Inspection on 19/01/06 for Churchvale Rehabilitation & Recovery Centre

This inspection was carried out on 19th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Churchvale Rehabilitation &... 18/07/07

Churchvale Rehabilitation &... 27/07/06

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 Mike Kirton Unannounced Inspection 19th January 2006 09:30 Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 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.V279270.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 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.V279270.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Churchvale Rehabilitation & Recovery Centre Address Lowry Close Smethwick West Midlands B67 7QT TBC TBC 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.V279270.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th June 2005 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 will be 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-suit 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 are plans to landscape the gardens 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. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours and included a tour of the buildings, and informal discussions with the staff on duty and service users at the home. Personal files were also examined for 2 employees and 2 service users, along with health and safety records, and medication procedures. What the service does well: What has improved since the last inspection? 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. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 6 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.V279270.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 27th June 2005. The homes statement of purpose and service users guide still needs to contain all the information required under regulation 4, 5, 6, and schedule 1 of The Care Home Regulations 2001. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 27th June 2005. Care plans still need to be implemented upon admission based upon initial assessments. These can be updated and reviewed as needed. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 27th June 2005. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The assessment and monitoring of service users mental health is very good however the home must also address physical health care needs. Whilst the approach to self-care and medication promoted independence the home has not followed safe ordering and administration procedures. EVIDENCE: Service users were observed to be making their own decisions on how to live their lives such as when to get up or whether they wanted to go out. Feedback received from service users and staff was very positive. They felt the home allowed them to develop skills for living independently and were happy with the level of support provided. Assistance was provided by care staff as needed including escorted visits. Personal files contained copies of staff and residents agreements detailing personal goals, responsibilities, and any restrictions that were in place. There was also a drug and alcohol contract, social functioning questionnaire, selfcare, and medication assessment including authority for administration. Rules on smoking were clearly displayed, and a copy of the latest inspection report was available in reception. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 11 Each resident has a Care Programme Approach (CPA) assessment and care plan. These were regularly reviewed and updated. The home works closely with the service users Consultant Psychiatrist and other professionals involved in their care including social worker and community psychiatric nurse (CPN). Mental health care needs are closely monitored and records were accurately maintained. All service users are registered with a GP and medical appointments are entered into the homes diary. However physical health care needs such as when a last opticians or dentist appointment was made, are not routinely assessed by the home. The records were also not being completed daily and the outcome of appointments not recorded. The home has a policy and procedure for the ordering, storage, and administration of medications including a 3-stage assessment leading to full personal responsibility. Each bedroom has locked space for drugs with a key held in the main storage room. Copies of prescriptions were being kept and checked against the order when received by the home A full audit trail of medication was not being maintained. Several boxes of tablets found had not been entered into the homes receipt book and a record of any returned to the pharmacist had not been consistently made. A record sheet for administration had several gaps where staff had not signed and not all signatures could be identified against the list of named staff responsible. Medications given only when required (PRN) were not being added to the record sheet. One box had the original individuals name crossed out and another added. The home should also obtain a new bound book for recording controlled drugs as the current copy was held together with sticky tape. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a number of options available should anyone wish to make a comment or complaint. Better opportunities for adult protection training must be provided for all staff and specific procedures implemented for the home. EVIDENCE: The home is managed by Sandwell Mental Health NHS and Social Care Trust and uses the Patient Advice and Liaison Service (PALS) should anyone wish to make any complaints. Contact details are clearly displayed with the option of written feedback, which can be placed inside a post box. The homes complaints procedure was updated to include telephone numbers for the Commission along with the address. This must also be clearly displayed. Any confidential information must also be removed from the comments and complaints folder in reception. The homes uses the trusts whistle blowing and adult protection policy, which was due for review in June 2005. The home must develop their own procedures, and obtain a copy of Sandwell Social Services procedures who would take the lead role in investigating allegations of abuse. Training must also be provided for all staff and evidence available that they have read and understood all the documents. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 27th June 2005. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 27th June 2005. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The Commission must be kept better informed of changes or incidents, which occur in the home. More evidence is needed to demonstrate that the necessary health and safety checks are being completed. EVIDENCE: The registered manager has been away from the home for 6 months secondment to another project. The Commission was not informed of this absence or alternative management structures that were put in place. The home must implement a quality assurance system including the views of service users, staff, visitors and others involved with the home, which is published on an annual basis along with an action plan for improving the service provided. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 16 Records required to ensure the health and safety of staff and service users were inspected. Fridge, freezer, water, and cooked meat temperatures were recorded. The homes gas landlords certificate was last dated 13/05/04 and needs renewing every 12 months. Portable electrical equipment was tested, however evidence of a 5-year electrical wiring test could not be provided. Risk assessments on the building and staff/service users activities were last carried out on 29/12/05 and need updating. There was also no evidence of public liability insurance. A fire risk assessment and evacuation plan is in place, and all equipment is regularly serviced and tested as required. All Staff must be involved in a fire drill at least twice a year. Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 17 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 18 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 YA1 Regulation 4,5&6 Requirement Timescale for action 01/04/06 2. YA5 4,5&17 3. YA6 14,15&17 4. YA7 14,15&17 To make available a service users guide and statement of purpose, including a copy of this inspection report and a standard contract. This is an outstanding requirement from 27th June 2005. 01/04/06 All service users must have a statement of terms and conditions to include all the information required under this standard. This is an outstanding requirement from 27th June 2005. Care plans must be developed 01/02/06 and implemented upon admission detailing specific action required to meet all identified needs and including relevant risk assessments. This is an outstanding requirement from 27th June 2005. Risk assessments for the building 01/04/06 and safety of staff, visitors and service users carrying out practices both inside and outside the building must be DS0000062420.V279270.R01.S.doc Version 5.1 Churchvale Rehabilitation & Recovery Centre Page 19 5. YA19 12, 13 6. YA20 13(2) 7. YA23 13 8. YA34 19 9. 10. YA35 YA42 19 37, 26 implemented and reviewed annually. Service users physical health care needs must be assessed and appropriate actions taken. This should include dentist, optician, audiologist, chiropody, and other specialist treatments. All medication received by the home must be recorded. All medication returned to the pharmacist must be recorded. There must be no gaps in the record sheet for administration. All signatures for named staff responsible for administering medication must be identifiable. Prescription labels must not be altered or medications prescribed for the named individual given to another. A bound book must be used for the recording of controlled drugs. The home must develop their own adult protection procedures specific to their service, and obtain a copy of Sandwell Social Services. Evidence must be available that these have been read and understood by all staff. Records must be kept at the home of a satisfactory CRB & POVA for all staff. The registered manager must be able to evidence that she has seen these. All gaps identified in the mandatory training must be met including adult protection. Regulation 37 notices must be sent to the Commission as required. This is an outstanding requirement from 27th June 2005. 01/02/06 19/01/06 01/04/06 01/04/06 01/06/06 19/01/06 Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 20 Regulation 26 reports of the responsible individuals monthly visits must be sent to the Commission. The home must have a valid gas landlord’s certificate. A 5-year electrical wiring test certificate must be available. Risk assessments on the building and staff/service users activities must be updated. The home must have public liability insurance. All Staff must be involved in a fire drill at least twice a year. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 21 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: 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 Churchvale Rehabilitation & Recovery Centre DS0000062420.V279270.R01.S.doc Version 5.1 Page 22 - 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!