Inspection on 24/04/06 for Churchfields Nursing Home

This inspection was carried out on 24th April 2006.

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 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 10/11/05

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 Unannounced Inspection 09:30 24th April – 25th April 2006 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.V291981.R01.S.doc Version 5.1 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.V291981.R01.S.doc Version 5.1 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 churchfields37@btinternet.com 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.V291981.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 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 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 en-suite 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. The Statement of Purpose and the Service User Guide are issued to every prospective service user and both of these documents are displayed on the residents, notice board, which is situated in the entrance hall of the home. A copy of the most recent inspection report is also displayed on the notice board, A resident or relative/representative could ask for his or her own copy which the manager would make available. The fees for the home are £520 - £595. The manager made this information available on 5th May 2006. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and lasted twelve hours in total. The inspector spoke to six residents about their experience of living at the home and to nine relatives whilst visiting the home. Discussions took place with the providers, the manager, deputy manager and several members of the care and nursing staff. 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. A tour of the home took place and a number of staff and residents’ care records were examined. The views of three health professionals who visit the home were also sought during the inspection and some of their comments have been incorporated in this report. What the service does well: What has improved since the last inspection? Eight of the previous requirements and the one recommendation have been met. The manager ensures that all residents have a full assessment of their needs prior to admission to the home. All care plans and risk assessments are now being reviewed on a regular basis. Social activities within the home are more varied and individualised. The Statement of Purpose has been amended and it now states ‘that residents can share a bedroom, if that is their choice’. Bedrooms that were overlooked by neighbouring properties have been furnished with net curtains. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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.V291981.R01.S.doc Version 5.1 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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents and their relatives have detailed information on the home to enable them to make an informed choice about moving into the home. Each resident has a written contract and statement of the home’s terms and conditions’ so that they are clear about the provider’s obligations and their own. A detailed pre-admission assessment is undertaken of all prospective residents, this will ensure that their identified needs can be appropriately met by the home. Prospective residents and their relatives are able to visit the home prior to their admission and obtain a copy of the service user guide. Standard 6 is not applicable to the residents of Churchfields. EVIDENCE: The Statement of Purpose has been revised and further developed. It now clearly sets out the objectives and philosophy of the service. Comments on one part of the Statement of Purpose are included in the section on environment. A Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 9 previous Requirement requiring the provider to change the statement regarding ‘residents sharing bedrooms’, has now been met. Files that were examined showed each resident had a contract and a copy of the home’s terms and conditions. Each resident has also been issued with a service user guide to the home, which states what the resident can expect from the home. The residents’ files need to be organised in a way that it is easy to obtain information more readily. All of the information was in the files, but it was not in subject or date order. This is Recommendation 1. The file of a fairly new resident was looked at. An in-depth assessment and an assessment from the local Authority had been undertaken. At the previous inspection it was noted that the home was using two separate assessment forms, with some of the information being duplicated. These forms have now been unified, which now ensures that all appropriate information is gathered on the one form. This Requirement is now met. Further information was also obtained from health professionals and family, prior to the resident’s admission. Residents and relatives are able to visit the home prior to a resident moving in. The inspector spoke to six relatives, who all stated their parents or wives were unable to visit the home prior to their admission due to their frailty. However all of the relatives had visited this and other homes before making their choice. One relative stated that she had visited five homes and stated ‘she had chosen Churchfields because it had a homely atmosphere and she was made to feel very welcome’. Another relative stated that ‘she had visited other homes but she liked the atmosphere, people were chatting and laughing and the manager was able to reassure her’. The home has had one new resident since the last inspection. The home does not provide intermediate care. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal care needs of each resident are set out in individual care plans. These plans provide the staff with sufficient information to ensure that care needs are being met on a daily basis. The daily report sheets are not being completed by members of staff who delivered the care, this could lead to residents not receiving the appropriate care. There are clear medication policies and procedures for staff to follow and medication records are being completed correctly, which safeguards the residents with regard to their medication. Residents are treated with respect and the arrangements for their personal care ensure that their right to privacy is upheld. Residents’ wishes in relation to death and dying are clearly identified on their care plans. EVIDENCE: Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 11 Each resident has their own care plan, four of these care plans were examined by the inspector. The care plans are detailed and comprehensive, identifying the residents’ personal, social, cultural, religious and health needs and how these needs should be met. However it is not clear how care plans are being implemented on a daily basis. The daily report sheets need to be more informative and relate to specific care plan goals and outcomes. This is Requirement 1. There was evidence that body maps are routinely completed following an incident or accident. The recordings of fluid and food intake and pressure wound charts were all completed satisfactorily. The tissue viability nurse is involved with the care of two of the residents and she is satisfied with the actions of the staff. All residents are weighed on a regular basis and if weight loss is noted over two consecutive weighings then the resident is referred to their GP and the dietician. Residents’ care plans that were examined showed that they are being evaluated on a monthly basis and that these evaluations are reflecting changes to the care required and detailing the progress of an individual. This was a previous Requirement that has now been met. Residents’ files now have written evidence that they are seen by other health professionals including opticians, dentists, chiropodists, tissue viability nurse, GP and hospital out-patient appointments. This was a previous Requirement that has now met. One resident told the inspector that she had seen the dentist recently as she had lost a tooth. Another resident stated that she had not been happy with her hearing aids and the manager had arranged an appointment at the audiologist clinic. The inspector contacted three health professionals who visit the home, they all stated that they were satisfied with the care that the residents received and that staff were kind and caring. One health professional stated that advice and instructions that were given to staff were acted upon. Risk assessments were examined. The risk assessments are detailed and cover areas such as use of a hoist, wheelchair and cot sides, nutritional needs and continence. Residents where possible, relatives and health professionals have been consulted in the formulating of these risk assessments. The manager was using different formats of risk assessments these have now been unified to ensure uniformity in completion. This was a previous Requirement that has now been met. There was evidence that 6 monthly reviews are now taking place. The registered manager has ensured that all interested parties including the resident, relative and social worker, can give an opinion as to whether the home is continuing to meet the resident’s needs. This was a previous Requirement that has now been met. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 12 Medication policies and procedures were examined and found to be up to date. Only nursing staff can administer medication. Four residents’ Medication Administration Records (MAR) charts were examined and all had been completed appropriately and medication given correlated with the MAR charts. Regular management checks are recorded to monitor compliance. Home remedy book was up to date and had been signed by the GP. The inspector spoke to a number of residents and relatives who all said that staff were respectful and thoughtful when attending to personal care. One relative stated that ‘staff are very caring and treat my wife with dignity’. Another relative stated that ‘the staff are excellent, they have loads of patience’. A resident said ‘I couldn’t fault the staff, they are kind’, another resident said ‘the girls are so kind’. Staff talked about and were observed to treat residents in a respectful and sensitive manner. They understood the need to promote dignity through practices such as in the way they addressed residents and when entering bedrooms, bathrooms and toilets. Residents’ privacy and dignity are covered during the staff’s induction programme. Residents’ wishes in relation to dying and death are clearly identified in their care plans, including the involvement of relatives in their final hours. Staff have received training in dying and death, they and the other residents have the opportunity to attend residents’ funerals, if they so wish. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Two of the senior care staff now have designated hours to ensure a more varied programme of activities is available, which suits individual needs, preferences and capacities. Visiting times are flexible and people are made to feel welcome when visiting the home. This ensures that residents are able to maintain contact with their family and friends as they wish. Residents are assisted 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 residents. EVIDENCE: Residents were asked their views and care plans were examined. The signing in book shows that there is a steady stream of visitors to the home on most days. Visitors are invited to join in activities such as the weekly film shows and Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 14 the monthly entertainment. The care plans contain information about preferred activities, including spiritual and cultural activities. Regular church services are held in the home. Residents are encouraged to go out with relatives where possible, One resident had recently been to stay with her son for the weekend and another resident goes out to lunch with her son. Members of staff were observed sitting knitting and reading with residents. One resident is Chinese and she has a visitor who speaks Cantonese, as does a member of staff. On the day of the inspection the hairdresser was visiting and many of the residents were having their hair cut and set. A clothes show has been organised later this week, where residents will be able to buy items of clothing. Two senior care staff have designated hours to organise activities and since the last inspection further activities have been arranged, every Saturday afternoon armchair exercises are organised by a physiotherapist and Pets As Therapy (PATS) visit once a month, where residents can sit and stroke a dog. Both of these activities have been very successful with the residents and one lady stated that ‘she worked with animals when she was younger and loves seeing the dog’. Individual activities are also taking place puzzles, manicures, walks to the local park and shops and care staff are spending time talking to residents on a one to one basis. This previous Requirement has now been met. Visiting times are very flexible and visitors confirmed that they could visit at any time. All of the relatives spoken to stated that ’they are made to feel very welcome and always offered tea or coffee’. One relative stated that if he is visiting at lunchtime, he is offered a meal. Residents have the choice of where to see their relatives, either in one of the lounges or their own bedroom. Residents’ care plans indicate their preferred name, their choice as to where they take their meals, whether they choose to have a bath or shower and their wishes regarding their death. One resident handles their own finances and there is a clear policy and procedure in place to protect the resident. Residents are encouraged to bring in their own personal possessions with them when coming to live at the home and this was evident when the inspector visited residents’ bedrooms. Items such as radios, televisions, photographs, pictures and ornaments enable the rooms to feel more homely. Meals are mostly served in the dining room, though one resident prefers to have her meals in her bedroom. There are two choices of the main meal, however the chef stated that she would cook something different if either of the choices were not to a resident’s liking. The meals that were seen on the days of the inspection looked appetising and nutritionally balanced, the fish pie was homemade and the alternative meal was liver, mashed potato and mixed vegetables. Both residents and relatives were very complimentary of the food and one relative stated ‘since this chef had been in post, there had been a vast improvement in the food’. The chef keeps a daily book of residents’ choices and this assists her in planning future menus ensuring she meets caters for their varying cultural and dietary needs. During the inspection some of the residents were observed having their breakfast later in the morning. Residents Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 15 spoken to stated that this was their choice, as they did not like to eat early. Each dining table was set with a small vase of flowers and jugs of juice, staff were seen offering each resident the gravy boat rather than every dinner being served with gravy already on it. 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. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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 the following standard(s): 16, 17 and 18 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Residents and their relatives can be confident that their complaints will be listened to, and acted upon. Residents’ legal rights may not always be protected. Residents are protected from abuse by the policies, procedures and practices within the home. EVIDENCE: The complaints book was examined during the inspection and no complaints have been recorded since the last inspection. The inspector discussed with the manager that all concerns or complaints whether written or verbal needed to be recorded and dealt with appropriately. The complaints procedure is on the notice board. Four residents were asked ‘if they were unhappy about anything in the home, who would talk to’? Two residents said they would talk to the manager, another resident said she would talk to the nurse and another resident said she would tell her daughter. All of the relatives that were spoken to said that they would talk to the manager if they had any concerns and felt confident that they would be listened to and their complaints acted upon. One Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 17 relative stated ‘she had some concerns in the past and they were dealt with straight away’. Health professionals who visit the home were very clear that they would report any concerns or complaints to the manager and would ensure that the concern or complaint was dealt with to their satisfaction. The majority of the residents have relatives, friends or volunteers who can advocate on their behalf, if they so wished. The manager needs to ensure that an advocacy service is offered to residents who do not have a relative/representative to represent their views. This is Requirement 2. There is a written policy and procedure for dealing with allegations of abuse and whistleblowing. The home has a copy of the Department of Health’s document ‘No Secrets’ and copies of the local authority (Redbridge) documentation on adult abuse. Adult Protection/ Abuse Awareness is dealt with as part of all new staff’s induction programme and there is an ongoing training programme with the local authority. Staff that were spoken to confirmed that they had attended training and were aware of the actions to be taken if there were any concerns about the welfare and safety of residents. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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 the following standard(s): 19,20,21, 23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is welcoming and provides the residents with a safe, well-maintained environment. There are sufficient and suitable toilets and bathrooms for the number of residents. Residents’ bedrooms meet their needs and are furnished with their own personal possessions. Residents live in a home that is comfortable, clean and hygienic. EVIDENCE: The registered persons have an ongoing redecoration programme as well as a daily and weekly maintenance programme, which ensures that the residents Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 19 live in a comfortable and safe home. The home employs a maintenance person and there is an effective system in place for staff to report items requiring repair or attention. The living area of the home consists of a large dining room and three comfortable lounges, which are appropriately furnished. The patio and rear garden are reached via one of the lounges. None of the bedrooms are en-suite but all have washbasins and are appropriately furnished. All of the bedrooms had personal possessions such as, family photographs, ornaments, radios and televisions. 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. At the last inspection it was noted that a block of flats, which could have an impact on people’s privacy, overlooked some of the bedroom windows. It was a recommendation that those residents are given a choice as to whether they wish to have net curtains to preserve their dignity. These bedrooms have now been furnished with net curtains. This previous Recommendation is now met. There are two double bedrooms and the Statement of Purpose stated that ‘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. The Statement of Purpose has been amended and now states ‘that it is the resident’s choice as to whether they wish to share a double room’. This previous Requirement is now met. On each floor there are sufficient bathrooms and toilets, all were very clean and tidy. Each bathroom has an assisted bath and all of the toilets are wheelchair accessible. The home is cleaned on a daily basis and throughout the inspection it was noted that, in the home, the standard of cleanliness was very high. Two members of staff have recently attended training on infection control and there are adequate control systems in place to ensure that the home is free from any offensive odours. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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 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): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are satisfactory and there are sufficient staff on duty. However not all of the staff have the appropriate skills and training to meet the individual needs of the residents. The registered persons must ensure that all staff have an understanding and command of the English language, which enables them to communicate with residents, relatives and other interested parties. Failure to do so may place residents at risk. The home’s recruitment procedure is not always being followed and appropriate checks are not always being undertaken, which could put residents in a vulnerable position. EVIDENCE: On the day of the inspection, staffing levels were observed to be sufficient to meet the needs of the residents. Staff rotas were examined and the rota correlated with the number of staff on duty. The manager has recently adjusted the rotas, to ensure that early morning and lunchtime there is an extra member of staff on duty. This will ensure that residents do not have to wait for assistance at particularly busy times within the home. Since the last inspection, staff files showed that staff have undergone further training in diabetic awareness, computer skills, manual handling, medication Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 21 awareness, infection control. Some staff have recently attained their NVQ 3, new care staff have commenced their NVQ 2 and the senior nurse has commenced her NVQ 4. More than 55 of the care staff have attained NVQ2/3. All new staff undertake a six week induction programme that covers areas such as, fire procedures, health and safety, communication, care of residents personal hygiene, adult protection/abuse awareness. Two of the nurses have carried out mentorship training for nurses on adaptation courses. Staff files that were examined showed that not all of the relevant recruitment procedures are being followed. The manager had received criminal record clearance from the new member of staff’s country of residence, however she had commenced work prior to being checked on the Protection of Vulnerable Adults (POVA First) list or an application submitted for Criminal Records Bureau (CRB) check. This is Requirement 3. The inspector spoke to a number of care staff and was concerned at the limited English of one of the staff. The member of staff had difficulty in understanding the questions posed by the inspector and was unable to give any meaningful answers. The inspector shared her concerns with the providers and the manager as to whether the member of staff could meet the needs of the residents. Their ability to complete an induction programme, to be able to follow instructions, to give and receive information and to be able to communicate with residents is questionable, and could put residents at risk. The manager must ensure all staff can understand and speak English at a level that does not put residents at risk. This is Requirement 4. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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 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): 31,33,35,36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a home that is run in their best interests by an experienced and qualified manager. Residents’ financial interests are safeguarded by the policy and procedures of the home. The manager does not have adequate systems in place to ensure that residents are supported by staff who are appropriately supervised and whose performance is appraised regularly in order to adequately meet and understand their individual needs Resident’s rights and best interests are not always safeguarded by the home’s record keeping and policies and procedures. Residents and staff’s health, safety and welfare are promoted and protected. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 23 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. Comments from residents and relatives were complimentary, saying that she is kind and helpful. The providers also spend a considerable amount of time at the home and are very involved in the running of the home. The home has instigated an annual development plan that reflects the aims and outcomes for the residents. This plan comes from the result of the home’s quality assurance survey. Some of the recommendations from the survey have already been acted upon such as, more entertainment, different menus. The providers are actively pursuing planning permission to extend the home’s capacity from 25 to 37 residents. The providers must be mindful to engage with residents and relatives on a regular basis, to ensure that they are fully informed of the developments within the home. Monthly visits are carried out by the provider under the requirements of Regulation 26 of the Care Home Regulations and reports of these visits and significant events are being submitted to the Commission. The home has an appropriate policy and procedures regarding safeguarding residents’ finances. The inspector checked five residents’ accounts, all of the monies checked against their balance sheets and all items of monies spent were reconciled with receipts for goods obtained. A senior carer has responsibility for residents’ finances and she audits every account on a monthly basis. It is a recommendation that another senior carer or the manager countersigns the monthly auditing of resident’s finances. This is Recommendation 2. From discussions with staff and the manager it was evident that there are opportunities for ad hoc supervision and staff meetings. However, there was no evidence that both nursing and care staff receive regular formal supervision or yearly appraisals. This was a requirement from the last inspection and is repeated with a new timescale. This is Requirement 5. Some of the home’s record keeping need to be more robust; Daily report sheets need to be completed by the person carrying out the task and not the nurse on duty and the tasks carried need to relate to the goals and outcomes Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 24 set out in the residents’ care plans. Staff are writing in the communication book but are not signing their entry. This is Requirement 6. The home has carried out all health and safety checks. Fire drills and alarm testing are undertaken regularly. Water, freezer and fridge temperatures are also recorded regularly. All staff have undertaken manual handling training, which is updated on a regular basis. Residents’ files that were examined showed that all risk assessments are being reviewed on a regular basis or when a change in need is identified. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 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. 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 2 3 Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17 (1)(a) Requirement Daily report sheets need to be more informative and relate to specific goals and outcomes in residents’ care plans. The registered persons need to ensure that an advocacy service is offered to residents who do not have a relative/representative to represent their views. The manager must ensure that a CRB check is undertaken prior to employment and that POVA First guidelines are followed. The manager must ensure that all staff can understand and speak English at a level that does not put residents at risk. The manager must ensure that all staff receive formal and regular supervision as well as yearly appraisals. Previous timescale of 31/01/06 has not been met Daily report sheets need to be completed by the person carrying out the task. Staff must sign their entry in the communication book. DS0000062553.V291981.R01.S.doc Timescale for action 31/07/06 2. OP17 12(2) 30/05/06 3. OP29 19(1)(b) 31/05/06 4. OP30 18(1)(a) 30/06/06 5. OP36 18(2) 31/07/06 6. OP37 17(1)(a) 30/06/06 Churchfields Nursing Home Version 5.1 Page 27 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. 2 Refer to Standard OP37 OP35 Good Practice Recommendations Residents’ files need to be organised in a way that it is easy to obtain information more readily Another senior carer or the manager countersigns the monthly auditing of residents’ finances. Churchfields Nursing Home DS0000062553.V291981.R01.S.doc Version 5.1 Page 28 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.V291981.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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