Inspection on 26/09/05 for Churchill House

This inspection was carried out on 26th September 2005.

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

The inspector 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 23/01/07

Churchill House 06/01/06

Churchill House 14/10/04

Churchill House 17/06/04

Churchill House 14/01/04

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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 26th September 2005 01.00p 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.V253370.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 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 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.V253370.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th October 2004 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 sitting area for residents is situated to the rear of the property. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. Some parts of the building were looked around and a few of the records were inspected. A number of residents were spoken with along with visitors to the home. Chats were held with staff members as they worked. The manager was available during the inspection. What the service does well: What has improved since the last inspection? The home now has it’s own Performa available to enable assessments to be carried out on prospective residents who are privately funded; this will inform the completion of a care plan. Advice has been taken from the fire officer in relation to risk assessments and fire precautions. The decoration of areas, which required freshening up, has continued. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 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. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 5. The admission procedure ensures that a proper assessment is carried out prior to people moving into the service. This process means that a resident and their representatives can be sure the home will meet their needs. 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. Assessments of prospective residents are carried out and information is also obtained from community care assessment for local authority funded residents. A new care assessment sheet is now available for privately funded residents, which would be completed following a visit by the homes manager. All residents have care plans, which are developed from the assessments now undertaken. Residents and relatives are able to visit the home prior to any admission and a trial stay can be arranged. The home does not take emergency admissions or offer intermediate care. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 9 Two relatives who were visiting during the inspection confirmed that they were able to make visits to the home prior to their relative been admitted. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Health care needs of residents are identified and met. Residents are able to live in the home experiencing respect and privacy. EVIDENCE: All residents have care plans, which contain information on the basic care needs. The care plans are reviewed by key workers on a monthly basis with any changing needs recorded. All residents are registered with a GP and evidence on resident’s files was available which demonstrated a proactive approach to dentist and opticians appointments. Community nurses are accessed should any resident have a nursing need. Medication is provided by a local chemist who also instructs relevant staff members on storage recording and administration. Policies and procedures are held in relation to medication. Staff members observed during the visit were seen to deal with residents in a dignified manner, respecting their privacy at all times. Any preferred form of address for a resident is recorded on their individual file. A visitor stated that “the staff speak to residents with dignity and my mum is given privacy when she wants it.” Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 11 Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. A range of recreational activities is provided in the home and resident’s preferences are accommodated. Daily choice for residents is enabled and contact with friends, family and within the local community is encouraged where appropriate. Residents have choice, diversity and experience good quality in the meals provided. EVIDENCE: Daily routines enable residents to make choice, allowing their individual needs to be met along with those of the group. Activities are undertaken, including spelling quizzes, games with balls, slide shows by visiting presenters and artists to entertain. Trips out are also undertaken and a meal was taken recently at a local public house with the aid of transport provided by age concern. Two residents spoken with explained that they complete the crossword in a national paper on a daily basis. One resident spoken with said, “The entertainment is very good”. Visitors are made welcome to the home and some were present during the inspection. They confirmed that they were given information about the home and were able to visit their relative whenever they wished. Residents meetings are held and choice is able to be exercised on a daily basis. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 13 Evidence was available on individual files that they have been accessed by residents or their advocates. Residents spoken with confirmed that they are able to choose when to go to bed and when they wish to get up. Food provision at the home is wholesome and nutritious; residents confirmed that they are able to exercise choice over what they eat. Assistance is given to those who require it in a sensitive manner. One resident stated,” The food is always good.” Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18. The home has a complaints procedure, which meets the needs of residents, and relatives who feel their views are listened to. A vulnerable adults procedure and policy is available and staff are formally supervised and trained in order to protect residents from abuse. EVIDENCE: The home has a displayed complaints procedure, which indicates that complaints will be responded to within seven days. There has only been one recorded complaint since the last inspection and the outcome of this is recorded appropriately. There is one outstanding complaint, which was made to the Commission for Social Care Inspection; the homes proprietor is presently investigated this. Some niggles have been raised; mainly in relation to the laundry provision and these have been dealt with at the time the issue has risen. All service users are on the electoral role and would be assisted to partake in the civic process if they so wished. Appropriate policies and procedures are available in relation to the protection of vulnerable adults and the local adult protection procedures are also available. Staff members are given guidance on these matters internally via supervision by the manager and deputy who have attended training. All staff are checked via the Criminal Records Bureau including a POVA 1st check. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 15 A visitor spoken with said she would know who to contact if she had any concerns about the care in the home. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,& 26. The home provides a safe, comfortable and clean environment for residents, which is pleasant and homely. Rooms available meet the needs of individual residents. EVIDENCE: The home continues to be suitable for it’s stated purpose and provides a safe and well maintained environment. A routine maintenance programme continues to be undertaken and required maintenance is recorded in written form. The manager stated that a budget had now been identified for property maintenance as part of the forthcoming business development plan. The manager has completed fire risk assessments and has taken advice from the fire officer regarding the safety of the building; advice was given by him regarding ventilation via the sluice windows. There is no use of CCTV cameras in the home. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 17 The home has two lounges and a dining room available for communal use, access to the outdoor area is via ramps making it accessible to all residents. Furnishings and lighting in the communal areas are suitable for residents needs. 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. An assessment of the home has been carried out in regard to the home been physical able to meet residents needs and some of the recommendations in that report have been carried out. 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 processions and furniture if appropriate. A lockable storage provision is available in each resident’s room. Ventilation and heating is satisfactory in the communal areas of the home and in those residents’ rooms seen during the visit. All small electrical equipment has been tested and fire prevention and detection equipment is serviced by a main contractor. The home was clean and hygienic with no malodours detected Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Procedures for the recruitment of staff are satisfactory and offer protection for the residents in the home. Staff training needs to be addressed so as to ensure staff member’s competence can be assured. EVIDENCE: The staff group at the home is a reasonably consistent one, enabling staff’s own development to occur and resident’s needs to be known across the team. All staff undergoes the homes recruitment process, which includes the taking of references, checks on qualifications and a criminal records bureau check. Whilst staff training is recognised as an important part of the homes development, there has been little movement in the availability of an induction package and NVQ qualification levels of staff have remained at the same level recorded at the last inspection. Of the 16 care staff employed at the home only four hold a relevant NVQ qualification, 3 at level two and 1 at level three. The standards require at least 50 of staff to be qualified to this level, presently this figure for the home remains at 25 . The manager explained that a meeting is planned to be held with the Independent Care Group training association, when it is hoped that funding will be accessed to enable more staff to undertake training. It is imperative that induction and NVQ training is provided as soon as practical for all care staff. General training in areas such as infection control and moving and handling does take place. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 19 Staff supervision is undertaken on six occasions a year, records are held of these sessions. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 38. The management of the home is carried out with leadership and appropriate guidance; ensuring residents receive a quality of care, which is consistent. A resident centred ethos is promoted within the home. The completion of a management qualification will enhance the leadership style. Health and safety provision within the home is addressed positively. EVIDENCE: The registered manager has many years experience working with the client group and has managed Churchill House for over 10 years. She is, along with the deputy manager qualified to NVQ level 4 in care and is an NVQ assessor. The manager is presently undertaking the registered managers award, which will enable her to hold the required management qualification. Staff and residents meetings are held which enable all to give opinions on how the service should be run. Residents and visitors seemed at ease with the Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 21 manager and a good example was seen of communication with regard to a residents needs taking place. The home holds the local authority QDS monitoring scheme which was reviewed in August 2005, the proprietor also hands out an annual questionnaire to relatives and residents. An annual business development plan is in the process of been developed, this has been outstanding for some time and a copy should be forwarded to the Commission for Social Care Inspection upon completion. No one at the home acts as an appointee for residents, families or solicitors been encouraged to deal with financial affairs. 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. Health and safety of residents is protected by the management ensuring safety certificates are up to date and appropriate risk assessments are carried out. Accident records were completed appropriately. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 22 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 3 3 3 Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 23 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 OP33 Regulation 24 Requirement A business development plan must be available for view at the home. Timescale for action 31/12/05 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 OP31 OP28 Good Practice Recommendations The registered manager should hold a management qualification equivalent to NVQ level 4. At least 50 of care staff should be qualified to NVQ level 2 or equivalent. Churchill House DS0000000840.V253370.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000000840.V253370.R01.S.doc Version 5.0 Page 25 - 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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