Inspection on 18/07/07 for Churchvale Rehabilitation & Recovery Centre

This inspection was carried out on 18th July 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Churchvale Rehabilitation &... 27/07/06

Churchvale Rehabilitation &... 19/01/06

Churchvale Rehabilitation &... 27/06/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Churchvale Rehabilitation & Recovery Centre Lowry Close Smethwick West Midlands B67 7QT Lead Inspector Mr Jon Potts Key Unannounced Inspection 18th July 2007 09:55 Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.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 Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.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. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Churchvale Rehabilitation & Recovery Centre Address Lowry Close Smethwick West Midlands B67 7QT 0121 6126720 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) Sandwell Mental Health NHS & Social Care Trust Mrs Julie Frances Taylor Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2006 Brief Description of the Service: Churchvale is registered to provide 24 hour residential care for 13 people aged between 18 and 65 who are experiencing mental ill health. The focus of the service is to provide intensive rehabilitation to enable service users to live independently in the community. The home is situated close to Smethwick town and has good access to public transport networks. Accommodation is provided over two floors accessible via stairs or passenger lift. All bedrooms have en-suite shower and toilet facilities with communal bathrooms available if preferred. There are also many lounge and kitchen areas around the home, a meeting room and laundry. Ample parking facilities are provided at the front of the building and there is a large garden at the rear. Visitors can contact individual service users via the intercom system installed in the main entrance. There is also a pay phone where private calls to be made. The home is staffed by nurses and support staff that are supervised by a registered manager and deputy. The registered manager is responsible to senior managers within Sandwell Mental Health NHS & Social Care Trust All the fees for staying at Churchvale are met by the Health Authority with no cost to service users. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was initially unannounced and took place over two days. All the Key Standards of the National Minimum Standards were assessed. During the course of the day three residents were spoken to, two of whom were happy for their rooms to be seen. Three members of staff were spoken to, as well as the Manager of the home. A number of service users’ assessment information and care plans were seen and three residents care was tracked. A sample of staff files were seen in order to check recruitment procedures. The medication procedures and administration records were inspected. A tour took place of all the communal areas and two bedrooms within the building and other documents were also inspected in order to assess the homes practices. Supporting information was also available from the AQAA (annual quality assurance assessment) that was completed and submitted to the CSCI by the manager, as well as a number of questionnaires sent out by the CSCI and completed by residents and relatives. What the service does well: What has improved since the last inspection? There have been a numerous improvements in the service since the time of the last inspection, and out of seven requirements from the last inspection six have now been fully met. The homes admission procedure was seen to have developed significantly and the documentation and feedback from residents clearly indicated that this was well managed, providing a smooth process for Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 6 the individual concerned as well as ensuring the home obtains sufficient information as to prospective residents needs. Documentation in respect of care plans and healthcare records was found to be better organised and completed. Medication records, whilst still improving with the assistance of advice from the PCT’s pharmacist, were better than at the previous inspection. Staff files seen now evidence the carrying out of satisfactory pre – employment recruitment checks for staff and evidence of staff training has improved. Overall though it was noted that whilst the home is still developing its approach to continuous assessment, this has improved and allowed the home to easily assess what it does well, where it needs to improve and how to further improve its service. 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. The summary of this inspection report can be made available in other formats on request. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 7 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 Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and are fully involved in the admission process. The home is currently developing a more detailed contract that tells service users about the service they will receive. EVIDENCE: The home provides a detailed Statement of Purpose that is specific to the individual home, and the service it provides with the objectives and philosophy of the service set out. The guide details what the prospective individual can expect, this assisted by supporting documentation that is given to the prospective resident at the point of admission in the form of an agreement between the home and resident. The homes statement of purpose details specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint in addition to numerous contact numbers for agencies that will offer prospective residents support. This information about the home is available to all prospective residents and time is taken by staff to explain this verbally (this seen to be documented on admission checklists). Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 9 Three residents confirmed that they had received sufficient information to be able to make a decision as to their admission to the home and one relative stated that the home was good at ensuing the information was available, and they were updated verbally or with written information. One resident spoken to stated that they knew exactly what was happening during the admission process and was very involved. There was clear documented evidence that residents had opportunity to visit the home and stay for the day and then overnight prior to admission, this so they could ample the service and staff were able to continue the assessment process. Whilst the homes contract/terms and conditions that are in current use do not fulfil national minimum standards the manager has drawn up a revised version that does and this is currently awaiting approval from clinical governance prior to implementation. At the point of the last inspection there were issues in respect of the homes admission processes and it was pleasing to see from discussion with the manager and tracking a recent admission to the home that the home has made significant improvements in this area. One of the improvements is the use of an admission checklist, which records that the staff have carried out the required steps prior to and during the admission. This ensures that admissions are not made without the home obtaining a comprehensive assessment. The assessment involves the individual, and their family or representative, where appropriate, with clear evidence that the home insists on receipt of CPA (Care Programme Approach) documentation. Residents are assigned a named nurse who is available to assist them with any queries or to provide them with support during the admission process. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals are fully involved in decisions about their lives, and play an active role in planning the care and support they receive with the support of staff. The assessment of resident’s primary needs is carried out although more generic assessment of risk could be expanded. EVIDENCE: Discussion with residents evidenced that they were involved in the planning of their care in respect of their lifestyle and quality of life. Care plans were seen to be signed by residents and those spoken to confirmed that they were aware of and agreed with the contents. The staff spoken to underlined the importance of residents being supported to take control of their own lives, this fitting in with the homes ethos in respect of rehabilitation of service users. The care plans are centred mainly on the needs that were important in respect of the resident’s mental health although where necessary focussed on health, Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 11 social and emotional care as well. Residents were able to understand the care arrangements and it was underlined that staff had assisted with this. The home has a named nurse system that allows staff to work on a one to one basis and contribute to the care plan with the individual, although this does not preclude the resident seeking one to one support from other staff. There was clear evidence that the individual’s residents plan was reviewed on a regular basis this with the input of the resident and where appropriate their relatives. There was also involvement of the psychiatrist retained at the service, this to ensure that the strategies adopted were appropriate for the needs of the individual. All plans contain clear goals that the resident had set themselves with support from staff, these focusing on how they would develop their skills and consider their future aspirations. Risk assessment in respect of management of a resident’s mental health and any possible outcomes that may occur as a result were clearly detailed although there was scope to develop assessment of other potential hazards that may present due to increasing independence (for example going out alone). The resident’s records did however contain clear detail of any potential limitations; these set down and agreed with the resident. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and supported to develop their life skills in preparation for independent living. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The homes main aim is the rehabilitation of the residents within the service and the staff actively encourage and provide imaginative and varied opportunities for the residents to develop and maintain social, emotional, communication and independent living skills wherever possible. Individual goals are set through the care planning process and residents are supported by staff to maintain existing links within the community and develop new ones outside of the home. Many residents are involved activities off site during the day these supporting the development of work skills, assisting with health and Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 13 fitness or developing links that would be important for them in respect of their planned independence. Numerous residents (either by questionnaire or when spoken to) confirmed that they could do as they wished on evenings and weekends and usually during the day, although there was minority comment as to staff encouraging a resident go out in the day, even when occasionally they may not wish to, this however in accordance with the residents developing their independence and the home’s main aim of rehabilitative care. The home has its own activity room, which contains a pool table, dartboard, and board games etc. The notice board is filled with information on leisure centres, colleges, job centres, day centres, public transport times and other community information. There is also a multi faith Chaplaincy nearby whose representatives visit the home. The home has a budget for social activities and service users make suggestions as to how this is used. Residents spoke of trips out that have been arranged. The manager stated that the home does have access to transport from a related service although not all residents were aware of this. Residents spoken to were supported by staff in respect of training to develop employment skills, with use of such as a resident’s office where residents undertake such as administrative tasks. The manager spoke of developing the homes relationship with other agencies such as back2work to assist with the resident’s employment opportunities. Visitors may call at any reasonable time or with prior agreement and can be seen where the resident prefers, either in one of the numerous lounge areas, meeting room or bedroom. The intercom system allows the individual to be contacted directly by their visitors. Relatives responding to CSCI questionnaires confirmed that the home contacted them when there were issues of importance. All service users have their own keys to their rooms and it was observed that staff only enter individual rooms when invited to do so by the service user. Any tasks, which the service users are expected to perform around the home, are stated in the Service Users’ Guide, as are any rules (re. smoking, alcohol and drugs). Residents have unrestricted access to the communal areas of the home. All service users are responsible for their own meals including shopping, preparing and cooking and as such are able to select their own choice of meal, although advice is readily given by staff on healthy eating, this confirmed by residents and supported by the range of information available on the subject within resident’s communal areas. The home has also purchased a smoothie maker to encourage residents to make drinks based on a range of fresh fruit Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 14 and vegetables. Assistance is provided as required including individual staff support with any of the above areas. Food is kept in the service users own identified storage facility. In addition to the kitchenette areas the home has a training kitchen that is adapted for use by wheelchairs users. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. The home is actively seeking to improve their practice in respect of the handling and administration of medication but is proactive in promoting selfadministration. EVIDENCE: The resident’s mental health needs are clearly recorded in care plans with additional information in respect of any other relevant health need. As such the residents plan acts as an overview of the individual’s heath needs and would identify any change in how a resident needs to be treated, this supported by regular review by a consultant psychiatrist and other health/social work professionals. The staff do need to ensure that where a resident makes choices in respect of not seeing a health care professional (i.e. optician), that this choice is explicit and documentation reflects this. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 16 Residents are supported by a ‘named nurse’ system that means they are allocated a member of staff to assist them with any queries, with the staff member ‘advocating’ for the resident, assisting residents with finances, confidentiality of notes etc. Staff spoken to stated that they constantly reinforce to residents they have rights and that they can contact others for advice (with supporting information seen to be freely available in the home). Staff spoken to did however stress this does not prevent a resident approaching another member of staff for advice if they prefer to do so. Residents spoken to confirmed their awareness of the named nurse system. Whilst there have been some past issues on occasions with staff ensuring withdrawn residents are not given as much support as they may require, it is positive that this issue was identified by the manager and has been addressed and monitored since the last inspection. This underlines the manager’s commitment to ensuring that staff response appropriately to residents personal needs. The consistency of the service provided by the home was seen as a strength with one comment from a relative stating that ‘ The fact that the residents have the stability of seeing the same staff and doctors I feel is a great benefit’. All service users take charge of their own personal care, with advice given if needed. Service users spoken to confirmed that staff supported them in a positive way that was in keeping with their preferences and to support their achieving greater independence. All service users are registered with a G.P. and medical appointments are entered in the home’s diary, with consultations clearly documented within a physical healthcare checklist, which can be found on individual case files. Service users’ written consent to medication is retained in their care plan. All service users have a lockable space in their bedrooms in which to keep their medication. Service users are assisted (if that is their wish) to be in charge of their own medication. They usually do this through a process of 3 stages so that eventually, as part of their rehabilitation they become self-medicating. Robust assessment documentation was seen in individual case files to accompany this and there was on –going monitoring by the staff that was recorded. The home has a basic medication policy that the manager is in the process of reviewing against legal requirement and good practice guidance. Following this review the procedure will be updated as and where necessary. The manager stated that the Primary Care Trust’s pharmacist has advised her on the homes system, and at the time of the last visit had no concerns as to its management. Written confirmation of this would however be useful as evidence and would support the homes quality assurance processes and the manager’s medication audits. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 17 There are plans to improve the homes medical administration records, with copy of the new pro forma seen at the time of the visit, this to carry the evidence of the regime for medication from entries by the prescribing doctor/consultant. There were however no gaps seen in the records inspected when staff directly administer medication, with staff only signing medication out when actually observing the resident take said medication at the point of administration. Nurses need to sign/document medication sheets if seeing / consulting with residents in respect of medication administration however. Residents pick up their own prescriptions from the G.P. and take this to the Chemist. When they are in Stages 1 and 2 the tablets are logged in by staff, but when at Stage 3 service users take straight to their rooms and medication is not logged by the home. Any surplus medication is kept in the home’s medical room where dates and dosages are noted. Surplus medication is then returned to the Pharmacist and a record is kept of this. Only trained nurses assist with medication and all have received NMC training. The nurse’s train support Workers, so that they have an understanding of the medication administration procedures. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. Staff whilst aware of when to ‘whilstleblow’ need to be more aware of where to take such concerns to outside of the immediate home environment. EVIDENCE: The home has a detailed complaints procedure and all service users have a copy of this, which is in the Service Users’ Guide, with additional information available on display within the home. 3 Residents stated in questionnaires returned pre inspection that they knew who to speak to and that they were aware of the complaints procedure. The same three also stated that staff usually listened to what they had to say and responded to these comments. The residents meetings were stated to be a useful forum for raising concerns that were dealt with by staff. Relatives that responded to questionnaires also stated that they were aware of the homes complaints procedures and the agency responded appropriately when concerns were raised. Residents spoken to at the time of the inspection confirmed the above and also stated that they were aware that if they put written concerns in the homes complaints box that the staff on site had no direct access to these, with the complaints forms collected by an external representative of the agency. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 19 Churchvale has a robust Adult Protection Policy and Procedure and have also obtained a copy of the Sandwell Social Services Procedure. The majority of Staff have taken part in Adult Protection Training. Residents are given a leaflet entitled “Information if you are at risk of abuse.” The Registered Manager and staff spoken to during the inspection were fully aware of their responsibilities with regard to the Protection of Vulnerable Adults, although there was a lack of clarity in some cases as to which outside agencies they should approach if there were concerns, suggesting that some refresher training would be appropriate. There have been no adult protection issues at the home in the last 12 months this judged to be as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. The home was seen to have procedures in respect of dealing with physical and verbal aggression and staff have or are booked to attend training in respect of these. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The premises were found to be bright, airy and comfortable. There is maintenance and renewal programme in place and repairs are usually carried out as needed. There are however carpets in some of the lounge areas are badly in need of replacement, this as deep cleaning has been unable to remove staining and some refurbishment of the ‘consultation’ room would be merited. Of note there were numerous images on the walls around the home that promoted positive cultural identity. The home is in a convenient spot for access to local amenities, been within walking distance of Smethwick town. There is a vertical lift and good access for all service users to the communal areas of the home. There are a numerous lounge areas, including an activity Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 21 room, which enables service users to have a choice about TV programmes, music or whether they simply want a quiet area. The home has now, as part of the Trust’s Policy the home become a “non smoking” environment. To the rear of the property there is a large garden and residents are fully involved in the upkeep of this area as was seen to be the case on one of the days the inspector visited the home. All service users have their own single rooms, with an en suite shower, wash hand basin and shower (although separate bathrooms were seen to be available for those they preferred a bath). Two residents showed the inspectors their rooms, these seen to be comfortable and well furnished. Service users are responsible for keeping their own rooms clean. All bedrooms are fitted with a lock with an override device, which can be used in an emergency and all service users have their own key. All of the residents at the home at the time of the inspection were physically able, although the home has adaptations that would allow the accommodation of a resident who is a wheelchair user, this including such as adapted kitchen facilities and a shaft lift. Service users do their own laundry, with assistance from staff if needed. The laundry is small and domestic in style and there is a rota in place. There are systems in place for the control of infection. Staff spoken to had a good awareness of how to promote the control of infection this supported by the homes policies and procedures and training provision. The environment was found to be clean and free from any unpleasant odours (except in respect of specific carpets although these had been cleaned) and there were handwashing signs, liquid soap, paper towels and hand scrub available on the upstairs corridor. Residents spoken to were all very happy with their rooms and the accommodation at Churchvale. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with the homes statement of purpose, and to support the smooth running of the service. The manager is now better involved in respect of decisions regarding staffing. EVIDENCE: The home was found to be appropriately staffed on the days of the visits to the home, this supported by sight of staffing rotas. Information as to which staff are on duty is clearly available to residents and visitors in the homes foyer. The home does not employ agency staff. The staff group comprises staff of diverse backgrounds both in terms of gender and culture. Residents who responded to CSCI questionnaires confirmed that they were treated well by staff and residents spoken to at the time of the inspection confirmed this. Residents also stated that staff offered them the right support and information, including advice regarding their rights. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 23 Staff spoken to all stated that they are well supported with training from the organisation, whether formal or in house. The home was seen to have its own training room and there was much information available here for staff to refer to, this used by the registered manager as a base for in house training. All Staff spoken to stated that they had received training in mandatory areas such as 1st aid, health and safety, fire, abuse, equality and diversity etc, this confirmed by the homes training records. There was discussion as to the manager producing a simpler training record that showed which staff held what training, when updates where needed, and the dates training was booked in an easy to read format. It was however pleasing to hear the organisations training section was monitoring staff training, and alerting the manager to which staff needed core training as it arose. The home was seen to have a staff induction, this documented in staff files and showing a basic day 1 induction followed by a ‘part 2’ which goes into more depth with the policies and procedures. Discussion around this with the manager led to agreement that some expansion would be beneficial with greater detail of the evidence and questioning (based on common induction standards already available within the home) to test new starters knowledge of good care practice and the homes policies. The service has a good recruitment procedure that defines the process to be followed. There has been improvement in the verification of this process since the last inspection and the manager was seen to have evidence from the organisation’s human resources department that all the necessary checks on staff are carried out, this evidenced by sight of the files for the two most recently employed staff. The recruitment process was seen to include systems for the monitoring of staff diversity, and ensuring that the equality in recruitment was observed. Discussion with the manager indicated that she was now better involved in the selection process for new staff at the home. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective, developing, quality assurance systems that allow the provider to carry out an effective self audit. The manager is experienced, well trained and judged to be competent. EVIDENCE: The manager in discussion with the inspector, and based on the completed AQAA (annual quality assurance assessment) was seen to have a clear understanding of the key principles and focus of the service, this based on the homes stated aims and values. Outcomes from the inspection underlined that the manager has a strong ethos of being open and transparent in those areas of running of the home, where she is able. Staff spoken to were positive as to Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 25 the support provided to them by the manager (and deputy) with both said to be easily accessible to them. The manager was also said to be fair and approachable with comment that the style of management allows staff to do their job better. The manager and other staff have been developing the homes systems for quality assurance and it was clear that management are easily able to identify what they do well and areas where they need to improve. These were detailed in the home annual quality assurance assessment and the statements within this were supported by the findings of the inspector. The home has robust systems in place for consultation with residents that include regular meetings, a robust complaints process, questionnaires, and regular reviews of their care. The manager has continued to develop systems for audit of key working practices within the home since the last inspection, examples of which include medication audits, audits of the premises etc. The manager has firm proposals for development of an ‘off the shelf’ quality assurance tool that could be seen to strengthen the homes quality monitoring processes. Residents spoken to, and responding to questionnaires nearly all indicated that they were involved and their views were listened to by staff. The manager stated that she is in the process of reviewing all the homes policies and procedures and recording on the documents did evidence this process of review, that the manger felt would be guided by residents & staff comments as well as outcomes from quality monitoring. Staff stated that the homes policies and procedures were readily accessible to them (as was seen to be the case). The homes records overall were seen to be well documented and although there was some room for improvement there was evidence that there has been clear development since the time of the last inspection. This was seen to go hand in hand with the homes ability to audit itself. There was however concern that the senior management of the organisation have not supported this through their required unannounced monthly visits to monitor the quality of provision at the home. Copies of reports from these visits must be forwarded to the CSCI. The home was seen to have policies and procedures in place in respect of the homes safe working practices and discussion with staff evidenced their awareness of these and their own personal responsibilities, this including the actions to take if they could not resolve an issue. The homes deputy carries out a bi- annual health and safety check that covers all areas in respect of safe working practices and potential hazards. There was some scope for improvement in the homes assessment of risk in some areas for example; whilst the home had information sheets related to cleaning materials there was no risk assessment in respect of the residents independent use of these. The development of general risk assessments in Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 26 respect of safe working practices was seen to have been commenced however with the following areas covered to date: alcohol and hand rubs, lone working, candles, and off site activity and young persons at work. The manager was advised to seek the views of the organisations health and safety officer to assist with development of these risk assessments. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 3 27 4 28 3 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 3 Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 28 YES 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. Standard YA24 Regulation 23(2)d Requirement The registered provider must replace carpets that are worn and stained (in the green room and the downstairs lounge) and replace the settees in the consultation room. This is so to provide a better environment for the residents The Registered Person (or their representative) must visit the home each month and provide the Commission with a written report on the conduct of the home. This is a repeated requirement with the Previous timescales of 19/01/06 and 31/8/06 not met. Timescale for action 31/10/07 2. YA39 26 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 29 No. 1. 2. 3. 4. 5. Refer to Standard YA9 YA19 YA20 YA20 YA23 Good Practice Recommendations The registered manager should ensure that risk assessments in respect of tasks residents may carry out independently should be fully documented. The registered manager should ensure that resident’s choices as to not seeing such as an optician every 12 months are explicit when documented. The registered manager should request a report from the PCT’s pharmacist to reflect his audit of the homes systems for the administration and management of medication. The registered manager needs to ensure that nurse’s document and sign medication records if they see residents administering their medication. The registered manager should update staff on who to contact if whistle blowing on any practices within the home. Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Churchvale Rehabilitation & Recovery Centre DS0000062420.V340738.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!