Care Home: Church House

Similar services:

• Chirnside House
• Keer Sands Residential Home
• Ruskin Lodge
• Bushell House
• Langrigg House
• Parkside
• Dystlegh Grange
• Thornton Lodge

What the care home does well People interested in going to live at Church House are assessed before admission to make sure that their needs can be met at the home. Residents and their families were very satisfied with the care provided at Church House. A comment received from one relative was: My mother has been a resident for five months her health has improved a great deal, her physical appearance is always good, I feel that the care she receives is very good. Residents receive regular visits from a local GP and the support is provided by other healthcare professionals as and when it is needed. Residents` medicines are well managed. People who live at the home are able to exercise choices in daily living and social activities are provided for those who wish to participate. All areas of the building were very clean and there were no unpleasant odours. The home has a full complement of competent and experienced staff, and regular training is provided for staff. The staff have a kind and caring attitude towards residents.There is a stable management team and their record keeping is of a good standard. What has improved since the last inspection? A new pre-admission assessment tool is now in use and this gives more information to staff about a new resident. Some bedrooms have been decorated and fitted with new carpets. A system of staff supervision has been introduced. What the care home could do better: Regular fire drills must be held so that all staff know how they should respond if a fire should occur. Care plans should be improved so that they contain an assessment of residents` social and emotional needs. Handling plans should provide information for staff about what type of hoist and sling is needed for each person. Risk assessments for the use of bedrails need to be more thorough to show that any risks involved in the use of bedrails have been considered. These points will be addressed with the introduction of the new care documentation provided by Southern Cross. Staff need to receive training about the new policies and procedures, including complaints and safeguarding, to ensure that they are all aware of their roles and responsibilities if they have any concerns. The driveway needs to be repaired so that staff and visitors to the home do not have to negotiate potholes. Some bedroom furniture has become shabby and needs to be replaced, and lumpy pillows should be replaced. Care staff should be encouraged and enabled to achieve a national vocational qualification in care. CARE HOMES FOR OLDER PEOPLE Church House Coole Lane Austerson Nantwich Cheshire CW5 8AS Lead Inspector Wendy Smith Unannounced Inspection 10:30 8 January 2008 th 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 Church House DS0000071061.V354342.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 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. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church House Address Coole Lane Austerson Nantwich Cheshire CW5 8AS 01270 625484 01270 611706 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) Southern Cross BC OpCo Ltd Yvonne Jacqueline Hof Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 44 2. The maximum number of service users who can be accommodated is: 44 Date of last inspection Brief Description of the Service: Church House is a detached, listed building which has been extended and converted into a care home with nursing. The home provides accommodation for up to 44 older people. It is situated in approximately one acre of grounds and is surrounded by countryside. The home is one mile from the town of Nantwich. The home’s fees are from £490 to £590 per week. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. An unannounced visit took place on 8th January 2008 and took four and a half hours. The home had 38 residents, all over 65 years of age. Of these, 27 people were receiving nursing care and 11 were receiving personal care. A tour of the building, including all communal areas and most bedrooms, was completed. A sample of records was looked at and time was spent in conversation with residents, staff and the manager. Some of the information contained in this report is taken from the Annual Quality Assurance Assessment that was completed by the home manager at the request of the Commission for Social Care Inspection. Prior to the visit, comment cards were provided for a number of residents, visitors, social workers and GPs to give their views of the home. The home changed ownership at the end of October 2007 and had a new registration with the Commission for Social Care Inspection. What the service does well: People interested in going to live at Church House are assessed before admission to make sure that their needs can be met at the home. Residents and their families were very satisfied with the care provided at Church House. A comment received from one relative was: My mother has been a resident for five months her health has improved a great deal, her physical appearance is always good, I feel that the care she receives is very good. Residents receive regular visits from a local GP and the support is provided by other healthcare professionals as and when it is needed. Residents’ medicines are well managed. People who live at the home are able to exercise choices in daily living and social activities are provided for those who wish to participate. All areas of the building were very clean and there were no unpleasant odours. The home has a full complement of competent and experienced staff, and regular training is provided for staff. The staff have a kind and caring attitude towards residents. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 6 There is a stable management team and their record keeping is of a good standard. 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 summary of this inspection report can be made available in other formats on request. Church House DS0000071061.V354342.R01.S.doc Version 5.2 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 Church House DS0000071061.V354342.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People interested in going to live at Church House are assessed before admission to make sure that their needs can be met at the home. EVIDENCE: Church House accommodates people needing nursing care and others needing personal care. At the time of the inspection all residents were over 65 years of age. Two people were having a short stay at the home; this service is offered when a room is available. When a referral is received, the manager goes out to assess the person. The Southern Cross pre-admission assessment form is now in use at Church House and had been completed for a resident admitted in December 2007. There was also written information about this person’s needs from health and social care professionals. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 9 If a resident’s needs change then they are referred to social services for reassessment. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents are met to a good standard. EVIDENCE: Each resident has a care plan that contains an assessment of their needs and sets out how their needs are to be met. The care plans are kept in the nurses’ office on the ground floor. A sample of care plans was looked at and they had been completed to a satisfactory standard and kept up to date. Care plans will be gradually changed over to the Southern Cross documentation. The nurses spoken with said that they have been given dates to attend training about completing the new care plans. A ‘dressing plan’ is drawn up for any resident who requires wound care. At the time of the inspection no residents had any significant wounds or pressure sores. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 11 Positive comments about the care provided were received from relatives who completed comments cards. One relative observed that ‘The care received by both of my parents at Church House is excellent. I visit at different times of day and never have any cause for concern or complaint.’ A GP commented that staff are competent and caring. A social worker commented that staff need more training about palliative care. The home receives a regular, two-weekly visit from a local GP and the care plans showed that other health professionals visit residents as required including dentist, district nurses, occupational therapist, dietician, continence advisor, speech and language therapist and tissue viability nurse. A tour of the building showed that residents have the equipment they need for their care. Most residents have a pressure-relieving mattresses and pressurereliving cushions were also provided for people who need them. A number of the more frail residents were put back into bed after lunch for an afternoon rest. Two residents spoken with said that they like to go to their bedroom about 4pm and have their tea in their room. Moving and handling equipment is provided for residents who need this, but handling plans in the care plans did not specify what type of hoist and sling each person needs. A lot of bedrails were in use. These were generally fitted safely and had protective covers, but the risk assessments for bedrails need to be more thorough to ensure that any risk involved with the use of bedrails is identified. There is a locked medicines storage room on the first floor. This was clean and tidy with medicines, including controlled drugs, stored in an orderly and appropriate manner. Medication administration records are well maintained. Good systems are in place for ordering and checking-in monthly prescriptions. Medicines are handed only by registered nurses. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to exercise choices in daily living and social activities are provided for those who wish to participate. EVIDENCE: A programme of social activities is provided from Monday to Friday including bingo, quiz, musical entertainment and manicures. The activities organiser, who is employed for 25 hours a week, also spends social time with residents who choose to stay in their own rooms. The care plans do not currently have any social information or life history for residents, but this should improve with the introduction of the new documentation. Residents spoken with said that they are able to get up and go to bed at a time that suits them. They have a choice of comfortable areas to sit in. There are no restrictions on friends and family visiting. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 13 The menus show that a varied diet is provided for residents and people spoken with were generally very happy with their meals. There is only one main meal shown on the menu each day but residents spoken with said that the cook will always provide an alternative if they don’t like the meal on the menu. Most residents take their meals in the dining room but some prefer to eat in their own room. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place so that people who live at the home, and their relatives, can be confident that their complaints will be addressed and that they are protected from abuse. EVIDENCE: The manager keeps a record of any complaints that are received. No complaints had been recorded during 2007. The home is now adopting the Southern Cross policies and procedures for dealing with complaints and adult protection. Staff will need to receive further training to ensure that they are familiar with the new policies and procedures. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, clean, safe and homely environment. EVIDENCE: The home is set in a rural location surrounded by open countryside. The driveway leading to the home has again become potholed despite being repaired in 2006. There is plenty of communal space and residents have a choice of comfortable sitting areas. The carpet in the dining room is going to be replaced with nonslip flooring in the near future. There is no indoor area where residents or staff are permitted to smoke. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 16 Bedrooms vary in size and some have an en-suite toilet. Some bedrooms are personalised with many of the residents’ belongings. There are two double rooms but both were singly occupied by residents who had chosen to pay for a larger room. Some of the bedroom carpets have been replaced. Carpets in three bedrooms were wrinkly, although they did not appear to present a trip hazard. Some of the bedroom furniture, vanity units and cupboards, have become shabby and there were some lumpy pillows. There are enough assisted bathrooms and shower rooms to meet the needs of residents. The laundry and sluice rooms were clean and tidy. All parts of the building were clean and there were no unpleasant odours. A representative from Southern Cross estates department has surveyed the building and identified repairs that needed to be carried out including an external door to be replaced, problem with the hot water supply in part of building, and new bath panels. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough qualified and experienced staff to ensure that the needs of the residents can be met. EVIDENCE: The home has a full complement of staff. There are two nurses and seven carers on duty in a morning, two nurses and five carers in an afternoon/evening, and one nurse with three carers at night. The manager said that, if the home has more than 40 residents, a fourth carer is put on at night. There is minimal use of agency staff. All of the staff spoken with were friendly and helpful and the residents spoken with expressed their satisfaction with the staff and with the kindness they receive from staff. Recruitment records for the two most recently recruited staff were looked at. The records showed that good recruitment procedures had been followed. A POVA first check had been received and they were awaiting return of criminal records bureau disclosures. The manager said that new staff have two days classroom based training followed by three days supernumerary working alongside experienced staff. After this there is a probationary period of induction and a record of the induction is kept. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 18 Seven of the care staff have achieved a national vocational qualification in care. Others are waiting to start but this is a little delayed due to the change of ownership of the home. The manager keeps a training matrix and this showed that all staff have attended mandatory training to ensure that they work safely. The home is now moving to the Southern Cross training programme. All catering and care staff will be doing Food Hygiene training during January and February 2008. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable and experienced management team who ensure that the health, safety and well-being of residents are protected. EVIDENCE: The manager, who is a qualified nurse, has been in post for three years. She works supernumery to the staffing rota and has a deputy manager who shares ‘on call’ management cover. The manager is working towards the Registered Manager Award. An administrator is employed to deal with office tasks. In a survey form, a social worker commented that the manager is approachable and a relative considered that: the manager and deputy are always willing to discuss any concerns I may have. The manager will be starting a weekly ‘evening surgery’ for families to come and discuss the care of their relative. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 20 The home was previously owned by Bondcare, but in 2007 became part of the Southern Cross group. Southern Cross policies and procedures are now being introduced. A quality assurance system, including weekly and monthly auditing, is in place. The home does not handle any residents’ finances except for personal spending money. There is a satisfactory system to enable residents to have personal spending money available at the home. The annual quality assurance assessment provided details of the testing and servicing of plant and equipment in the home. The home’s maintenance person does weekly emergency lighting, fire alarm, and hot water checks. There is a fire risk assessment for the building and this is being reviewed and updated. At the time of the inspection regular fire drills were not being carried out and the manager was advised that fire drills should be started without delay. The names of staff attending fire drills need to be recorded. Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 21 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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 OP38 Regulation 23(4)(c) Timescale for action Ensure that all staff participate in 28/02/08 regular fire drills so that they are familiar with fire procedures. Requirement 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 Refer to Standard OP19 OP19 OP18 Good Practice Recommendations Improve the driveway so that staff and visitors do not have to negotiate potholes. Some bedroom furniture has become shabby and needs to be replaced, and lumpy pillows should be replaced. Staff need to receive training about the new policies and procedures, including complaints and safeguarding, to ensure that they are all aware of their roles and responsibilities if they have any concerns. Encourage and enable care staff to achieve a national vocational qualification in care. 4 OP28 Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Church House DS0000071061.V354342.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!