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Inspection on 30/08/05 for The Churchley Rest Home

Also see our care home review for The Churchley Rest Home for more information

This inspection was carried out on 30th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager and staff provide a very caring and individual service in a homely environment, which is clearly valued by the residents. All residents seen by the Inspector were fulsome in their praise of the staff and the overall service provided. The care is provided in the context of a well maintained building.

What has improved since the last inspection?

Work has continued on the fabric of the building both internally and externally. The outcome is that the building is maintained to a very high standard. The dynamics of the group has changed resulting in an overall improvement in the well being of the total resident group.

CARE HOMES FOR OLDER PEOPLE The Churchley Rest Home 91 New Church Road Hove East Sussex BN3 4BB Lead Inspector Paul Endersby Unannounced 30 August 2005 10:00 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Churchley Rest Home Address 91 New Church Road Hove East Sussex BN3 4BB 01273 725185 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) The Churchley Rest Home Ltd Mrs Karen Lewis Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (OP), 18 of places The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users should be aged 65 years or over on admission 2. The maximum number of service users to be accommodated is 18 3. That one named service user who has dementia may be accommodated in the home Date of last inspection 28 February 2005 Brief Description of the Service: The Churchley rest home is registered to provide accommodation and personal care for up to 18 older people. The registered provider is the Churchley Rest Home Limited and the registered manager is Karen Lewis. The home is located in Hove with good access to local transport and amenities. It is a large property that is set out over three floors. There is a passenger lift from the ground floor to the first floor and a chair lift from the first floor to the second floor. There are sixteen bedrooms, fourteen of which are single. Seven bedrooms have en-suite facilities. There is a good range of communal space. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the morning and early afternoon. The Inspector met with the provider/registered manager plus other staff members and some of the residents. The inspection included a brief tour of the building and a review of care plans, records and other documentation. The inspection lasted 4¾ hours 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. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 5 Satisfactory arrangements are in place to enable prospective residents and/or their relatives or advocates to make an informed choice about whether to reside at the home, and to be confident that the home can meet their assessed needs. EVIDENCE: The manager undertakes a comprehensive assessment prior to the admission of a new resident. This involves the resident and their families or other representative. The findings of the pre-assessment are entered into the individual plan of care. Admissions made via the Social Services Department are subject to an assessment undertaken by care managers. This was confirmed by the assessments that are contained in resident’s personal files. The normal practice is for prospective residents to make pre-admission visits to the home to meet staff and current residents. Admissions are normally for an initial 4/6 weeks trial period. Emergency admissions are not normally accepted. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 10 Care plans ensure that a comprehensive record is maintained of resident’s needs and that there is a consistent response made by staff. Appropriate arrangements are made to ensure the residents health care needs are fully met in a respectful and dignified manner. EVIDENCE: Residents care plans are extensive and detailed. They provide evidence that the staff team undertake a clear and detailed needs assessment for each resident. Documentation is reviewed on a monthly regular basis. Individual care plans contain risk assessments and there is evidence that these are kept under review. Since the last inspection action has been taken to expand most of these in order to provide staff with more detail on how to manage risks. Daily notes are maintained on all residents. However these tend to use standard phrases and do not always fully reflect the actual situation. There is evidence that the content of the care plans is discussed with residents or with their relative/representative who are invited to sign their care plans. All residents have access to community health services. A record of visits to residents by GP’s and other medical personnel is maintained. Arrangements are made for residents to receive dental treatment, normally by visiting surgeries which are close to the home. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 9 Specialist advice is sought about the promotion of continence on an individual basis, and regular reviews are undertaken. Residents are encouraged to take regular exercise both within the home and outside, which includes use of the garden during the summer months. Residents are weighed regularly depending upon their personal situation. It was evident that resident’s privacy and dignity are respected. This was confirmed by individual residents in discussion with the Inspector. Additonally guidance to staff and residents is included in the staff handbook and the Service Users Guide. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 14 Resident’s expectations and preferences including their ability to make choices are largely met and links with family and friends plus the community are encouraged and facilitated. Opportunities are provided for residents to enable them to make choices on a daily basis. EVIDENCE: It is evident that residents can choose to spend time as they wish. Some spend time in their own accommodation, others prefer to be with other people in one of the communal areas. There are a range of activities available to residents. Additionally the provider/manager arranges occasional group outings to local places of interest. Feedback from residents about the home’s routines and activities was generally very positive. Residents are able to maintain links with the local community, e.g. attendance at church activities and specialist interest clubs. They are able to receive visitors in private in their own room or in the ground floor lounge which is generally underused as most residents prefer to use the conservatory. Residents can choose who they see or do not see. The overall ethos of the home is to maximise residents capacity to exercise personal autonomy and choice. There is only very limited involvement by the provider/manager in the managing of residents money. Currently she holds the pension books for two residents. Additionally the provider manages small floats on behalf of two other residents. Information is provided in the Service Users Guide to the arrangements for residents to access their records. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Residents have confidence in the home’s complaints procedure and the service provider or acting manager’s ability to listen to and act on any complaints made. Appropriate arrangements are made to ensure residents are protected from abuse. EVIDENCE: There is a policy on complaints which is displayed on the residents notice board and included in the staff handbook. Residents identified the service provider/manager as the person they would take complaints to and were confident they would be listened to and acted upon. A record of complaints is maintained. This revealed there have been no complaints since the last inspection. An adult protection procedure has been prepared for the guidance and instruction of staff. Additionally there is a Whistle-Blowing policy and procedure to enable staff to raise concerns. Records revealed that all staff have had training in Adult Abuse and Adult Protection. All staff have been checked by the Criminal Records Bureau (CRB). The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 25 & 26 The overall standard of the environment and maintenance of the home is good, providing residents with an attractive and safe place to live. EVIDENCE: The location and layout of the home is suitable for it’s stated purpose; it is accessible, safe and well maintained and meets resident’s individual and collective needs in a comfortable and homely way. The garden at the rear of the home is of an ideal size and on level ground. There are annual checks by a specialist fire safety company to ensure the home meets the requirements of the Fire Brigade. The last visit by the Environmental Health Officer resulted in a small number of minor requirements and recommendations, that have been implemented. All rooms are naturally ventilated and centrally heated. Guards have been fitted to radiators or hot water pipes. Emergency lighting is provided throughout the home as recommended by the fire brigade. A central valve has been fitted to the tank to ensure the safe delivery of hot water to outlets used by residents. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 13 On the day of the inspection the premises were clean, tidy and free from offensive odours. The location of the laundry is such that items do not have to be taken through communal or kitchen areas. Hand washing facilities are provided in the laundry and kitchen. Policies and procedures for the control of infection have been prepared. Gloves and aprons and other protective clothing are available to staff. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, & 29 The staffing levels are sufficient to meet the needs of the current residents. The recruitment procedures are in need of improvement to ensure safeguards to people living in the home. EVIDENCE: Normal staffing levels for each morning is three carers, one of whom spends some of their time preparing meals, plus a cleaner for every morning, Monday to Friday. During the afternoon period and into the early evening there are two carers, who are also responsible for preparing and serving the evening meal. The provider/manager is normally present each day from 8.00am to 3.00pm, and at other times as required, including weekends. At the weekends the normal provision of staff is three carers each morning, including one who is designated for catering, and two in the afternoon. No cleaner is present during the weekends. Night staffing is one person awake throughout the night. The Inspector reviewed a small selection of staff files. These are well presented, clear and comprehensive. Prospective staff are required to complete an application form. Two independent references are received on all staff. However there are some shortfalls noted in recruitment documentation. Specifically there is no evidence that gaps in employment are being explored and the explanations recorded. This partly due to the insufficient information being provided by prospective staff members. In addition two staff files did not contain photographic identification. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 37 & 38 The home is well managed by a suitably qualified and experienced manager. However the arrangements for staff supervision are inadequate. The quality assurance systems need to be extended. Appropriate arrangements have been made for providing a safe environment for residents. EVIDENCE: The provider/manager is a trained nurse and has extensive experience in managing the home. More recently she has successfully completed the Registered Managers Award. Additionally she has qualified as Work Based Assessor (WBA). The manager also undertakes routine training to up date her knowledge and information. There is a formal and ongoing system of quality assurance in place in the form of an annual questionnaire. The results have been aggregated and made available to residents, relatives and other visitors to the home. However they have not yet been included in the Service Users Guide. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 16 The Inspector discussed with the provider/manager the desirability of extending the quality assurance system to relatives and visiting professionals. Although individual supervision of care staff is provided this is not on a regular basis nor at the frequency recommended by the National Minimum Standards (NMS). Further, not all supervision records were up to date. The Inspector recommended that the provider/manager undertake some training in staff supervision. Staff receive a yearly appraisal. An extensive induction process takes place for all new staff. The provider/manager has prepared a comprehensive set of policies, procedures and record keeping systems. These are generally well maintained and up to date. Residents have been advised through the Service Users Guide of their rights of access to their records and information about them held by the home. All individual and confidential records are kept securely in the provider/manager’s office. The provider/manager has provided a range of health & safety policies. Records show that staff receive regular training, including mandatory training., including moving and handling, first aid and food hygiene. Fire safety training is provided by an external specialist firm. Since the last inspection additional approved door stops have been fitted to many doors to eliminate the use of wedges. Arrangements have been made for the safe storage and disposal of hazardous substances and the regular servicing of gas appliances. Routine checks by a qualified electrician are undertaken. Windows have been made safe through the fitting of restrictors. An accident book is maintained. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 4 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x 2 3 3 The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 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 29 Regulation 19(1)(a)(i )& Schedule 2(1-6) Timescale for action Recruitment of staff must comply 30.08.2005 with the Care Homes Regulations 2001 Requirement 2. 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. 2. 3. 4. Refer to Standard 7 33 36 36 Good Practice Recommendations There should be a review of the arrangements for daily recording on individual care plans. The result of the quality assurance review should be included in the Service Users Guide. The manager should undertake training in staff supervison. The programme of formal supervision of care staff should meet the recommendations of the National Minimum Standards. The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT 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 The Churchley Rest Home H59-H10 S14250 Churchley Rest Home V245880 300805 Stage 4.doc Version 1.40 Page 20 - 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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