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Inspection on 31/01/06 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 31st January 2006.

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 outcomes for residents living at The Churchley Rest Home are very positive. The home provides a relaxed and friendly atmosphere and staff were seen to be caring and knowledgeable about residents needs. The owner/manager runs the home in a professional yet caring manner and supports her staff team well. The staff team work well together and all stated that they were happy working in the home. Accommodation within the home is of a high standard and rooms were seen to be comfortable and homely.

What has improved since the last inspection?

Since the last inspection the home has reviewed the way daily entries are made into residents care plans. Quality Assurance information is now included into the service users guide. All doors within the home now have magnetic closures and no longer need to be wedged open. Three bedrooms have been redecorated and the external fascias and guttering have been replaced. The kitchen has been totally refurbished. Two of the senior staff members successfully completed their NVQ Level 4 training in October 2005. The owner/manager is undertaking a training course in staff supervision.

CARE HOMES FOR OLDER PEOPLE The Churchley Rest Home 91 New Church Road Hove East Sussex BN3 4BB Lead Inspector Merle Blakeley Announced Inspection 31st January 2006 10:00 X10015.doc Version 1.40 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 The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000014250.V269538.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Churchley Rest Home Address 91 New Church Road Hove East Sussex BN3 4BB 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) 01273 725185 The Churchley Rest Home Ltd Mrs Karen Deborah Lewis Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users should be aged 65 years or over on admission The maximum number of service users to be accommodated is 18 That one named service user who has dementia may be accommodated in the home 28th February 2005 Date of last inspection 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 ensuite facilities. There is a good range of communal space. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection was carried out over a period of five hours on 31st January 2006. The inspection process included a returned pre-inspection questionnaire, twenty-eight returned service user and relative feedback forms, discussions with several residents, a tour of the premises, document reading and informal talks with the owner/manager and staff on duty. Comments from the fourteen service user feedback forms were very positive towards the care the home is providing. There were also many positive comments about the staff. The fourteen relatives/visitors feedback forms also provided very positive comments, such as “The home is excellent, friendly, homely and comfortable with nice staff” and “an excellent home, well run and always friendly”. One relative stated that they would like to see residents encouraged to participate in more physical exercises. What the service does well: What has improved since the last inspection? Since the last inspection the home has reviewed the way daily entries are made into residents care plans. Quality Assurance information is now included into the service users guide. All doors within the home now have magnetic closures and no longer need to be wedged open. Three bedrooms have been redecorated and the external fascias and guttering have been replaced. The kitchen has been totally refurbished. Two of the senior staff members successfully completed their NVQ Level 4 training in October 2005. The owner/manager is undertaking a training course in staff supervision. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 6 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 DS0000014250.V269538.R01.S.doc Version 5.1 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 1&2 The home has produced a service users guide. Residents are provided with contracts once they have moved into the home. EVIDENCE: The home has produced a service user guide, which includes information about the services provided, aims and objectives of the home, terms and conditions, residents charter of rights, staffing, records, complaints, facilities and mealtimes. There are also copies of contracts and residents survey forms included. Each resident is provided with a contract, which is signed by the resident and the manager. Residents are given a copy of their contract. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 9 & 11 Staff will need to update their medication training. Resident’s personal wishes are recorded in regards to illness and dying. EVIDENCE: Medication records were viewed during the inspection and two errors were identified. Currently one resident self medicates and a risk assessment has been carried out. This risk assessment is reviewed once a month to ensure that the resident is still able to manage her own medication. Staff last attended medication training in March 2004 and it was discussed with the manager that an update on training for staff would be recommended. The vast majority of residents have relatives who will carry out their wishes regarding illness and dying. The home has recorded the wishes of those residents who do not have any family members. All residents have now had their wishes recorded in their care plans. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 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 the following standard(s): 15 The home ensures that residents receive a well-balanced diet. EVIDENCE: Staff prepare meals for the residents on a daily basis and a fairly traditional menu is offered. Residents are consulted about the menu and they are offered various options. The senior staff member who prepares the meals from Monday to Friday has previous catering experience. Of the fourteen service user feedback forms that were returned twelve residents stated that they liked the food and two stated that they liked the food sometimes. Overall, residents appeared to be quite happy with the quality and quantity of the meals provided. The kitchen has undergone a total refurbishment. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 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 the following standard(s): 18 The home has an Adult Protection policy and procedure. EVIDENCE: The home has produced a policy and procedure in relation to adult protection. All staff have attended adult protection training during 2004/2005. An adult protection alert had been raised in the past but this was found to be unsubstantiated. All staff have undergone CRB checks. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 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 the following standard(s): 21, 22, 23 The home has sufficient bathrooms and toilets. The home has been assessed by an occupational therapist. Residents live in comfortable and well-furnished bedrooms. EVIDENCE: The home has sufficient toilets and bathrooms throughout; seven of the bedrooms have en suite facilities. The home was assessed by an occupational therapist in 2004 and it was recommended that the home provide two additional grab rails in the communal toilets. This was carried out at the time. Resident’s bedrooms that were viewed on the day appeared homely and comfortable. Although all bedrooms are furnished residents are able to bring in small pieces of their own furniture and other personal belongings. This helps to make the rooms much more personalised for each resident. All areas within the home are maintained to a high standard. All rooms contain a telephone point, a TV point plus an emergency call bell. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 13 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 Three staff have obtained NVQ qualifications. Staff recruitment files need to contain recent photos of all staff members. The home provides staff with a good level of core skills training. EVIDENCE: To date three staff members have obtained NVQ Qualifications and this represents 25 of the team. Two staff have NVQ Level 4 and one staff member has NVQ Level 3. The two staff that have obtained their NVQ Level 4 are continuing on with their studies and are being supported to complete the Registered Managers Award. This is very commendable. The owner/manager stated that other staff members are not very interested in participating in the NVQ training. It will be recommended that the home try to encourage more staff to commence NVQ training. The staff team on duty appeared caring and friendly and were very knowledgeable about each residents needs. Three staff members were spoken to during the inspection and they all stated that they enjoyed working in the home and felt well supported by the owner/manager. Staffing recruitment files were viewed and although up-to-date they still need to be provided with photos of each staff member. This was highlighted during the last inspection. The application forms also need to include a statement as to whether the applicant is mentally and physically fit to carry out their duties. Staff training was discussed and it was evident that staff are receiving a good level of core skills training. Staff stated that they had attended training in The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 14 infection control, adult protection, food hygiene and fire safety. Training planned for 2006 includes first aid and medication training. The owner/manager has also booked to attend a training course on staff supervision. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 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 31, 33, 35 and 38 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, 35 & 38 The home is managed in an open and friendly manner. The home carries out suitable financial procedures. Most of the residents deal with their own finances. There were no major health & safety issues identified during this inspection. EVIDENCE: The home has a relaxed and friendly atmosphere and residents confirmed this. The owner/manager was seen to have a very good working relationship with both residents and staff. Residents said that they would not hesitate in going to the manager or any other staff member if they had any worries or concerns. Staff meetings are held several times a year. The home carries out all the required financial procedures. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 16 Most residents attend to their own financial affairs with the help of relatives and friends. The owner/manager is an appointee for one resident and these records were viewed and found to be in order. Since the last inspection a Fire Safety report was carried out in October 2005 and during this time staff also received fire safety training. It was stated that checks are carried out on hot water outlets on a two-monthly basis. These checks need to be carried out much more frequently and need to be done weekly to ensure that hot water is being delivered at the correct temperature. The call bell system is being checked on a quarterly basis and again this also needs to be checked on a weekly basis. Refurbishments to the home since the last inspection have included a redecoration of three bedrooms and new fascias and guttering to the exterior of the building. The kitchen has also been totally refurbished. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 3 3 X X X STAFFING Standard No Score 27 X 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 X X 2 The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Timescale for action 19(1a)(i)& Recruitment of staff must comply 31/03/06 Sch2(1-6) with the Care Homes Regulations 2001 and include photos of each staff member. (Previous Requirement) 12(1)(a) 12(1)(a) To ensure that hot water temperatures are checked and recorded weekly. To ensure that all call bells are checked weekly. 01/02/06 01/02/06 Regulation Requirement 2. 3. OP38 OP38 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. Refer to Standard OP9 OP28 Good Practice Recommendations That staff update their medication training. That more staff are encouraged to undertake NVQ Training. The Churchley Rest Home DS0000014250.V269538.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex 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 DS0000014250.V269538.R01.S.doc Version 5.1 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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