Archived: Christian Head

Updated 24 April 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 6th March 2015 and was unannounced. The inspection was carried out by an adult social care lead inspector.

During the inspection we spoke with 11 people who lived in the home, two relatives/visitors, five care staff, domestic staff, the supervisor on duty and the registered manager. We observed care and support in communal areas and spoke to people alone and in groups, in private and communal areas. We also spent time looking at records, which included looking at six people’s risk assessments and care plans to help us track how their care was being planned and delivered. We also looked at staff rotas, staff training and supervision and records relating to the maintenance and the management of the service and records regarding how quality was being monitored.

As part of the inspection we also looked at medicines and care plans relating to the use of medicines. We looked at their storage, administration and disposal to see if they were handled safely.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. It is a tool to help us assess the quality of interactions between people who use a service and the staff who support them.

Before our inspection we reviewed the information we held about the service. We also spoke with the local authority and social workers who came into contact with the home to get their views of the home. We looked at the information we held about notifications sent to us about incidents affecting the service and people living there. We looked at the information we held on safeguarding referrals, concerns raised with us and applications the manager had made under Deprivation of Liberty Safeguards (DoLS).

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. They provided this information in good time.

Updated 24 April 2015

This unannounced inspection took place on 6th March 2015. We last inspected Christian Head in October 2013. At that inspection we found the service was meeting all the regulations that we assessed.

Christian Head is a residential care home that provides personal care and accommodation for up to 31 people. Accommodation is provided over two floors and within four units, one of which specialises in providing care for people living with dementia. Christian Head is located close to local shops and services in Kirkby Stephen including doctors' surgeries, banks and churches. There is a well maintained secure garden for people living there to use and some car parking available for visitors and staff.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People were not safe because there were not sufficient staff on duty at certain times of the day. There had not been any risk assessment or needs analysis done as the basis for deciding staffing levels and deployment to make sure there were always enough staff available to meet the needs of people

Despite having been reviewed some information in the care plans was contradictory and changes in care had not always been recorded for staff to follow. Care records were not always completed fully on how to support people.

The service was not well managed and the systems used to assess the quality of the service were not effective in identifying where records were not correct.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to maintaining staff levels at all times, care records that were not always completed to provide up to date information for staff to follow and not monitoring the quality of service well enough.

You can see what action we told the provider to take at the back of the full version of the report.

At the time of the inspection there were 28 people living in the home. We spoke with people in their own rooms and with those who were sitting in the communal areas. We were told by people that they were “comfortable” and that staff were “very good” and “Look after us well”. People told us that they felt safe living in this home. One person told us, “I am happy living here” and “They (staff) are all nice, they come and help me”.

Staff we observed with people living at Christian Head were patient and polite when supporting people who used the service. We observed staff supporting people to eat their meals sensitively and in the way the person wanted. Staff supported people to maintain their dignity and were respectful of their privacy and respected their choices. Activities were on offer at the service and people told us how they were able to go out and access activities in the local community.

People told us they were able to see their friends and families as they wanted and go out into the community with support. The visitors we spoke with told us that staff were “friendly” and “welcoming”. People were asked for their views of the home and their comments had been acted on indicating an open and inclusive environment.

The registered provider for the service had good systems in place to ensure staff were only employed if they were suitable and safe to work in a care environment. Staff training needs were planned for.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. The service has worked with external agencies such as social services and district nursing services to provide appropriate care to meet people’s different needs.

Medicines were stored safely and records were kept of medicines received and disposed of so all of them could be accounted for.

People knew how they could complain about the service they received and were confident that action would be taken in response to any concerns they raised.

The home was being maintained and we found that all areas were clean and free from lingering unpleasant odours.