Inspection on 01/09/06 for Churchill House

This inspection was carried out on 1st September 2006.

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 no outstanding requirements from the previous inspection report, but made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Churchill House 02/12/05

Churchill House 26/10/05

Churchill House 18/08/04

Churchill House 27/04/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Churchill House 48-50 Mawney Road Romford Essex RM7 7HT Lead Inspector Ms Rhona Crosse Key Unannounced Inspection 1st September 2006 09:40 Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Churchill House Address 48-50 Mawney Road Romford Essex RM7 7HT 01708 732558 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) Kulwant Singh Mann Mr Ramjit Nunkoo Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include 4 named people over 65 years of age Date of last inspection 2nd December 2005 Brief Description of the Service: Churchill House is a care home providing personal care and accommodation for twelve service users. This includes younger adults and 4 service users over 65 years of age, all of whom have a mental illness. The home provides a service to both men and women. The home has no passenger lift therefore the home cannot accommodate anyone with physical disabilities. The home opened in 1996 and is located in a residential area of Romford near to Romford High Street. There is car parking to the front of the building. Churchill House consists of a three-storey building that is divided into two units and annexed via an activity room. There is a large garden with a shared patio area and swimming pool. All bedrooms are single occupancy, one of which in each unit is sited on the ground floor with the rest on the second and third floors. Some bedrooms have a shower cubicle fitted in them. There is a lounge in each unit on the ground floor in which service users relax, smoke and watch television or engage in activities of their choice. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that means that the home did not know the inspector was coming. The manager was at the home when the inspector arrived at 9.40. The inspector looked at documentation relating to the care of service users, spoke with service users and staff as well as the manager. An inspection of all of the rooms in the home was undertaken with the exception of 2 bedrooms in both 48 and 50, as service users were out for the day. The fees for the home range from £750.00 to £980.00 per week (this depends on the individual needs assessment of the service user). The home has a large garden and swimming pool this was used in good weather. A new recreation room is planned and is to be built in the grounds. What the service does well: What has improved since the last inspection? Since the last inspection when the CPA (care programme approach) reviews have been held the information is now being updated as necessary onto the care plan drawn up by the home. The decoration of the outside woodwork and drainpipes has taken place and a decorator has visited and viewed number 50 to see what work requires to be undertaken there. However neither the manager or the proprietor’s daughter were aware if any estimates had been provided or what work was detailed to take place. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 6 A new Television had been purchased for number 48. The manager stated that in number 50 the service users wanted a new flat screen TV. What they could do better: The Statement of Purpose and the Service Users Guide need to be updated to ensure that all information provided to any new service users is current. The Statement of Purpose has the wrong street number for the address of the Commission the correct number is 113 Cranbrook Road (not as identified in the current document 109 – 133). In the Service Users Guide some of the activities in ‘Life at Churchill House’ are incorrect. Reflexology is only undertaken if the service user wishes this and pays for this themselves; therefore it is not an activity that the home provides. Also ‘tea dancing’ does not take place. These activities should be removed from the Service Users Guide as this is a misrepresentation of what is provided by the home. On admission to the home the daily record of a new service user did not identify the needs of the service users or the current medication that the person was admitted to the home with. This should form part of the recording on admission. The home must ensure that when any future service uses is admitted that the person’s needs likes and dislikes and medication are recorded in the daily record on admittance. Care plans and risk assessments were provided by the home the service users was previously living at. Health care records were inspected it was observed that a follow up to a dental appointment had not been recorded and no information was held to evidence if any further treatment was necessary. There are areas of the environment that require decorating and refurbishment. This is discussed in the body of the report. The training details provided by the home to the inspector identifies the training that has taken place. However there is statutory training that does not appear to have been provided and other training that staff must undertake to meet the needs of the service users. Only 2 staff are identified as having training in mental health. As this home cares for people solely with mental illness all staff must be provided with this training. Not all of the staff have attended training in the protection of vulnerable adults. Not all staff have had training in basic first aid. Not all staff have attended training in infection control. No staff appear to have had any training in fire prevention, health and Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 7 safety or COSHH (control of substances hazardous to health. These are statutory training courses that all staff must undertake. Due to the needs of the service users staff should also have training in dealing with challenging behaviour. 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. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 The quality in this outcome area is good therefore there are more strengths than weaknesses. These standards showed that appropriate assessments were made prior to admission ensuring the home could meet the needs of prospective service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and the Service Users Guide need to be updated to ensure that all information provided to any new service users is current. The Statement of Purpose has the wrong street number for the address of the Commission is 113 Cranbrook Road (not as identified in the current document 109 – 133). In the Service Users Guide some of the activities in ‘Life at Churchill House’ are incorrect. Reflexology is only undertaken if the service user wishes this and pays for this themselves. Therefore it is not an activity that the home provides. Also ‘tea dancing’ does not take place. These activities should be removed from the Service Users Guide as this is a misrepresentation of what is provided by the home. On admission to the home the daily record of a new service user did not identify the needs of the service user or the current medication that the person was admitted to the home with. This should form part of the recording on Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 10 admission. The home must ensure that when any future service user is admitted that the person’s needs, likes and dislikes and the medication they bring with them is recorded in the daily record on admittance. However care plans and risk assessments were provided by the home he was previously living at. New care plans were in the process of being drawn up, some areas still had to be addressed, however these assessment are completed over a period of time as service users needs may not always be apparent on admission. An assessment had been carried out by the home prior to admission and the placing authorities assessment was also held on file. On the day of inspection a relative of a service user was visiting the home with a view to admission when a vacancy becomes available. Service uses are able to ‘test drive’ the home if they wish prior to being admitted. The admissions process would be designed around each individuals needs. Contracts were observed to be held on the files of service users. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The quality in this outcome area is good therefore there are more strengths than weaknesses. The majority of documentation held had been reviewed and updated as required. Greater care needs to be taken to ensure that all risk assessments are updated and that any update is recorded and dated to ensure that appropriate care is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care management assessments are taking place and there was evidence that records were updated after these assessments were completed. Each service user has an identified ‘key worker’ who pays particular attention to the needs of that allocated service user and will provide support at Care Programme assessment reviews. CPA reviews took place on the 25/4/06, 6/6/06 and a CPA review is diarised to take place on 10/10/06 for another service user. Service users are supported to take reasonable risks. Risk assessments are completed where there is a need for these. However it was observed that risk assessments were not always being updated. If there is no change to the risk Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 12 assessment then ‘No change’ and the date of this should be recorded to enable the home to evidence that they are monitoring the care of the service users appropriately. For one service user who’s cigarettes are being restricted throughout the day, an ‘infringement of rights’ form should be completed. The form should record the action the home is taking to ensure that all staff deal with this in the same way. This infringement of rights should be reviewed at regular intervals. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality in this outcome area is good therefore there are more strengths than weaknesses. The home encourages service users to be as independent as their abilities allow without any pressure being placed upon them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are encouraged to help around the home to improve and maintain their daily living skills. A roster of chores is drawn up to identify who does the chores at particular times. The majority of service users assist with some tasks during the week. In conversation with service users they stated that they helped out with the daily chores. Some felt they should not have to do anything, whilst others were very proud of the fact that they were keeping the home and their own rooms clean and tidy. Three of the service users attend supported work projects each week, another service user is attending a local college for computer skills. A further service user is attending Havering college to take advanced maths. In discussion with Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 14 one service users he stated: ‘ I go to work and do the cooking, I cook for the other service user’s who work at the project. I cooked sausage rolls and Swiss roll and Irish stew today’. Another service users is awaiting a placement at the local college. ‘In house’ activities take place and an art class is held at the home on a weekly basis. At the time of the inspection as the art teacher comes from a local college the class was not taking place due to the summer holidays. Some of the service user who participate in the art class showed the inspector the things that they had made and drawn, one service user in particular has a real flair for drawing. Other ‘in house’ activities range from board games to badminton, table tennis and swimming in the homes own pool. Trips out to various places of interest are undertaken. A summer holiday took place on July when the service users all went to Bognor Regis to Butlins. A service user who attends a local club went on an outing to Brighton which was arranged by the club. Shopping trips take place both locally and further a field. In discussion with one service user she stated how she liked to go shopping and takes a pride in her appearance. At the time of the inspection one service uses was out taking his daily walk. Other service users go out independently and follow their own interests. Service users use the facilities in the local community for GP and other health professionals visits. Local libraries, cinemas, pubs and cafes are used. Family links are encouraged and one service user goes to visit relatives every weekend. No restrictions are placed on visiting times and relatives are able visit at any time. No relatives were visiting at the time of the inspection. Service users are able to follow their own religion if they choose. One service user goes out to the local Methodist church independently from time to time. Service users stated that they meet to discuss the menu for the coming week this usually takes place on a Sunday when a shopping list of meal choices will be drawn up. In conversation with one service user he stated: ‘Some of them always pick the same things to eat each week when they choose the meal for their day.’ ‘They are not very adventurous like me I like lots of different meals’. In discussion with staff it was stated that they try to steer service users into having a balance diet. Fresh fruit was seen to be available at the time of the inspection. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The quality in this outcome area is good therefore there are more strengths than weaknesses. Greater care needs to be taken when follow ups are required to be undertaken with health professionals to ensure the continued health and well being of all service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are asked at the time of assessment what support they need. If someone chose to have same gender care then this can be provided as there is a mix of gender within the staff group. In the main health care needs had improved with information about GP and specialist visits being well recorded. However one record of a dentist appointment where staff were asked a second time to make contact with the dentist, this was not recorded as taking place. No entry could be seen in any documentation when cross referencing records for the dates when this should have taken place. The home must make contact with the dentist to find out what the outcome was and whether any further treatment is required. Part of the inspection process was to observe the ‘handover’ from one staff team to the next staff team coming on duty. Information relating to all service users was passed onto the next staff team, including one service users who’s Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 16 health was being monitored. The next staff team stated the action they would take in relation to the person’s health. The team then discussed which tasks they would undertake for that shift. The home has policies and procedures for the administration and safekeeping of medicines. Staff have received training in medication administration. Medication held by the home was appropriately stored and all medication held corresponded with the medication that had come into the home and had been administered. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome area is good therefore there are more strengths than weaknesses. The homes policies and procedures detail the action and protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a policy and procedure for dealing with any complaints. The complaints record was inspected and no complaints had been received since January 2006. The service users are not currently using any advocacy services. When spoken about with the manager he stated that there are no services in the area. The manager should make contact with ‘Mind’ who may be able to advise him of any service operating locally. The majority of service users visit either work placements or other services outside of the home. Therefore they would be able to raise any concerns about the home, with people who are not connected with the running of the home if they were unhappy about the service provided. The home has policies and procedure for the protection of service users from abuse. Some of the staff employed have received training in the protection of vulnerable adults. However some staff have now left the home’s employment and new staff have been employed. From an inspection of the training record there appears to be at least 8 staff employed that are not identified as having taken this training. All staff currently employed who have not attended POVA training must be put forward to take this training. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 18 Money held in safekeeping for service users was inspected. All records corresponded with money spent and receipts held. It is recommended that the home number the receipts, this make it easier to check these when monitoring the finances held. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30. Standard 29 does not apply to this home. The quality in this outcome area is adequate therefore there are some strengths but areas of particular weakness that must be addressed. A well maintained home enhances the life of service users. House number 50 requires extensive redecoration to bring it up to the same standard as house number 48. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The outside of both sides of both 48 and 50 Churchill House have had the windows, woodwork and drainpipes painted recently. An inspection of the home was made. 2 bedrooms in number 48 could not be inspected as the service users were out for the day. The majority of the building (48) is in good decorative order. One bedroom has a water leak in the corner of the ceiling of one bedroom and the wardrobe in this room also needs replacing/repairing as it is broken. These problems were pointed out to the manager who was accompanying the inspector. Two bedrooms in number 50 could not be inspected as the service users were out for the day. House number 50 requires decorating throughout. The lounge walls and woodwork require decorating as does the hallway and the dining Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 20 room walls and woodwork. The flooring requires replacing in the dining room. The kitchen also requires decorating and needs the floor covering replacing as the tiles are cracked in places. The banister of the staircase is loose and wobbles when lent on this needs to be secured. The home was free from odours throughout. The laundry room was clean and service users bring their own laundry to the laundry room. Machines were observed to be in working order. Service users are able to lock their bedroom doors and some choose to do this, whilst others are happy to leave their doors closed, but unlocked. Service users bedrooms seen by the inspector evidenced that they can make their bedrooms more homely buy bringing personal possessions with them. The home is not designed or suitable for people with a physical disability, therefore there are no aids and adaptations provided. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 The quality in this outcome area is adequate therefore there are some strengths but areas of particular weakness that must be addressed. Staff have attended a range of training sessions which enhances the way they are able to care for service users, however there is training that is lacking and this must be addressed. Recruitment and selection records inspected showed that appropriate checks are undertaken to protect vulnerable service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All staff have attended training in the recording and administration of medicines. The home is aware that they must have 50 of the staff team employed are qualified to NVQ level 2. Only 4 staff hold this qualification (this includes one staff member who holds NVQ level 3 qualification). The home must ensure that staff are put forward to take this qualification. There is a staff training record however several names do not appear on the training records provided to the inspector as having undertaken statutory training. All staff must attend training appropriate for the role they undertake. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 22 All staff must undertake basic first aid training. 2 staff failed to achieve this training last year when they took this course. It does not appear to have been achieved or rebooked since May 2005 for these two staff members. The manager must ensure that all staff attend this training including any new staff employed. Other training that should be undertaken is understanding mental health, only 2 staff are identified as having undertaken this training. As this home cares for people with mental illness the home must provide this training for all staff. None of the staff team have attended training in dealing with challenging behaviour. Due to the particular needs of some of the service users this training should be provided to all staff. All staff must attend training in fire prevention, infection control, control of substances hazardous to health (COSHH) and health & safety. Records held evidenced that staff are being provided with formal written supervision. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 The quality in this outcome area is adequate therefore there are some strengths but there are areas of particular weaknesses that must be addressed. All health & safety documentation was in order ensuring as far as possible the safety of the home and that of the service users. Report writing was poor in some cases with the wrong language being used. This needs to be addressed as a matter of urgency. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has monthly service users meetings and minutes are kept of these. At times service users take the minutes and chair their own meeting. At other times it is staff that chair and minute the meetings. It would be more appropriate if an advocacy service was used to undertake these meetings. The registered person should consider this. This would be seen as good practice. Although the Service Users Guide holds comments made by service users, about what their experiences are living at Churchill House. An appropriate quality assurance system must be in place. A quality assurance questionnaire Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 24 must be given to service users sent to relatives and health professionals who deal with the care of the service users to gain their views on the operation of the home. When the questionnaires are returned an analysis of the comments must be made and this analysis must form part of the Service Users Guide. This must be updated annually. In a service user’s daily record it was stated that the person had become ‘mentally unstable’ referring to his actions whilst in the activities room. The staff should not make assumptions of service user’s mental health in this way, to described what the service user was doing. The comments should give a clear descriptive account of the actions. This entry was poorly written and suggests that the writer is not aware of the use of appropriate language. A further example of the poor use of language used in documentation was in an accident/incident record where a staff member had recorded that a service user had had and episode of violent behaviour – when in fact it had been verbally abuse behaviour. The registered person must monitor the contents of all records to ensure that staff make appropriate comments. It may be necessary for some staff to attend report writing training sessions to ensure the appropriate use of language is understood. All health and safety documentation was found to be in order when inspected. Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 N/A 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 X 2 X 2 3 X Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 26 No 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 2 3 Standard YA1 YA1 YA6 Regulation 4 5 15 (1) 7 (2) & 13(4)(c) Requirement Statement of Purpose must be updated to hold the current information. Service Users Guide must be updated to hold current information. When reviewing risk assessments the home must record ‘no change’ and date this if no change has taken place to evidence that they are monitoring the risk assessments. An ‘infringement of rights’ form must be written up for the service user who’s cigarettes are restricted throughout the day Ensure that all health care needs are followed up (dentist) and a record is made of the outcome. All staff must be provided with POVA training who have not yet undertaken this course. Decorate the ceiling in house 48 that has the water stain in the ceiling. Replace/repair the broken wardrobe. Decorate the lounge, dining room kitchen, hallways and DS0000027836.V310680.R01.S.doc Timescale for action 30/11/06 30/11/06 30/11/06 4 YA7 15(1)&(2) 30/11/06 5 YA19 12 (1) (a) 30/11/06 6 7 8 9 YA23 13(6) 23(2)(d) 16(2)(c) 23(2)(d 30/12/06 30/12/06 30/12/06 30/01/07 YA24 YA24 YA24 Churchill House Version 5.2 Page 27 10 11 12 13 14 15 16 17 18 19 YA24 YA32 YA35 YA35 YA35 YA35 YA35 YA35 YA35 YA39 23(2)(d) 18(1)(c) (i) 18(1)(c) (i) 18(1)(c) (i) 18(1)(c) (i) 23(4)(d) 18(1)(c) (i) 18(1)(c) (i) 18(1)(c) (i) 24 20 YA41 18(1)(c) (i) bedrooms of no 50 both walls and woodwork Replace the flooring in the dining room and kitchen of number 48. 50 0f the staff team must hold NVQ level 2 qualifications. All staff must attend mental health training. All staff must have basic first aid training who have not attended this course. All staff should attend training in dealing with challenging behaviour. All staff must attend training in fire prevention. All staff must attend training in infection control who have not attended this course. All staff must attend in Health & Safety & COSHH training. All staff must attend basic food hygiene training that have not attended this course. A quality assurance questionnaire must be sent to given to service users and sent to relatives and health professionals. An analysis of the comments returned must be made and this must form part of the Service Users Guide. This must be reviewed annually. Specific staff require training in report writing due to the inappropriate use of language in records, which was observed to be incorrectly used. 30/01/07 30/09/07 30/12/06 30/12/06 30/01/07 30/12/06 30/12/06 30/12/06 30/12/06 30/01/07 30/12/06 Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations On care plans or risk assessments as necessary, it is recommended to state ‘refer to medication administration sheet’ to avoid errors in medication recorded not being updated when medication is reviewed. It is good practice to number the receipts of expenditure for ease of checking. 2 YA23 Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 29 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 Churchill House DS0000027836.V310680.R01.S.doc Version 5.2 Page 30 - 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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