Inspection on 23/01/07 for Churchill House

This inspection was carried out on 23rd January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Churchill House 29/01/09

Churchill House 06/01/06

Churchill House 26/09/05

Churchill House 14/10/04

Churchill House 17/06/04

Churchill House 14/01/04

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Churchill House 745 Holderness High Road Hull East Yorkshire HU8 9AR Lead Inspector Malcolm Stannard Unannounced Inspection 23rd January 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Churchill House DS0000000840.V329548.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 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. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Churchill House Address 745 Holderness High Road Hull East Yorkshire HU8 9AR 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) 01482 709230 F/P 01482 709230 Wealdplace Limited Mrs Anne Melbourne Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2006 Brief Description of the Service: Churchill House is positioned on the eastern outskirts of the city of Hull. It is situated on a main road, which enables easy access to public transport, shops and health facilities. The home is registered to provide care and accommodation for up to 25 older people who may also have dementia. All bedrooms in the home are on the first or ground floor and all provide single accommodation with the exception of one shared room. Car parking and an external seating area for residents are situated to the rear of the property. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visits to the home were carried out on an unannounced basis. Two visits were made, as the manager was not available during the first. A tour of some of the premises was undertaken, residents were spoken with, some of the records were looked at and conversations were held with the manager and some staff. All of the accumulated evidence has been used to say how the home is doing. What the service does well: What has improved since the last inspection? What they could do better: Whilst a development plan is now in place, it would be beneficial for this to be enhanced using information from quality assurance processes. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 6 All appropriate incidents must be notified to the Commission for Social Care Inspection promptly. The complaints record needs to be enhanced to ensure the satisfaction of complainants can be proved. The person making an entry in a plan of care needs to make sure they sign the record so that it can be identified who carried this out. Activities were seen to be taking place in the home, however, practice would be improved by all activities which have taken place being recorded in one place enabling a history of those undertaken to be available. It would be beneficial for more staff to be trained to be able to administer medication; this would ease the requirements of management to be present. Health information available could be condensed into one record allowing all information to be readily available. The manager of the home should divide her time more appropriately between administration tasks and the care of residents. This would enable tasks such as the updating of risk assessments etc. to be carried out. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 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 Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Where assessments of need from the local authority are not available the homes management carry out their own. Information is available for prospective residents and their relatives to make an informed choice. EVIDENCE: A statement of purpose and a service user guide are both available for prospective residents or their advocates. Both of these meet with the requirements of the standard containing appropriate information. A statement of terms and conditions is available for all residents, which clarifies the terms of residency. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 9 Although the management team at the home said that they normally carry out their own assessment of a prospective resident, there was evidence that this was not always the case. On occasions the assessment of the Local Authority was used to clarify whether needs could be met or not. Whilst this is acceptable if the person is funded by the Local Authority and a community care assessment is available, the management must carry out their own assessment for privately funded residents. Assessments of need had been carried out by the home and recorded on the residents files looked at during the visit. The home does not offer intermediate care. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The medication system in use in the home offers protection for residents. Plans of care are available to inform staff of residents needs. EVIDENCE: Plans of care for individual residents were seen on the files viewed. These consisted of sheets covering areas such as mobility, dressing, motivation, eyesight, hearing, nutrition, memory and communication. Evidence was available that these plans are reviewed on a monthly basis and updated where necessary. Whilst all health care information was available on these records it was split between the differing headings. It would be beneficial, and is recommended, that all health information be held collectively on a dedicated health record sheet. Recording of all medical visits etc. were also recorded on the daily report file for each resident. The manager explained that when a resident enters the home and their GP is out of the area, a list of Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 11 local GP’s is given to them to enable them to make a choice. Some literature is available for staff to increase their knowledge of some health conditions. Records of residents weight were available to see in their individual records, however, in some cases these had not been updated since 2005. The manager explained that some of the residents were not able to use common floor scales and they were waiting for an external agency to visit the home with more appropriate equipment. Although it was apparent that the plans of care had being updated, there was not always a date when this had been done nor a signature of the person carrying out the review. A monitored dosage blister pack system is in use at the home, which is supplied on a monthly basis by a local pharmacy. A pharmacist visits to audit the systems approximately every six months. The storage and recording of the medication was found to be satisfactory when checked. A returns book was available which receipts all medication disposed of to the pharmacy. There were no controlled drugs held in the home at the time of the visit, a separate storage facility is available for these if required. At the present time only the manager and her assistant administer medication. This could be impractical should one of them not be on duty, resulting in them having to return to the home to carry out the giving of medication and could be problematic in times of illness. The manager explained that two further staff are shortly to attend training in medication administration allowing the duties to be shared. The course to be attended is the approved medication training for adult services staff, operated by Hull City Council. It will be beneficial to the residents to have more staff available who are capable of administering medication. One gentleman spoken with said that the staff treat him with respect and involved him in conversations even though he preferred to spend time alone in his room. He also stated, “They leave me to be on my own when they know I need some time to myself” and said that staff would knock on his door prior to entering. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Choice is available for residents. Relatives are able to maintain contact with relatives and friends. Food provision is of a high quality. EVIDENCE: Whilst general daily activities are held in the home, the method of recording these can make it difficult to evidence what has taken place. During the visit an external visitor to the home was giving a slide show. The subject was life in Hull in the past and this generated a good amount of discussion amongst the residents present. Residents said that they are able to take part in quizzes, motivational activities and on occasions visiting entertainers. One lady spoken with said that she had just returned from a visit to the local shops where she had been able to buy herself a magazine and some sweets. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 13 Whilst residents are encouraged to join in with activities taking place they are able to make a choice and one resident said that she preferred to stay in her room during the day where she listened to the radio and completed crossword puzzles. A record of activities undertaken is held on an individual basis, however, it was apparent that these were not always kept up to date. Some of the files looked at had no record of activities having taken part since 2005 and October 2006. It is recommended that a central record be held of all activities undertaken within the home to enable evidence of stimulation etc. having taken place. Visitors to the home are encouraged and welcomed at all reasonable times. The residents can meet with their relatives and friends in private if they wish or can use one of the communal areas. One resident spoken with said that his friends visit him at the home once every week and are able to see him in his room. Some residents have the availability of a telephone in their own room. Food provision at the home remains at a good standard and the provision was recently awarded 85 out of 100 in a “scores on the doors” initiative run by the Local Authority’s Environmental Health Department. A resident spoken with said that there is always an alternative offered to the main meal, which can be chosen if desired. Menus, which detail meals planned, are available to view. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure is available which is made known to residents and relatives. Some amendment is needed to the holding of information relating to complaints. Knowledge of safeguarding adults procedures is available and an internal procedure is also available. EVIDENCE: The home has a written complaints procedure which is displayed within the home. This procedure states that any concerns raised will be responded to within seven days. A form is available for residents/relatives use should this be required. The manager stated that she would deal with any niggles made known straight away. Although the manager said that there had been no recent complaints made to the homes management, there was information available regarding previous complaints. It was observed that complaints and niggles were not all recorded in one specific record and those recordings which were available did not fully indicate the outcome of any investigation or the action taken. The record also needs to demonstrate that the complainant was happy with the outcome of any investigation. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 15 One complaint relating to the home has been made to the Commission for Social Care Inspection and this is in the process of being addressed. Appropriate policies and procedures are available in relation to the protection of vulnerable adults and the local adult protection procedures are also available. The manager and deputy who have attended relevant training give staff members guidance on these matters internally via supervision. The manager stated that four staff members have been identified to attend formal training in the near future. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bedroom provision is good with appropriate furnishings and personal possessions are apparent. The home is well maintained with a budget available to carry out any remedial work. Appropriate communal areas are available for residents use. EVIDENCE: The home continues to be well maintained and a budget is available for ongoing repairs etc. Ventilation and heating in the communal areas and those individual rooms seen during the visit was satisfactory with the exception of one small area of Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 17 the corridor where the radiator was found to be giving out little heat and a small cold spot was experienced. The deputy manager said she would ensure this radiator was checked. Seven toilets and three bathrooms are available for residents use; one of the bathrooms is equipped with a hoist. There is no mobile hoist available in the home. The home offers accommodation in 23 single rooms and 1 shared room. Furnishings available in the rooms have been discussed with the resident and an agreed position has been recorded as to the number and type of furnishings provided. Residents are able to personalise their rooms with their own possessions and furniture if appropriate. A lockable storage provision is available in each resident’s room. Signed slips are available on resident’s records which indicate that the furnishings and access to a key for individual rooms have been discussed. Room risk assessments are also carried out. A shaft lift is available in the home and the deputy manager explained there had been some temperamental problems with this recently, however, these were being addressed with the maintenance company. There are two lounges and a dining room available for communal use. On the day of visit the home was clean and hygienic with no malodours apparent. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures remain robust. Appropriate training programmes for staff members are now in place. EVIDENCE: There are fifteen care staff presently employed at the home. Seven of these hold an NVQ level 2 qualification and one an NVQ level 3. 53 of care staff therefore hold a relevant qualification meeting the standard that recommends 50 of the staff group to be qualified. The manager explained that funds were presently being identified to enable further staff to access training and qualification. Each staff member has an individual training plan and log, an induction plan is now available for staff to follow and mandatory areas of training are also identified. These include first aid, moving and handling, bereavement awareness, use of incontinence products and introduction to diabetes care. On the staff files seen, training in the areas of mental health capacity, Parkinson’s disease and first aid was planned for staff members to undertake. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 19 Evidence was available that formal supervision of staff is undertaken by the management team. The manager explained that each staff member is planned to receive supervision on six occasions per year. All new staff at the home are employed using the home’s recruitment procedures; this includes the taking of references, checks on qualifications and a criminal records bureau check. Completed criminal records checks were observed on staff files that were looked at; advice was given regarding recording the check number and shredding these, unless the form was the staff members original in which case it should be returned to them. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified and experienced. Internal and external quality assurance monitoring tools are in place. Residents state they are happy with the way the home is run. EVIDENCE: The registered manager is experienced in working with the older people client group; having many years of experience. She has managed the home for a number of years. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 21 The manager holds an NVQ level 4 in care and the registered managers award. She is also an NVQ assessor. The deputy manager of the home has also undertaken the registered managers award and is presently waiting for this to be accredited. Good interaction was observed between the management team and the staff group during the site visit. A business development plan is available for the home, which is in the early stages of development. The plan would benefit from being expanded to include an overview of information collected from the monthly regulation 26 visits and other quality assurance practices. The home holds the Local Authority QDS monitoring scheme and the proprietor also hands out an annual questionnaire to relatives and residents. Visits are undertaken by the registered provider on a monthly basis to compile a regulation 26 report, which a copy of is forwarded to the Commission for Social Care Inspection. No one at the home acts as an appointee for residents, families or solicitors are encouraged to deal with financial affairs. The manager explained that she tends to spend a good proportion of her work in the main body of the home, interacting with residents etc. She said that this could make it difficult on occasions to devote enough time to the administration duties required. It is recommended that the manager puts aside one or two days per week primarily for administration duties and makes these days known to the staff group so that expectations of her being available to assist in day to day issues in the home are lessened. Gas, electrical and fire detection and prevention equipment is serviced under annual contracts. Certificates seen demonstrated that all equipment had been checked as required. A fire risk assessment is also available. Some of the generic risk assessments seen require updating. It was evident from conversation that at least one event affecting the safety and well being of services users had occurred recently in the home. This event had not been notified to the Commission for Social Care Inspection as required by Regulation 37, it must be ensured that all notifications are made as required. Residents spoken with during the visit stated that they felt their needs where met and that they were able to make choices in relation to their daily routines and the general manner in which events occurred in the home. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 22 Records are held in relation to each individual resident with information being contained in three separate files. Evidence was available on the files seen that residents had been made aware they could see the information held at any time and a signed slip was available to evidence this. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP38 Regulation 37 Requirement The registered provider must ensure that all appropriate incidents are notified to the Commission for Social Care Inspection. The recording of any complaints made needs to include full details of outcomes and satisfaction. All updates of individual plans of care must be dated and signed by the person making the entry. Timescale for action 07/03/07 2. OP16 22 28/02/07 3. OP7 15 28/07/07 Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 25 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. 3. 4. 5. 6. Refer to Standard OP12 OP9 OP7 OP29 OP32 OP38 Good Practice Recommendations It is recommended that a central log is held of all activities undertaken. It is recommended that further staff are suitably trained to undertake the administration of medication. It is recommended that all health information is held collectively in a health record for each individual resident. Evidence of staff CRB checks should be held appropriately. It is recommended that the manager allocate appropriate periods for the completion of administration duties. It is recommended that all generic risk assessments are audited to ensure they remain up to date. Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Churchill House DS0000000840.V329548.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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