Inspection on 27/06/05 for Churchvale Rehabilitation & Recovery Centre

This inspection was carried out on 27th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Churchvale Rehabilitation &... 18/07/07

Churchvale Rehabilitation &... 27/07/06

Churchvale Rehabilitation &... 19/01/06

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 and Recovery Centre Lowry Close Smethwick B67 7QT Lead Inspector Mike Kirton Announced 27 June 2005 th 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 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 Stationary 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 E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Churchvale Rehabilitation and Recovery Centre Address Lowry Close Smethwick West Midlands B67 7QT (0121) 555 7519 Telephone number Fax number Email 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 Acting Manager Julie Taylor Care Home 13 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia (13) of places Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First Inspection Brief Description of the Service: Chuchvale 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 independantly in the community. The home is situated close to Smethwick town and has good access to public transport networks. Accomodation is provided over two floors accessible via stairs or passenger lift. All bedrooms have en-suit shower and toilet facilities with communial 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 E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8 hours and included a tour of the buildings, interviews with the manager, deputy, 5 service users and 3 staff members. Records were examined for 2 employees and 2 service users. 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 E55 Churchvale 270605 Stg 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 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 standard(s) 1,2,3,4&5 Improvements need to be made to the homes admission procedures to ensure that perspective service users make an informed decision before deciding whether to move in on a trial basis. Current practices are not good enough to enable the manager to fully assess whether the home can meet their needs. EVIDENCE: The home has a ‘Residents Guide’ and ‘Statement of Purpose’ which provides much useful information about the home, the services provided, what can be expected and local resources. However not all the information as required under the Care Homes Regulations 2001 is provided (see Schedule 1 of the Act for a full list). Examination of service users records contained copies of a referral form, Care Programme Approach (CPA) assessments and care plans and Occupational Therapy reports that had been obtained before they were admitted. The home also carried out a Community Living Ability Assessments after about 4 weeks. One service uses met had visited the home several times on a planned basis and was now having an overnight stay. This however was not standard practice. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 8 There was insufficient evidence that perspective service users were being assessed for Churchvale. They did not normally visit the home before moving in and written confirmation as to whether their needs could be met was not being provided. The decision on who is admitted currently remains with the referring team and not the manager. A residents agreement including restrictions on drugs and alcohol is completed once they have moved into Churchvale. The NHS provides funding for the placement and no fees are payable by the service users except their food and personal care items. This along with other information as required should be detailed in a statement of terms and conditions signed by them and the provider. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 9 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 standard(s) 6,7,8&9 There are many excellent practices at Churchvale, which ensure service users involvement in their care planning and rehabilitation. The current systems of recording and written documentation however must be improved to demonstrate all needs are being met. EVIDENCE: In addition to basic details and personal histories, service users have a ‘my recovery plan’ with agreed review period, ‘community living ability assessment’ which is scored and reviewed, and an early warning sign and relapse plan. These were all developed and agreed with them and reviewed at ‘progress and planning meetings’ to which they and their key worker are involved. The care plans themselves however did not describe what specific actions are required and by whom in order that their needs can be met. For example one care need stated ‘mental and physical stimulation’ was needed but not how this should be provided. There was also no method of ensuring all health needs were monitored for example a tracker sheet for all appointments needed. One care plan also took 8 weeks before being implemented. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 10 Every day there is a formal handover to which service user can attend where they pass on information themselves to the team. The home is geared towards promoting decision-making and participation. For example the planned landscaping of the gardens have been designed by them. Advocacy contact numbers are available and the Patient Advice and Liaison Service (PALS) can also be accessed. Meetings are also planned and chaired by them including taking minutes and agreeing the agenda. 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 also provides a 3-month follow up service in the community. Individual risk assessments are completed with service users such as handling medication however there were also no specific risk assessments for reducing incidents of violence or self-harm. Similarly the home is yet to develop their own risk assessments for the building and safety of staff, visitors and service users carrying out practices both inside and outside the building. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 11 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 standard(s) 11,12,13,14,15,16&17 Churchvale has ensured that many opportunities are available and good information provided to enable service users to live an independent lifestyle. They are encouraged to make their own decisions about their daily routines to encourage independence. EVIDENCE: All service users are responsible for their own meals including shopping, preparing and cooking. Assistance is provided as required including individual staff support. Food is kept in their own identified storage facilities. In addition to the kitchenette areas the home has a training kitchen. A dietician is also available for advice and a group meal is arranged every Wednesday. The home has it’s own activity room which contains a pool table, dartboard, and board games etc. Set activities are organised such as a chess club however the main focus is to engage service users with outside organisations. The notice board is filled with information on leisure centres, colleges, job centres, day centres, public transport times and other community information. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 12 There is also a multi faith Chaplain who visits the home. All staff are given link topics to plan with users including sports, gardening, community, and health. Around the home there are also positive, multi cultural, images and statements. Information is also provided on individual rights, for example police stop and search powers. Trust strategies are also implemented including ‘patient, carer and public involvement’ which has prompted Churchvale to liaise with local schools and businesses. A recycling programme is also being implemented to cut back on waste. Churchvale also has a training and information room, which is fitted out with computers. There are links to a computer club operated in the local library and a lot of details on mental and physical health. Visitors may call at any reasonable time or with prior agreement and can be seen where the service users prefers, either in one of the lounge areas, meeting room, or bedroom. The intercom system allows the individual to be contacted directly. Service users spoken to said ‘ its great here, I have made lot’s of new friends’, ‘there are many opportunities to get out’ and ‘staff are always there to help you with cooking and stuff’. Others were particularly impressed that staff also go support them with social activities such as gong bowling and to the cinema. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 13 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 standard(s) Standards were not fully assessed on this occasion. EVIDENCE: Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 14 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 standard(s) Standards were not fully assessed on this occasion. EVIDENCE: Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 15 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 standard(s) 24,25,26,27,28,29&30 As Churchvale was purpose built as a care home it is not in keeping with other properties in the area and does lack a homely appearance. However the range of facilities available to promote independence compensates this. It is also very specious with plenty of room for individual activities and meetings to take place, and was found to be clean and hygienic. EVIDENCE: Churchvale has been designed specifically for the current service users group. It is modern, well decorated, comfortably furnished, and all areas were found to be clean and tidy. The home has maintenance and renewal programme and their own budget to carry our repairs as required. The laundry is suitable for the needs of the service users with health and safety guidance available. All washing is done by the individual at their agreed time with assistance if needed. They are also responsible for their own rooms and food storage areas. These were checked and found to be kept appropriately. Environmental health and fire safety inspections have recently been completed and no enforcement notices were made. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 16 An outside contracter maintains the communial areas. COSHH regulations were being followed and systems were in place to reduce the risk of cross contamination. The current practice of displaying cleaning checklists on walls and doors should be stopped, as this does not create a very homely environment. All bedrooms have a lock fitted with override devise to be used in a emergency. All rooms are linked by intercom and those inspected met with the required standards. Service users can decorate and furnish their own rooms as they wish (as long as fire regulations are met) and all have their own key. The rear enclosed garden is yet to be landscapes however work will commence shortly. Extra security lighting has been installed and appropriate fencing erected. Parking at the front of the building is shared with other residential properties in the area. Service users spoken to described Churchvale as ‘it is like a home’, ‘the furniture and beds are comfortable’, and ‘it is great having your own en-suit’. No negative comments were received other than a request for more rooms for smoking in. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34&35 There are good staff recruitment and training procedures in place to ensure service users health and safety is protected. However there were insufficient records available at the home to enable these to be examined. EVIDENCE: All staff spoken with demonstrated a good knowledge of the service users and specifically around mental health issues. They all said they enjoyed working at Churchvale, undertook regular training, and were impressed by the level of service users involvement. Two staff files were examined. Theses contained copies of their personal development plan and individual training plan. Gaps were highlighted in their basic training, which need to be met. All staff are employed by the trust and are required to submit an application form before being short listed for an interview from which records are kept. If successful they are then offered a position subject to police checks (CRB) health examination, and satisfactory references. There was no evidence available however of a police or adult abuse register check being received or proof of identification i.e. birth certificate. Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards were not fully assessed on this occasion. EVIDENCE: Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 2 2 1 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 4 4 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 4 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Churchvale Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 20 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 1 Regulation 4,5&6 Requirement To make available a service users guide and statement of purpose, including a copy of this inspection report and a standard contract. The Manager must ensure a comprehensive assessment is undertaken before a decision is made that a service users needs can be met. Written confermation must be sent to the service user stating whether their needs can be met. Potential service users must have the opportunity to visit the home, preferably with a planned introduction including overnight stays. All service users must have a statement of terms and conditions to include all the information required under this standard. Care plans must be developed detailing specific action required to meet all identified needs. Risk assessments must be implemented to reduce the liklehood of violenec and self harm. Risk assessments for the building Timescale for action 01/11/05 2. 2 14&15 27/06/05 3. 4. 3 4 14 5&14 27/06/05 27/06/05 5. 5 4,5&17 01/10/05 6. 6 14,15&17 01/10/05 7. 7 14,15&17 01/11/05 Page 21 Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 8. 9. 24 34 23 19 10. 11. 12. 35 43 43 19 37 17 and safety of staff, visitors and service users carrying out practices both inside and outside the building must be implemented. Remove the cleaning checklists displayed around the home. Records must be kept at the home of a satisfactory CRB & POVA for all staff. Proof of identification i.e. birth certificates must also be held. All gaps identified in the mandatory training must be met. Regulation 37 notices must be sent to the Commission as required. An appropriate accident book must be maintained. 01/09/05 01/08/05 01/10/05 27/06/05 27/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Churchvale E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Park Halesowen 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 E55 Churchvale 270605 Stg 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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