Inspection on 27/07/06 for Churchvale Rehabilitation & Recovery Centre

This inspection was carried out on 27th July 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 7 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 &... 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 Mrs Maggie Bennett Key Unannounced Inspection 27th July 2006 09:10 Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.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.V292974.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.V292974.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 555 7519 0121 533 2471 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.V292974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 19th January 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 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. All the fees for staying at Churchvale are met by the Health Authority. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on a weekday between 9.10 a.m. and 6.55 p.m. On this occasion all the Key Standards of the National Minimum Standards were assessed. During the course of the day five service users were spoken to, three of whom were happy for their rooms to be seen. Two members of staff were spoken to, as well as the Manager and Deputy Manager of the home. A number of service users’ assessment information and care plans were seen and their care was “case 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 in the building. Other documents were inspected in order to assess health and safety practice. At the last inspection of Churchvale, in January 2006, a total of 10 statutory requirements were made. 7 of those requirements have now been met and this represents continued improvement. A further 4 statutory requirements were made following this inspection. What the service does well: What has improved since the last inspection? Churchvale is now providing improved information to prospective service users (although some feel that this could be further improved (see below)). All service users now have a statement of the home’s terms and conditions. The home have improved its assessment and admission procedures, including an “On Arrival Plan”, although some of the systems in place are not used to good effect (see below). Risk assessments for the building and safety of service users, staff and visitors have now been carried out. There has been an improvement in medication administration and recording and the majority of Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 6 the discrepancies noted at the last inspection were no longer evident. A healthcare checklist has now been developed so that the staff have a better awareness of the service users’ physical healthcare needs. The home have developed their own Adult Protection Procedure, which is in line with the local Social Services Procedure and several staff have taken part in Adult Protection Training. 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.V292974.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.V292974.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. The overall outcome for this group of Standards is judged to be Adequate. There has been an improvement in the provision of information to prospective service users since the last inspection. The home now provides a Service Users’ Guide and an information booklet. Some service users, however, still feel that they are not provided with enough information before they move in. In order for Standard 2 to be fully met, the home must ensure that clear, comprehensive information on a prospective service user’s needs is obtained before they are admitted to the home. This information should include the Care Programme Approach assessment from the Care Co-ordinator, plus the home’s own assessment information. This should form the basis of the Service User Plan (see Standard 6) and at all stages there should be evidence of the service user’s involvement. Two service users, in their returned questionnaires, did not feel they had a choice as to whether or not they moved to Churchvale. Currently assessment information is filed in a rather haphazard way and is difficult to follow. EVIDENCE: Churchvale revised their Residents’ Guide in February 2006 and service users have been given a copy. This contains a copy of the Staff and Resident’s Contract. Not all of the service users spoken to could remember receiving the Guide or the Contract, but they did feel that these issues had been explained to them and one said: “I know the rules.” In addition prospective service Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 9 users are given an Information Booklet. A copy of the most recent CSCI report is available in the home for service users and their families or representatives. The Service User Plans of 2 recently arrived service users were seen in order to check that a full assessment had been completed before they were admitted to Churchvale. There was a Care Programme Approach assessment form on one file, although not all areas had been completed. The second file contained far less information and, again, some areas were left blank. Key areas such as the “Care Plan Section” were not completed. The Care Programme Form had not been signed by the service user and was not dated. The Registered Manager must ensure that a completed assessment from the Care Coordinator is received at Churchvale prior to the prospective service user being admitted. The home should not be taking service users in “blind”, as one staff member suggested that they did. Service users are visited in Hospital, or in their home, by a representative from Churchvale, prior to their admission. Staff from Churchvale will also attend the Discharge Meeting at the Hospital. In some cases service users are on leave on Section 17 of the Mental Health Act and in these situations their hospital place can be kept open while they are settling into Churchvale. During the assessment period the home complete a Social Functioning Questionnaire. Copies of these were seen on the service users’ files, but appear to have been completed after they had moved to Churchvale. The Registered Manager stated that a new procedure had recently been put into place whereby all new service users would, in addition to the above, have an “On Arrival Plan” and this information would be used in conjunction with the Care Programme Approach assessment to give staff an up to date picture of the service user’s needs. The “On Arrival” plans were not yet in place on the files seen. It was explained that this new procedure should cut down the necessity for service users being asked to repeat the same information they had recently given to other healthcare professionals. The hope is to create a “seamless pathway” from hospital to Churchvale. Overall it was found that there was quite a large amount of assessment information on the files, but that the organisation of files was haphazard, making it difficult to follow an audit trail through from hospital to assessment to admission to Churchvale. It was also unclear how much the service user had participated in their assessment. Service users spoken to all said that they had been shown around the home prior to admission. Churchvale offers its prospective service users a gradual introduction, with overnight stays being arranged prior to a four-week trial period. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 10 Of the 5 surveys returned, 2 people said that they were not asked if they wanted to live at Churchvale and did not receive enough information about the home prior to moving in. Their comments in the Surveys were as follows: “I did not know that I was going to live at Churchvale.” “I didn’t have a choice.” It is recommended that a checklist is provided on file to ensure that all prospective service users are provided with full information about the home and that this is explained to them prior to their admission. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 11 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): 6, 7, 8 and 9. The overall outcome for this group of Standards is judged to be Good. The systems for Care Planning at Churchvale need to be developed further and be better organised so that they provide an immediate, clear and up to date picture of the individual’s needs and how each need is to be addressed and progress monitored. There are many excellent practices at Churchvale, which ensure that service users are involved in their care planning and rehabilitation and in the day to day running of the home. Service users are very much encouraged to make decisions about their lives. Appropriate risk assessments have been completed to protect service users, their visitors and staff. EVIDENCE: As at the last inspection, there was evidence that the Care Plan had not been fully developed until the service user had been living at Churchvale for sometime. It was clear, however, that work had been carried out to address some of the areas within care planning identified as in need of improvement at the inspection in June 2005. All the files seen on this occasion contained a copy of “My Recovery Plan”, which is the plan developed with the service user, Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 12 keyworker and staff at the home and the Care Co-Ordinator. This plan sets out how the needs of each individual will be met. The Recovery Plan contains a Risk Support Plan, which provides guidelines to staff on how particular risks to the individual can be minimised. All files seen contained evidence of regular Progress and Planning Meetings and of service users’ involvement in these meetings. There is a good deal of information in the care plans, but they are difficult to follow and are not consistent. Different systems are included in some files. For example, one contained an uncompleted “OHIO Recovery Journey”, but none of the other files did. There should be clearer details on each file of service users’ physical healthcare needs (see Standard 19). The plans would benefit from re-ordering, so that any one looking at them can clearly follow through from Assessment to Planning to Interventions needed and to Reviews and Evaluation. They should also set out who is to be responsible for what action. The Plan should reflect the up to date needs, aspirations and goals of the individual, set out the services to be provided by the care home or in the community to meet needs and achieve goals, and should develop through regular review and evaluation as the service user’s life and circumstances change. There is a key worker system in place and service users confirmed this, several pointing out who their key worker was. Service users described how their key workers had assisted them, such as applying for accommodation. Another person said they had been helped with “getting out and about” and also with their cooking skills. The home is geared towards promoting decision-making and participation. Service users spoken to said that they were able to make decisions about their day to day lives. There was evidence in one service user’s file that he had been offered Advocacy assistance. Advocacy contact numbers are available in the home and the Patient Advice and Liaison Service (PALS) can also be accessed. The aim is for service users to manage their own finances and assistance is given with budgeting. This is done in a number of ways to suit the individual. Some service users are subject to Appointeeships (with Social Services acting as the Appointee), others request the home to look after some monies on their behalf, whilst others collect their own Benefits and take entire charge of their finances. Every day there is a formal handover to which service user can attend where they pass on information themselves to the team. Meetings are also planned and chaired by service users including taking minutes and agreeing the agenda. Service users are also involved in a Patient Forum with local residents and schools, which is held twice a year. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 13 Additional services provided include Behavioural Family Therapy (BFT) training in ‘Diversity and Equality’ and a personal skills programme. Service users can also attend training courses with staff whilst all staff are required to complete an activity handbook with service users to develop their empathy and understanding. Once discharged Churchvale provides a 3-month follow up service in the community. As stated in Standard 6 above, the Care Plan contained a Risk Support Plan. Risk assessments were seen on individual files, with guidelines for staff as to how to minimise risks. Risk assessments for the building and safety of staff visitors and service users both inside and outside the building have now been developed. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 14 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): 12, 13, 15, 16 and 17. The overall outcome for this group of Standards is judged to be Excellent. The home has built up excellent links with the local community and service users have the opportunity to engage in a variety of educational, occupational and leisure activities. Service users are enabled to maintain family links and friendships. Staff work closely with service users to help them achieve their goals of independent living. EVIDENCE: All of the service users spoken to said that they had received assistance to engage in both educational and leisure activities. There are a number of facilities nearby. Several service users attend Simpson Street where they are able to take part in relaxation and literacy groups, to name but a few. Some service users attend the local Asian Men’s Group and there is also a local African Caribbean Centre. At Beeches Road Enterprise Centre service users are able to undertake NVQ qualifications in catering, photography and jewellery making. Some service users have been engaged in the “Groundbreaking” project. There is a leisure centre nearby and the team’s Occupational Therapist offers swimming training. Service users are also able Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 15 to take part in football and weight training. The home is currently setting up links with ‘A’ Level students at a local school. This has been at the suggestion of the service users. 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. To date trips out have been arranged, including a trip to the Zoo and this money has also gone towards some golf lessons. Service users spoken to said that staff had assisted them to find opportunities locally, including voluntary jobs. Visitors may call at any reasonable time or with prior agreement and can be seen where the service users prefer, either in one of the lounge areas, meeting room or bedroom. The intercom system allows the individual to be contacted directly by their visitors. 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). There is unrestricted access to the communal areas of the home. All service users are responsible for their own meals including shopping, preparing and cooking. Assistance is provided as required including individual staff support with any of the above areas. Food is kept in the service user’s own identified storage facility. In addition to the kitchenette areas the home has a training kitchen. Group meals are arranged every Wednesday and Sunday. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 16 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 and 20. The overall outcome for this group of Standards is judged to be Adequate. Service users are enabled to exercise independence and choice in their lives. Those spoken to feel that they are well supported by staff in ways which suit them. Service users’ mental and emotional healthcare needs are well documented. There is now a system in place for checking that physical healthcare needs are also documented. This needs to be utilised in order to ensure that physical healthcare needs are met. Service users are assisted from the start to become independent in obtaining their medication and in selfadministering. There are some areas where recording needs to be tightened up to ensure that service users are protected. EVIDENCE: All service users take charge of their own personal care, with advice given if needed. Service users spoken to confirmed that they were supported by staff in a positive way and in a way that suited them. They felt that staff listened to them. There are no restrictions in terms of getting up/going to bed, although some service users said that they had appreciated help getting up in the mornings when they needed it. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 17 Service users’ mental healthcare needs are well documented. The home works closely with the service users’ Consultant Psychiatrist and other professionals involved in their care, including social worker and community psychiatric nurse. All service users are registered with a G.P. and medical appointments are entered in the home’s diary. The home have introduced a Physical Healthcare checklist, which can be found on individual care plans. The checklist was blank on one of the care plans seen and it could not, therefore, be verified that in all cases physical healthcare needs are being monitored and outcomes of appointments recorded. 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: Stage 1 – the medication is taken to the service user’s room and the service user, supervised by a member of staff, dispenses the medication from its original container into a medidose. This can include clozoril, which arrives separately from the Hospital Pharmacy. The member of staff observes the service user take the medication and then signs the handwritten medication administration sheet. On observation of the MAR sheets it was found that there were some gaps where staff had either not been signing when the medication had been taken or had not entered a code to explain why the medication had not been taken. Stage 2 – As above the service user dispenses the medication into a medidose with staff supervision. The service user ticks the MAR chart to verify that they have taken the medication and the member of staff signs. Stage 3 – the service user keeps their own MAR chart and ticks this when they have taken the medication. The Manager states that the home’s policy is clear – guidance only is given to service users, who dispense their own medication. It was explained that if service users spend time away from the home, they will either take their medidose with them or the “finger” for that particular day. Service users 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 Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 18 a record is kept of this. It is recommended that the Pharmacist be asked to sign the record when medication is returned. Only trained nurses assist with medication and all received NMC training. Support Workers are trained by the nurses, so that they have an understanding of the medication administration procedures. Currently one of the nurses is conducting an audit with regard to medication protocol. This commenced in April 2006 and is due to be fed back within the next few weeks. On this occasion there was no evidence of prescription labels being altered. A new Controlled Drugs Register has been obtained. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 19 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 and 23. The overall outcome for this group of Standards is judged to be Good. The home has a comprehensive complaints procedure and all service users have a copy of this, which is in the Service Users’ Guide. Service users spoken to during the inspection said that they would know who to complain to and felt that they would be listened to. One person said that, although they knew who to complain to, there were “no problems here.” There are robust policies and procedures in place to protect service users from abuse. EVIDENCE: The home has a comprehensive complaints procedure and all service users have a copy of this, which is in the Service Users’ Guide. Service users spoken to during the inspection said that they would know who to complain to and felt that they would be listened to. One person said that, although they knew who to complain to, there were “no problems here.” Churchvale has a robust Adult Protection Policy and Procedure and have also obtained a copy of the Sandwell Social Services Procedure. Staff have taken part in Adult Protection Training, apart from 5 people, who are due to go on the next training session. Service users 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. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 and 30. The overall outcome for this group of Standards is judged to be Good. Churchvale is comfortable and safe and provides accessible and wellmaintained accommodation, which meets the individual needs of the service users. Some rooms now need re-decoration and carpet cleaning. There are a range of facilities, which promote the rehabilitation of the service users and their plans for independent living. EVIDENCE: The premises were found to be bright, airy and comfortable. Good standards of hygiene were observed. There is a maintenance and renewal programme in place and repairs are carried out as needed. The home is in a convenient spot for access to local amenities. There is a vertical lift and good access for all service users to the communal areas of the home. There are a number of different lounge areas, including an activity room, which enables service users to have a choice about TV programmes, music or whether they simply want a quiet area. Carpets in some of the lounge areas are badly in need of cleaning. Currently there is a Smoke Room, but as part of the Trust’s Policy the home will become a “non smoking” environment at the end of August 2006. In anticipation of this, service users have decided that the Smoke Room will be locked at certain times of the day and a shelter will be provided in the garden Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 21 for those who wish to continue to smoke. Service Users have been asked to make suggestions as to how this “new” room can be best used in the future. To the rear of the property there is a large garden and there are plans for this to be landscaped. All service users have their own single rooms, with an en suite shower, wash hand basin and shower. Several service users were happy for their rooms to be seen. All were comfortable and well furnished. Some rooms would now benefit from redecoration. 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. All service users have their own key. 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 and COSHH regulations are being followed. Service users spoken to were all very happy with their rooms and the accommodation at Churchvale. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. The overall outcome for this group of Standards is judged to be Adequate. There are sound recruitment procedures in place in the Trust, but evidence of proper checks must be available to the Registered Manager and in the home itself. Training receives a high priority at the home and service users benefit from well trained and supervised staff. EVIDENCE: Staff spoken with during the inspection demonstrated a good knowledge of the needs of individual service users and specifically around mental health issues. Staff were enthusiastic about their work and felt that the home offered a very good service. They felt that they were offered good opportunities for training. Three staff files were seen in order to check compliance with recruitment regulations. In all cases there was an application form in place, which contained a full employment history. Two written references are requested and of the newly appointed staff, these were still at the Trust’s Human Resources Department at the time of the inspection. The HR Department of the Trust carries out CRB and POVA checks, but the Registered Manager of Churchvale is denied access to these checks. It is considered that this is poor practice, as the Registered Manager must be able to feel confident that the person to be employed has satisfactory CRB and POVA checks and that Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 23 service users are protected. The checks do not necessarily have to be kept on the premises of the home, but written verification from the Registered Person that satisfactory checks have been carried out must be available on the premises. The only information to date received by the home is a checklist from their Human Resources Department, with a tick against CRB. There is no reference number, no date and the checklist is not signed. All files seen contained copies of the staff’s terms and conditions and the Rehabilitation of Offenders Declaration. There is a training plan in place for the staff group as a whole. In addition all staff at the home have an individual Personal Development Plan and training profile. This is in line with the Trust’s Knowledge and Skills Framework. There is evidence in staff files that they receive regular supervision. The nurses supervise the Support Workers and several nurses receive clinical supervision. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The overall outcome for this group of Standards is judged to be Adequate. There is a competent and well respected Manager in place who is experienced and committed to providing a well run home. Service users and staff feel that they are able to express their views about the home and that they are listened to. A representative of the Registered Persons must visit the home each month and prepare a report on the conduct of the home. The health, safety and welfare of service users and staff are promoted and protected. Evidence of staff training in health and safety areas must be available in their files. EVIDENCE: The present Registered Manager has been at the home since it opened in 2004. She is a qualified nurse and takes part in regular training to update her skills and knowledge. She was described by one staff member as a “really good Manager”. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 25 Churchvale have produced an Annual Report and Action Plan following on from a survey conducted at the home, seeking the views of service users. Evidence collected is kept in a Public Information folder in the home. Service users’ meetings are held each week. Verbal feedback is given to staff from visiting health and social care professionals. It is recommended that these visitors are also requested to complete satisfaction surveys. The home’s policies are regularly reviewed to ensure that they are in line with current good practice. The Registered Persons are not visiting the home on a monthly basis and providing the Commission with a report following this visit. There is a Fire Risk Assessment in place and fire safety checks take place at the required intervals. The Fire Detection system was checked in March 2006. The Health and Safety Officer of the Trust carries out fire training twice a year. Service users also take part in regular fire drills. There is always a trained nurse on shift. At the time of the inspection the Registered Manager stated that she had requested funds from the Trust for staff to take part in the Appointed Person First Aid training. There is evidence that staff take part in moving and handling training and food hygiene training. Several staff are booked to take part in Infection Control training. Certificates to verify all staff training must be available in individual staff files. The gas boiler was serviced in 2005 and the 5-year electrical safety certificate was seen. All electrical appliances have been tested. The home’s water system was found to have traces of legionella some months ago and at present the water is checked each month and is regularly run through the system. The lift was checked and maintained in May 2006. Risk assessments for the building have been carried out by a Competent Person and the Trust’s Health and Safety Officer has checked these. All new staff receive training in safe working practice topics at induction and are supervised by a named nurse. Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 26 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 X 3 2 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 4 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Churchvale Rehabilitation & Recovery Centre DS0000062420.V292974.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 14 Requirement The home must ensure that completed written assessment information is received prior to a service user being admitted to Churchvale. The systems in place, such as the Care Programme Approach Assessment and the home’s own assessment, must be fully completed, signed and dated. There must be evidence that the service user has participated in the assessment process. Care plans must be developed and implemented upon admission detailing specific action required to meet all identified needs. (Previous timescales of 27/06/05 and 01/02/06 not met). The Physical Healthcare checklist must be completed in all cases and signed and dated. There must be no gaps in medication administration record sheets. Staff must always sign when they have witnessed a DS0000062420.V292974.R01.S.doc Timescale for action 31/08/06 2. YA6 14,15&17 30/08/06 3. 4. YA19 YA20 12(1) 13(2) 31/08/06 27/07/06 Churchvale Rehabilitation & Recovery Centre Version 5.2 Page 28 5. YA34 19 6 YA39 26 7. YA42 18(1)(c) service user take the medication or fill in a code to explain why the medication has not been taken. Records must be kept at the 31/08/06 home of a satisfactory CRB & POVA for all staff. The registered manager must be able to evidence that she has seen these. (Previous timescale of 01/04/06 not met). The Registered Person (or their 31/08/06 representative) must visit the home each month and provide the Commission with a written report on the conduct of the home. (Previous timescale of 19/01/06 not met). Copies of training certificates 31/08/06 must be available in individual staff files. 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 YA1 Good Practice Recommendations It is recommended that the home provide a checklist on file to ensure that all prospective service users are provided with full information about the home and that this is explained to them prior to their admission. It is recommended that care plans are better organised, so that any one looking at them can clearly follow through from Assessment to Planning to Interventions needed and to Reviews and Evaluation. It is recommended that an audit is carried out of all bedrooms and that redecoration takes place as needed. It is recommended that carpets in communal areas are cleaned or replaced as necessary. It is recommended that visiting health and social care professionals are requested to complete satisfaction questionnaires. DS0000062420.V292974.R01.S.doc Version 5.2 Page 29 2 YA6 3 YA26 4 YA39 Churchvale Rehabilitation & Recovery Centre 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.V292974.R01.S.doc Version 5.2 Page 30 - 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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