoke to staff who confirmed that they had attended training and were able to inform the inspector of the action to be taken if there were concerns about the welfare and safety of residents. Since the previous inspection there has not been any adult protection investigations. But with the increase in training both at induction level and an ongoing programme for all other members of staff, and with discussion with the registered manager, the inspector feels that any allegation would be investigated and the correct adult protection procedure would be followed. This was a requirement of the previous inspection that is now met. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 26 The home is clean, pleasant and spacious with access to indoor and outdoor communal facilities which adequately meet the needs of the residents. There are sufficient, suitable toilets and bathrooms for the number of residents. Specialist equipment such as hoists, mattresses and walking aids are available to meet the needs of the residents. Residents’ bedrooms suit their needs, however there are two double bedrooms and it must be a preferred choice of a resident to share with another resident. EVIDENCE: The registered providers have owned the home for less than a year, but they have undertaken an ongoing programme of renewal of the fabric and decoration of the premises. A daily and weekly maintenance programme is undertaken to ensure that the residents live in a comfortable and safe home. There is a large dining room and three comfortable lounges. The doors from one of the lounges leads to a pleasant patio area and garden. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 18 There are sufficient toilets and bathrooms on each floor. Each bathroom has an assisted bath and all of the toilets are wheelchair accessible. On inspection of the bathrooms it was noted that all gloves, incontinent pads and other essential toiletries were appropriately stored. Residents’ bedrooms are appropriately furnished, indeed one resident’s bedroom was a testament to her culture with appropriate wall hangings and soft furnishings, also evident were videos and DVDs in her own language. It was noted that some of the bedroom windows could be overlooked by a block of flats. It is a recommendation that those residents are given the choice as to whether they wish to have net curtains to preserve their privacy. As stated in the judgement there are two double bedrooms and a previous requirement was set regarding sharing a bedroom has to be a choice. In the statement of purpose there is a document headed ‘Policy on admission of a service user’ and section refers to the use of shared rooms. It states ‘if the resident is to share with another resident he/she will be introduced’. This implies that the sharing of double rooms is not a positive choice made by the resident. If residents are to share, this must be their own choice. This requirement is outstanding and set with a new timescale. This is requirement 8. All of the home is cleaned on a daily basis. The home was very clean and tidy. One of the cleaners spoken to stated that she had been given a free hand to bring improvements and had recently purchased new table cloths. There are adequate control systems in place to ensure that there was no offensive odours. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual needs of the residents. The homes recruitment policy and procedure is being followed and appropriate checks are undertaken. Staff training is given priority to ensure that residents’ needs are met. EVIDENCE: Staff rotas were examined and the rota correlated with the number of staff on duty on the day of the inspection. During the day there are four care staff and an RGN, which is sufficient to meet the needs of the resident. In addition during the afternoon there is an activities co-ordinator and there are sufficient cleaning and catering staff. The home is approved by the nursing and midwifery (NMC) as a practice placement for nurses on adaptation courses. In these cases all checks are carried out by an agency but the registered person are still required to hold full documentation. At the previous inspection the file of the current placement held all the relevant documentation except a copy of their visa, this has now been rectified and all relevant documentation is now available. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 20 Other staff files were examined and all showed all the relevant documentation that is required including references and satisfactory Criminal Records Bureau checks. This requirement is now met. The registered providers have placed a high priority on training. 55 of care staff have NVQ 2/3, other staff are currently undertaking NVQ 2 and 3 and the deputy manager is to commence her NVQ4. Every new member of staff undertakes an induction programme which includes adult protection/abuse awareness, fire safety, infection control and manual handling. Other courses that have recently attended are fire training, listening skills, diabetes awareness, administration of medication and preventing falls. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37, 38 The manager of the home is a well qualified and experienced person and residents benefit as the home is run in their best interests. Staff receive 1 to 1 supervision however this needs to be on a regular formal basis. Resident’s rights and best interests are safeguarded by the home’s record keeping and policies and procedures. Residents and staff health, safety and welfare is promoted and protected. EVIDENCE: The manager is a registered nurse and has the relevant clinical and management qualifications. She has experience in providing and managing nursing care services. She has an understanding of the needs of the residents and the areas in which the home needs to improve and further develop. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 22 Relatives and residents commented that she is approachable and helpful. The owners also spend a considerable amount of time in the home, and are very involved with the running of the home. Comments from staff indicated that they appreciated the owners have a high profile within the home and commented on their open and friendly approach. The home has developed an annual development plan which reflects the aims and outcomes for the residents. This plan comes from the result of the homes quality assurance survey. The survey was completed by residents, relatives, staff and visiting professionals to the home. Some of the recommendations from the survey include staff training, encouraging residents to maximise their independence and to look at activities for residents with similar abilities and interests. This was a previous requirement which has now been met. Monthly visits are carried out by the registered provider under the requirements of regulation 26 of the Care Homes Regulations, and reports of these visits are submitted to the Commission. The regulation 26 reports were discussed during the inspection and the inspector provided a pro-forma of the regulation 26 to ensure that reports are clear as to what action needs to be taken in response to identified problems. Significant events are also being reported to the Commission. At the previous inspection it was identified that correspondence relating to complaints was held in residents’ files. On examination of residents’ files and the complaints files, all correspondence is now stored appropriately. This was a previous requirement which is now met. From discussions with staff it was evident that there are opportunities for ad hoc supervision and staff meetings. There was no evidence that staff, both nursing and care staff receive regular formal supervision. This is requirement 9. The home has carried out all health and safety checks. The most recent fire training, fire drill took place in October 2005. The fire officer visited in July 2005. There has also been recent visits by health and safety department and environmental health. Water safety checks and emergency lighting checks have also been carried out. Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 2 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 2 3 3 Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 24 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. The Requirements that are outstanding from the previous inspection, the timescales are shown in bold. No. 1 Standard OP1 Regulation 4 Requirement The registered persons must compile a statement of purpose covering the matters listed in Schedule 1 of the care Homes Regulations. This must be useful for the purpose of those wishing to place people at the home. 31/07/05 The registered person must ensure that all current pre admission assessment proformas are unified to ensure that all relevant information is gathered. Service user’s plan are being evaluated, but this evaluation needs to be meaningful and identify any changes in the residents’ needs. The registered person shall ensure that all records are kept up to date The registered person shall ensure that all risks assessments are unified and any unnecessary risks are identified and as far as possible eliminated The registered person shall keep the service users’ plan under DS0000062553.V258451.R01.S.doc Timescale for action 28/02/06 2 OP3 14(1)(2)( 3) 28/02/06 3 OP7 15(2) 28/02/06 4 5 OP7 OP8 17(3)(a) 13 (4)(c) 28/02/06 28/02/06 6 OP7 15(2)(b) 28/02/06 Churchfields Nursing Home Version 5.0 Page 25 7 OP12 16(2) (m) 8 OP23 23(2)(e) 9 36 18(2) review The registered person must ensure that each service user is provided with social activities that meet their assessed needs. 31/07/05 Where rooms are shared they must be occupied by service users who have made a positive choice to share with each other.30/06/05 The registered person must ensure that all staff receive formal and regular supervision 28/02/06 31/01/06 31/01/06 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 OP24 Good Practice Recommendations Residents whose bedroom windows could be overlooked, should be given the choice as to whether they wish to have net curtains, to preserve their privacy Churchfields Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Nursing Home DS0000062553.V258451.R01.S.doc Version 5.0 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. 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