Inspection on 06/01/06 for Churchill House

This inspection was carried out on 6th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Churchill House 29/01/09

Churchill House 23/01/07

Churchill House 26/09/05

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 6th January 2006 13:00 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.V277570.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 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.V277570.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2005 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.V277570.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over 3 hours. The deputy manager was spoken with, a tour of the premises was undertaken and a number of residents were spoken with. The focus of the visit was to review requirements and recommendations made at the previous inspection and to spend time with residents to gain their views of the care provided in the home. The home presently accommodates 23 residents including one who is currently in hospital. What the service does well: What has improved since the last inspection? What they could do better: The home need to ensure that a training programme which includes induction and the achievement of NVQ qualifications is put in place for staff members. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 6 The manager of the home needs to complete her registered managers award so that the management part of her qualification requirements is met. An annual business development plan for the home needs to be available to view within the home. The minor premises maintenance required needs 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. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were looked at on this visit, all having been assessed at the previous inspection and been met at that time. EVIDENCE: Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 9 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): 8 & 10. Residents are treat with respect and their privacy is ensured. Health care needs of residents are met. EVIDENCE: A couple of residents were spoken with at length; they spoke extremely positively in regard to the quality of care they received. They explained that staff always knock on their bedroom door prior to entering, call them by their preferred names and will respect any requests they may make. One said, “ The staff always make sure everything is alright”. Residents also stated that they are able to access any health care service when they required, “if I need to see a doctor, I only have to ask and the staff will ring for me”. The home has a proactive approach towards health care appointments. One couple spoken with said that they receive a visit from the community nurse on a weekly basis. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 10 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 A range of recreational activities is provided in the home and resident’s preferences are accommodated. EVIDENCE: A full activities programme continues to operate within the home. Residents spoken to said provision of entertainment at Christmas had been excellent. They explained that staff had gone out of their way to make sure everyone was catered for. Activities such as games with balls, entertainers, slide shows and quizzes continue to be planned. A record of activities undertaken is recorded on each individual residents file. Trips out are planned to take place when the weather becomes a little warmer. Some of the female residents said they were able to choose what type of activities they would like and whether they wished to join in or not. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 11 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 A complaints procedure is available which meets the needs of residents and relatives. EVIDENCE: The home has a displayed complaints procedure, which indicates that complaints will be responded to within seven days. There have been minimal complaints recorded over the last twelve months. One complaint was made via the Commission for Social Care Inspection and this has now been addressed. Any niggles made known are dealt with there and then, these usually relate to issues such as laundry or other items which are missing. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 12 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 The home provides a safe, comfortable and clean environment for residents, which is homely and pleasant. 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 any 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. One bedroom window was found to be stuck in an open position following the window frames having been painted; the occupant of this room had to use a towel to block the gap with. This window must be addressed as soon as possible. The deputy manager said this would be seen to immediately. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 13 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): 28 & 30. Evidence gained at the last inspection indicates that recruitment and selection procedures are robust. Staff training needs to be addressed so as to ensure staff member’s competence can be assured. EVIDENCE: NVQ qualification levels of staff have remained at the same level recorded at the last two inspections. 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 at least a level two or equivalent, presently this figure for the home remains at 25 . The deputy manager explained that one carer was close to obtaining her NVQ level 3. She stated that a meeting had taken place regarding funding and it was intended to promote the undertaking of NVQ’s in earnest once she and the manager had completed their qualifications. A formal induction system continues to be worked on and this is intended to be introduced soon, it is important that staff are given appropriate induction guidance. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 33. The management of the home is carried out with leadership and appropriate guidance; ensuring residents receive a good quality of care. The completion of a management qualification will enhance the leadership style. The production of a business development plan will aid the financial protection of residents. 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. The assistant manager explained that the manager had completed all the required units and Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 15 was awaiting accreditation. The assistant manager said she had completed eight of the ten units required for her management qualification. 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. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 16 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X X Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 24 Requirement A business development plan must be available for view at the home. A formal induction programme for staff must be in place. The window which is stuck in the open position must be addressed to ensure it can be closed as required. At least 50 of care staff should be qualified to NVQ level 2 or equivalent. Timescale for action 31/03/06 2. 3. OP30 OP19 12 17 31/03/06 31/01/06 4. OP28 18 31/03/06 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 OP31 Good Practice Recommendations The registered manager should hold a management qualification equivalent to NVQ level 4. Churchill House DS0000000840.V277570.R01.S.doc Version 5.1 Page 18 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.V277570.R01.S.doc Version 5.1 Page 19 - 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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