Inspection on 20/04/05 for Churchfields Nursing Home

This inspection was carried out on 20th April 2005.

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

The inspector found 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 10/11/05

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 Edi OFarrell Unannounced 20 April 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Churchfields Nursing Home Address 37 Churchfields, South Woodford, London, E18 2RB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8559 2995 020 8554 6982 Yewtree Care Ltd Elizabeth Matenga CRH Care Home 25 Category(ies) of OP 25 registration, with number of places Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Current owner - no previous inspection. Previous owners - 10 & 11 August 2004. Brief Description of the Service: Churchfields Nursing Home is a privately owned 25 place care home with nursing 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 bedrooms 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 an ensuite toilet or bath/shower. There are bathrooms and toilets on each floor. The doors from one of the lounges lead to a pleasant patio area and garden. Nursing and personal care is provided on a 24 hour basis. The ownership of the business has recently changed hands. Date of last inspection Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday from mid morning to late afternoon. Some service users were asked about their experience of living in the home, and two relatives who visited during the inspection were invited to comment. Some staff were asked about nursing and care practice and care records were checked. Staff were observed carrying out their duties, and the routine of those service users who were unable to provide comments due to their level of disability was also observed. Discussions were held with the deputy manager, as the registered manager was on leave on the day of the visit. Discussions also took place with the owners, who took over the home in February 2005. Several things that The Commission for Social Care Inspection (The Commission) had been concerned about over the past three inspections were included in this discussion. This inspection focused on assessing how the home is currently meeting the needs of the people who live there, and all key standards were assessed. What the service does well: What has improved since the last inspection? The ownership of the home changed in February 2005 and the new owners have already begun to make improvements. They have started by getting new carpets in the lounges, dinning room and corridors, and also getting those areas decorated. They have also cleared the garden, and had some of the windows repaired. Bedrooms are being decorated and fitted with new carpets as they become vacant. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 6 The new owners have identified the training that staff need and have made arrangements for in-house training for both nurses and care staff. They have identified many other aspects of the running of the home that need improvement, such as care planning and record keeping. The new owners spend much more time at the home than the previous ones, and staff said that this means that any concerns can be raised with them and be dealt with much quicker. Prior to the inspection, a representative of the Commission met the new owners and discussed with them ways of improving communication between the management team and service users and their representatives as well as with staff. The new owners had several ideas for ways of improving communication which they were planning to implement. Certain things have to be reported to the Commission so that we can monitor how homes are performing between our visits; this has greatly improved over the past few months. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 7 by contacting your local CSCI office. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 Service users and their representatives have sufficient information to make an informed judgement about moving into the home. However, more needs to be done by the registered persons to ensure that the pre-admission assessment undertaken by the home includes the collection of full information from relatives and professionals. This will ensure that the needs of the prospective service user can be appropriately identified and met. EVIDENCE: The change of ownership means that some documents are not up to date, but the new owners have started to rectify this. In practice this does not affect the information available to service users and their representatives. The new owners sent a copy of the revised statement of purpose to the commission and this was examined prior to the inspection. Feedback on the Statement of Purpose was given to the Proprietors on which areas needed to be developed. The draft needs some more work in order for it to be a useful and accessible document. There are currently some omissions, and some documents that do Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 10 not need to be in it. This is Requirement 1. Comments on some parts of the document were discussed with the owners and are included below in the sections on health and personal care, and complaints and protection. The service user guide was not examined on this visit. In discussion the two relatives spoken to were clear about what the home could offer, in both cases the service user had been admitted since the last inspection. Statements of terms and conditions were seen in files, and where the local authority fund the placements, these files include appropriate contracts. Community care assessments were seen on files along with pre-admission assessment by the manager or deputy. In one case, which was discussed with the deputy manager, information about the night behaviour of the service user had only come to light once they were admitted, as the hospital had not passed this information on. Subsequently both a relative and the GP had confirmed that this behaviour i.e. `wandering’ had been occurring for some considerable time. Had the home’s pre-admission assessment been more thorough this would have been known at an earlier stage and could have been planned for. The home’s pre-admission assessment must seek to obtain all relevant information from relatives and professionals. This is Requirement 2. Most new residents are admitted from hospital and it is their relatives who visit the home, one relative spoke about choosing this home over another because of the level of night staff. Intermediate care is not provided at this home. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 & 11 Many health and personal care needs are met but some are not. Some aspects of care practice do not ensure that the individual care needs of service users are being satisfactorily met. EVIDENCE: Six service users and two relatives gave their views and seven care files were examined, with four being case tracked in depth. Staff were observed, both directly and indirectly, providing care to the service users. Care plans are in place and in many cases these reflect the assessed health and personal care needs of service users. For example, two of the service users are insulin dependent diabetics and the care plans, daily logs, and observed practice show that there is regular attention to, and recording of, blood sugar levels, weight, fluid and food intake, and tissue viability. In comparison another file, where the service user is diet controlled diabetic states ‘fluid intake to the level of at least 1 litre per day’ and `GM at least once weekly’, and `keep accurate records’, but such records could not be found. In another file the notes written by the tissue viability nurse recommend `gentle massage from toes to knees and bilateral tubigrip’, this is not included in the care plan, and the service user does not have any tubigrip on her legs even though they are extremely Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 12 swollen. Whilst the nurses and care staff have obviously worked hard at care planning, these, and other, inconsistencies mean that some needs may not be being met. A requirement was set under Standard 7 at the previous inspection and this has been restated as Requirement 3 which also relates to Standard 8. The owners have recently met with the Continence Advisory Service regarding the supply of appropriate pads, this has led to the specialist continence adviser visiting the home, and providing advice which is recorded in the case files. They intend to visit on a regular basis and to assess up to three service users at each visit as well as to provide in-house training for staff. Their advice covers both continence promotion, and continence management. During the inspection one service user, sitting in the quiet lounge, reached out to the inspector as she passed; on enquiring of a carer if the lady may wish to go to the toilet, the carer replied `no, we took her after lunch’, indicating a lack of appreciation that the service user may need to visit the toilet again. One of the case files has a description of another service user’s preferences, supplied by relatives. This clearly states that this person will not ask for things and needs to be regularly prompted, including going to the toilet. This information has been included in the care plan as `encourage her to ask for the toilet – she does not ask for things’. This file also contains details of a recent complaint, which includes continence management; the records showed that this complaint had been responded to in a similar way i.e. that the lady had been `toileted’ after lunch and would be again after afternoon tea. This does not indicate a person centred. Of particular concern is that this approach seems to be applied to those service users who will not, or cannot, speak for themselves, due to their level of disability or personality. Incontinence, of any sort, is distressing to people, and should not be dealt with by simply putting pads on, and `toileting’ all at regular times that suit the home. Continence promotion and management programmes must be in place for each individual, not for the home in general. This is Requirement 4. In addition the continence promotion and management policies and procedures supplied by the owners to the commission must be reviewed, in consultation with the continence adviser, and taking account of relevant good practice guideline. This is Requirement 5 Looking into bedrooms, discussion with service users, and examining files shows that there is a very high use of `cot sides’ in this home. Staff explained, and this was documented in some risk assessments, that this was because of the risk of individual service users `falling out of bed’. Several service users, where cot sides are used, were observed during the day. Most did not move on the chairs where staff had placed them in the morning, apart from when they were wheeled to the toilet. The risk assessments, where in place, simply state that there is a risk of the person falling out of bed and that cot sides are needed. There is no indication of any consideration of a less restrictive approach. In one case the cots sides are being used because the person `wanders’ at night, but obviously do not contain the person effectively because they slide themselves down to the bottom of the bed. The policy on the use of cot sides, sent to the Commission by the new provider states that Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 13 relatives must be informed of their use, and, in some files relatives had signed consent forms. As with the approach to continence promotion and management this all indicates an approach to care that is not person centred. The use of cot sides must be reviewed on an individual basis and this must include thorough risk assessment detailing the risks associated with using and not using them. The resident and their relatives and/or relevant professionals must be fully consulted, and the use must be reviewed on a regular basis. This is Requirement 6. In response to concerns raised via both complaints and additional inspections the use of footrests on wheelchairs was specifically looked at during this visit. The owners reported that there were three service users who did not like the footrests being used, and that risk assessments had been carried out in response to correspondence from the commission. These service users repeated their dislike of the footrests, with one stating `I like my feet on the ground’, whilst another said `I don’t like them’. Service user choice and preference is obviously highly important, but this has to be balanced with their health and safety. Service users, staff and management were informed that a fuller risk assessment must be carried out on each wheelchair user. This must detail the risks associated with using footplates as opposed to not using them, only if the risk of using them is greater than the risk of not using them should they not be used. This is Requirement 7. The main reason given by staff for footrests not being used was that service users felt discomfort on bending their knees; this is not acceptable as a reason as there are suitable alternatives to attach to wheelchairs in these cases, including footboards. The mid day medication round was indirectly observed but this standard was not fully assessed during this visit. Staff were both indirectly and directly, observed, service users and relatives gave their views and records were checked in relation to dignity and privacy. Staff knocked on bedroom and bathroom doors, and denied access, at the request of the service user, whilst they were attending to personal care. Service users felt they were treated with dignity and respect. Care plans described how service users preferred to be addressed and treated. If the institutional practices as described above in relation to continence promotion and the use of cot side had not been identified then the home would have met this set of standards. Wishes in relation to dying and death are clearly identified in the care plans. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Some service users may experience a less than satisfactory lifestyle, because of some practices being carried out in the home. The home does a limited amount to engage service users who are unable/unwilling to speak up for themselves. Service users who are less disabled enjoy a more satisfactory lifestyle, with the aid of staff and relatives. EVIDENCE: The vast majority of people who live in this home are unable/unwilling to speak for themselves, either due to level of disability, or to disposition. Direct and indirect observation during the inspection showed that the more able service users received a considerable amount of attention, whilst the least able received an adequate level of personal care. One example was where it was clear in the case file that the service user needed to be stimulated, but the only time staff approached her during the visit was to provide food or drink, or to take her to the toilet. Some service users, with prompting, talked about activities, but again these were the more able ones. This is a nursing home and therefore many of the residents have severe physical and memory disabilities, but this does not have to mean that only physical needs are met. Care plans clearly stated that staff should engage in conversation with service users, if only for a short time each day. A recommendation was set at the previous inspection that the manager review the range of activities offered to Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 15 service users both individually and collectively. This has been taken forward as Requirement 8, and Requirement 9 has been set to draw the attention of the registered persons to the importance of maximising service users’ capacity to exercise autonomy and choice. Visitors are encouraged, and both those spoken to were pleased with the care being provided to their relative. The menus were checked, and the lunchtime meal observed, together with service users being asked about the food. Some service users were still taking breakfast at 10.00 a.m. Preferences regarding food were detailed in the care plan, and in one case in the kitchen. There has been a complaint about the evening meal, stating that this is heavily reliant on sandwiches. This was not found to be the case overall, though may be for individual service users, due to dietary needs. The Commission will continue to monitor this on future visits. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Service users and their relatives cannot be totally confident that they are protected from abuse at all times. Complaints are taken seriously but need to be addressed more robustly. Records of complaints are not stored appropriately. EVIDENCE: Some letters responding to complainants are stored in the service user files. In one case this identified a member of staff who had been reprimanded, this is not acceptable. This is Requirement 10. There is a log of complaints in each file, as well as in the central complaints log. The new owners stated that they were not happy with the system and were in the process of changing it. The complaints procedure states `In the event of a complaint or request not being dealt with, the matter may be referred to the registration authority’. This is inaccurate as complainants have the right to contact the Commission at any stage. The procedure also does not include that the placing authority may also be contacted. The procedure needs to be redrafted so that it is comprehensive. This is Requirement 11. The registered manager is on a three-week period of annual leave and has left detailed instructions for the deputy as to their duties. The memo dated 29/3/05 refers to the manager having previously heard carers shouting at residents as they wash them, and instructs the deputy to reprimand anyone that she hears doing this. The Commission is pleased that inappropriate behaviour by staff is being addressed; however shouting at residents is abusive practice. All potential and actual abuse must be thoroughly Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 17 investigated and correct adult protection procedure followed. This is Requirement 12. If, as suggested by the manager’s memorandum, this practice has occurred on several occasions, the Commission would expect to see the action being taken by the registered persons to address poor practice in relation to the care of residents whose behaviour challenges the ability of the staff who look after them, for example, through 1:1 supervision and through training and team discussions. This will be assessed more closely at the next inspection, when the new owners have had an opportunity to assess practice in the home. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 The home is clean, pleasant and spacious, and has benefited from new carpets and some redecoration since the new owners took over. There are sufficient, suitable toilets and bathrooms for the number of residents. Specialist equipment, such as walking aids and mattresses are in use where needed. The use of the two double bedrooms may not always meet the needs and preferences of the service users. EVIDENCE: Since taking over, the new owners have replaced the carpets in all communal areas, which have also been redecorated along with bedrooms as they become free, and repaired many of the windows. They have also had the garden cleared. One of the three lounges is designated a quiet room, and does not have a television. During the visit service users were enjoying listening to the radio instead. Service users said that they liked their bedrooms, and they had brought in some of their personal possessions. In the statement of purpose there is a document headed `Policy on admission of a service user’, and Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 19 section 10 refers to the use of shared rooms. It states `If the service user 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 service users. Where rooms are shared this must be the case. This is Requirement 13. There are sufficient toilets and bathrooms on each floor, and some of the service users have commodes in their bedrooms for the night time. Each bathroom has an assisted bath, and all toilets are accessible to wheelchairs and hoists. Care plans and daily records showed that specific types of hoists were being used for individual service users, and staff were observed following correct guidelines. As this has been an on-going concern, the Commission will continue to monitor practice at each future visit. All parts of the home are adequately lit, heated and ventilated, and there is an up to date check of the water systems. All parts of the home are cleaned on a daily basis, and one of the cleaners stated that the new owners had been very responsive to requests for cleaning materials. The home was clean and tidy during the visit and there were no offensive odours. Infection control systems are in place, as are effective systems for the handling of soiled linen. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Service users’ health and personal care needs are adequately met by the numbers of staff on duty during both day and night time hours. Staff training, for both nursing and care staff, is being given a high priority by the new owners. The recruitment policy and procedure is not always being fully followed, which could put service users at risk, if the appropriate checks on new staff are not undertaken. EVIDENCE: Since the last inspection there has been an increase in staffing, and there are now four carers and one RGN on each daytime shift. From observation, discussion with service users and staff, and checking records this is sufficient to meet service users’ needs if care plans are followed correctly. Staff meeting records showed that cleaning and catering hours are currently under review and that the owners are considering increasing these. An external organisation has been contracted to provide a 12-week in-house training programme, which will cover theory and practice of basic care including medication, infection control, health & safety etc. The continence adviser and the tissue viability nurse will also be providing training. Ten carers have commenced NVQ2 and a new induction programme has been introduced. The home is approved by the Nursing and Midwifery Council (NMC) as a practice placement for nurses from overseas on adaptation courses. In these cases all the checks are carried out by an agency but the registered persons are still required to hold full documentation. The file of the current placement, Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 21 whilst including all other relevant documentation, does not include a copy of their visa. There has been a requirement set at the last three inspections that all staff files must include all statutory documentation, and this must include people on placement. This is Requirement 14 and a new timescale has been set for the current owners to comply. The Commission will consider enforcement action to secure compliance if the requirement is not met by the new timescale. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37 & 38 The home is not always run in the best interest of the service users. Service users’ financial interests are safeguarded, but the health, safety and welfare of individual is not always promoted and protected. Record keeping and policies and procedures do not safeguard the rights of service users and staff. EVIDENCE: The registered manager was on leave on the day of the inspection, and in addition the home has recently changed ownership. For these reasons the standards relating to the management of the home were not fully assessed. The new owners spoke about how they expected the home to be managed, and the manager had left detailed instructions for the deputy manager as to how this should be done. Both these sources of information implied effective management practice, which will be fully assessed at the next visit. Some staff commented on the value of the more `hands-on’ approach of the new owners, who spend more time in the home than the previous ones. They felt Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 23 that decisions, particularly about resources, got made quicker. Staff meeting records showed some teething problems in relation to terms and conditions of staff, which the owners are dealing with on an individual basis. Two documents relating to Quality Assurance are included in the draft statement of purpose; one is headed `Quality Policy Statement’, and the other `Quality Assurance Policy’. Both these documents need further work so that they comply with Regulation 24 and National Minimum Standard 33. This needs to include details of an effective quality assurance and monitoring system, based on seeking the views of service users. This should then be used to produce an annual development plan, based on a systematic cycle of planning, action and review, reflecting aims and outcomes for service users. This is requirement 15. Although there is a considerable amount of work to be done in order for the home to meet this standard it has been scored at 2 instead of 1 to recognise that ownership has only recently changed, and a six month timescale for compliance has been set. In practice such a system has already been started by the owners sending out a survey to relatives. Monthly visits are being carried out by the providers to monitor the quality of the service, under the requirements of Regulation 26 of the Care Homes Regulations, and reports of the visits are submitted to the Commission, who have corresponded with the owners over some lack of detail. This was discussed with the owners during the visit, and they were advised to ensure that all future reports are clear as to what action they and the manager have taken in response to identified problems. Two members of staff take lead responsibility for the handling of service users’ weekly allowance. There is a clear audit trail, and the written accounts matched the actual money held. Significant events are now being reported to the Commission. As this has been a particular problem under previous owners the importance of this reporting as a monitoring exercise was discussed with the new owners. As stated earlier in this report some correspondence relating to complaints is currently held in the case files. In one case this identified a member of staff who had been reprimanded in response to a complaint. As other staff have access to these files, and service users and their representatives have the right to see the files this is unacceptable storage of records. This is Requirement 16. Two fire safety training sessions have recently been held as the new owners identified this as an priority. The handyman carries out health and safety checks regularly. Water safety checks have recently been carried out. Whilst all required health and safety checks and documentation are in place the inconsistent approach to risk assessment of health and personal care needs identified earlier in this report means that there is a considerable amount of Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 24 work to be done by management if standard 38 is to be met. This is Requirement 17. Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 25 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 2 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x 2 x 3 x 2 1 Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement Timescale for action 31/07/05 2. 3&4 12 (1) (2) & (3) & 14) 3. 7&8 12 4. 7&8 12 & 15 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 The registered persons must 31/07/05 ensure that prospective service users, their representatives, and relevent professionals are party to a full assessment prior to admission being agreed. The registered person is required 31/07/05 to undertake a review of service user care plan evaluation/documentation. Documentaion must be developed to ensure that information related to individual user care plan goals, and action taken in response is clearly recorded and updated. (Previous timescale of 30/11/04 not met) The registered persons must 31/07/05 ensure that needs are individually assessed, and that care plans are in place, and followed in practice, to meet these needs. In particular; continence promotion. Version 1.20 Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Page 27 5. 7&8 12 & 15 6. 7, 8 & 38 12 & 15 7. 7, 8 & 38 12 & 15 The registered persons must 31/7/05 ensure that a comprehensive policy and procedure on continence promotion and management is in place. This must include taking advise from the continence adviser, and taking acount of latest good practice. The document must clearly state that the individual needs of service users have to be identified and met in practice, and that the routine of the home cannot take precedence. The document must also clearly state how the needs and wishes of service users who cannot/will not ask for assistance have to be met. The registered persons must 30/06/05 ensure that a comprehensive review of the use of `cot sides is carried out. This must focus on the individual needs of each service user. Risk assessment must demonstrate that where cot sides are used they are the least restrictive option and do not pose any hazard to the service user. The use of cot sides for any service user must be agreed by their relatives/representatives, following a full explanation as to why they must be used. Relevant professionals must be involved in the assessments, and the use of cot sides must be regularly reviewed. 31/07/05 The registered persons must ensure that each person who uses a wheelchair is assessed by a competant professional. Where service users state a preference not to use the footrests this must be fully risk assessed. This must include a Version 1.20 Page 28 Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc 8. 12 & 14 16 (2) (m) 12 (2) (3) & (4) 9. 14 10. 16 22 11. 16 22 12. 18 13 (6) 13. 23 23 (2) (e) 14. 29 19 15. 33 24 consideration of balance of conflicting risks. These risk assessments must be regularly reviewed. The registered persons must ensure that each service user is provided with social activities that meet their assessed needs. The registered persons must ensure that the home is run in a manner that maximises the service users capacity to exercise personal autonomy and choice. Records relating to complaints must be stored seperately from case notes. Records relating to staff disciplinary matters must not be stored in files that can be accessed by other staff. The complaints procedure must be redrafted so that it is comprehensive and complies with Regulation 22 All actual or potential abuse of service users must be throughly investigated and correct adult protection procedure must be followed. Where rooms are shared they must be occupied by service users who have made a positive choice to share with each other. The registered person must ensure that staff files, including for people on placement, include all statutory documentation. Previous timescales of 01/04/04, 01/06/04 & 30/11/04 not met, but these were set under previous ownership. The registered persons must establish and maintain a system for reviewing, and improving the quality of care provided by the home, including the quality of nursing. The system must 31/07/05 31/07/05 30/06/05 30/06/05 30/06/05 30/06/05 31/07/05 31/10/05 Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 29 16. 37 17 17. 38 12 (1) (a) include seeking the views of service users and their representatives. All records required by regulation 31/07/05 must be securely stored. They must be organised in such a way so as to meet statutory requirements under data protection and freedom of information legislation. The registered persons must 30/06/05 ensure that the health, safety and welfare of service users are protected at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Churchfields Nursing Home G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 30 Commission for Social Care Inspection 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 G55_S0000062553_Churchfields_V222471_200405_Stage 4.doc Version 1.20 Page 31 - 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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