Inspection on 14/01/09 for Joybrook

This is the latest available inspection report for this service, carried out on 14th January 2009.

CSCI found this care home to be providing an Good service.

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

Joybrook 23/08/06

Joybrook 14/02/06

Joybrook 03/11/05

Joybrook 21/03/05

Joybrook 21/12/04

Joybrook 18/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Joybrook 86 Braxted Park Streatham London SW16 3AU Lead Inspector Alison Pritchard Unannounced Inspection 14th January 2009 12:30p 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 Joybrook DS0000022738.V374137.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. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Joybrook Address 86 Braxted Park Streatham London SW16 3AU 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) 0208-764-2028 0208679 1138 joybrook@hotmail.co.uk JoyCare Home Services Limited Mrs Janet DeHaney Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Joybrook DS0000022738.V374137.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 Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 15 15th January 2008 Date of last inspection Brief Description of the Service: Joybrook is a 15-bedded private home for older people operated by a small family business, which includes the manager. It is situated on the corner of a pleasant residential road, within walking distance of Streatham Common. It is a short bus ride from a local shopping centre which has rail and bus transport and full community facilities. The home has 11 single and 2 double bedrooms, some on the ground and some on the first floor accessed by a lift. All of the communal areas are on the ground floor. The Manager has been at the home for approximately 15 years and there is a stable staff group. There was one vacancy at the home in January 2009. The current weekly fees for placements at the home range between £427 and £589. Additional charges are made for: Clothing Dry cleaning Escorting to appointments Gifts Hairdressing/barbering Name branded food Newspapers and magazines Private phone installation, international and mobile calls Satellite/cable television Toiletries Treats Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 5 The Registered Manager has stated that information about Joybrook is available to potential residents through the home’s inclusion on the approved list of care homes for Lambeth and Wandsworth Councils. She also said that people who have had dealings with the home make ‘word of mouth’ referrals. Potential residents are referred to the CSCI website to read reports, and if they do not have access to the internet a copy of the most recent report is provided for them by the home. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was unannounced and carried out over two days in January 2009. The inspection methods included discussion with service users, the Registered Manager, the Deputy Manager and staff; observation of care practice; a tour of the building; inspection of files and a range of records and policy documents. Service users, staff and involved professionals were sent survey forms so that they could contribute to the inspection process if they wished. We are grateful for the contributions received. The CSCI has access to information gathered through notifications from the home. A document called an ‘Annual Quality Assurance Assessment’ (AQAA) was completed by the Registered Manager of the home and returned to the inspector. It provides information about how the home is addressing the National Minimum Standards along with factual information about the operation of the home. All of this information has been taken into account in compiling this report. The Registered Manager, Deputy Manager and staff facilitated the inspection visit. They were helpful and courteous throughout the process. What the service does well: Service users gave us good feedback about the home. One person said that they had settled in ‘very well’ and said ‘I’m very grateful to everyone, it’s very good, extremely good.’ The meals provided are enjoyed by the people who live at Joybrook. Plenty of choice is available, including a vegetarian option and a Caribbean dish at each lunch-time. One of the service users said ‘I like the soup, yam and dumpling served here.’ All of the staff have been trained and have an NVQ 2 or above. The staff are warm and respectful to the service users. Several members of the team have worked at the home for a long time and this provides stability for the service users. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: We have made three requirements and five recommendations. The requirements concern: • the need for service users who look after their own medication to be supplied with safe storage facilities; • the agreement of the GP to the homely remedies must be requested, and verified; • risk assessments must be full and detailed, particularly for moving and handling tasks and the use of bedsides. The recommendations concern: • an assessment of the home’s procedures using the Department of Health guidance (‘Essential Steps’) to ensure that they are meeting best practice guidelines in relation to infection control. • The Common Induction Standards produced by Skills for Care should be used for the induction of new staff. • Training should be provided for the home’s activity co-ordinator. • Advice should be sought on establishing an effective quality assurance system. • Staff who undertake risk assessments should receive relevant training. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 8 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. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 9 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 Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for admission mean that a potential service user and the home have enough information to decide whether a placement will be suitable. EVIDENCE: At the last inspection in January 2008 we said that some changes needed to be made to the service user guide so that potential and current service users were clear about the additional charges that would be made. The documents now include the necessary information. Service users receive contracts and a copy is included as part of the statement of purpose. The pre-admission assessment completed by the home includes a range of useful details which will enable the home to assess if they can meet the person’s needs, and will be used to formulate a care plan. Assessments by placing social workers are also obtained. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 11 A service user who has come to live at the home recently said that he had settled there and found that the care was good. He visited the home prior to moving in. The first month of a placement is regarded as a trial period. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A new care plan format is being introduced which is an improvement on that which was previously used. This will mean that service users’ care needs can be described properly and staff guided on how to meet them. Arrangements for the management of medication are better but there are two improvements to make. These should be easily achieved. Service users are treated well and with regard for their privacy and dignity. EVIDENCE: We looked at a selection of service user files and found that on some of them the new care plan format has been introduced. The Registered Manager is aware of the need for the new plans to be in place for all of the residents. The new format is much clearer than that previously in use and relates to the information gathered at the assessment stage. The Registered Manager and Deputy Manager have received training in care planning and this has been beneficial to them. The completed plans had relevant information including information about personal care needs, social needs, medication and nutrition. Each section Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 13 identified care needs, care goals and the interventions which would address these areas. One of the newer care plans had been signed by the service user, indicating his agreement with the needs identified and how the home intends to meet them. There is also a system for reviewing each of the care plans at monthly intervals, as a minimum. This changes meets the requirements of the last inspection, we encourage the home to implement the new plan for each of the service users. We found that there has been contact with a range of health care professionals relevant to the service users’ needs. If a service user has nursing needs these are addressed by the Community Nursing services. Service users who responded to the surveys said that they received the medical support they need. At the last inspection we identified that there had been a high number of falls in the home and that specialist advice was necessary. At this visit we saw evidence of contact with a specialist falls clinic and that there was a higher level of awareness about the risk of falls and that they are being monitored. The home has a clear medicines policy. When we visited one of the service users was looking after her own medication. When we asked further about this we were told that the service user did not have a lockable space within her bedroom in which to store her medication. In response the medication was stored safely in the main medication cabinet for the home. The service user to whom, this applied has now left the home. In order to enable service users to maintain as much independence as possible it is required that service users who wish, and are deemed capable of self medicating, are supplied with appropriate facilities. See requirement 1. The medication file was in good order, there is a photograph of each of the residents fore identification purposes, allergies were noted on the medication administration record and there were no unexplained gaps. A list of ‘homely remedies’ (over the counter medication) is in place but this has not been agreed by the GP. The Registered Manager must request that the GP look at the list of products specified as homely remedies and be asked to sign to indicate agreement or otherwise. See requirement 2. Four of the care staff have received training in medication issues and the Registered Manager and Deputy Manager had training arranged for late January 2009. The service users said that they are looked after in a way that meets their needs and that staff listen to them and act on what they say. We saw staff being respectful and kindly towards service users. The service users said that their privacy is respected, they can spend time in their rooms if they wish. Personal information is stored with regard for confidentiality. In the two double rooms screening is available to maintain privacy. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a range of activities in the home. Spiritual needs are attended to. Service users are assisted to keep in touch with people important to them. Meals are enjoyed by the service users, plenty of choice is available and cultural needs are included in the menu planning. EVIDENCE: There is an activity co-ordinator working at the home, she has been employed since our last inspection. While we were at Joybrook we saw her organising a music and movement session which service users said they enjoyed. A local tutor visits the home weekly to arrange gentle exercise sessions. Every fortnight people from a local Roman Catholic Church visit the home, some of the residents go out to local churches with the assistance of family or friends. Some of the service users are able to go out independently. During the warmer months outings were organised including to Brighton, a pub and for a picnic at the Rookery on Streatham Common. Over the Christmas period a party had been held. Some service users said that they would like to go out more often as this is something that they particularly enjoy. On the home’s AQAA they Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 15 acknowledged that although more outings had been arranged for this year this remains an area for development. Our second visit to the home took place on a service user’s birthday. The event was celebrated with a cake with candles and singing Happy Birthday. The lounge had been decorated with banners saying happy birthday. Family and friends can visit freely and stay in touch with relatives by telephone. The recent addition of a room in the communal area makes it more possible for service users to see their visitors privately. Some of the residents manage their own financial affairs, others have family to take on this task on their behalf. A small number of residents have the input of the Registered Manager to manage their finances. This is discussed further at ‘Complaints and Protection’ below. There is a four week rolling menu. The meals provided are enjoyed by the people who live at Joybrook. Plenty of choice is available, including a vegetarian option and a Caribbean dish at each lunch-time. One of the service users said ‘I like the soup, yam and dumpling served here.’ Another person said that she enjoyed the food and said ‘the meals are very good…you eat what you want you see.’ On one of the days that we visited the service users had a fish and chip take away meal from a local shop. Several people said that they enjoyed this and that the meal was hot enough. We noted that service users were regularly offered drinks and staff have been reminded of the importance of this. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 16 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): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know how to raise concerns. The home has made appropriate referrals to safeguarding authorities. This all assists in the protection of service users. EVIDENCE: The complaints procedure is included in the statement of purpose and is clear. Service users said that they knew who to speak to if there were not happy, although two of the six people said that they did not know how to make a complaint. This may suggest that it would be useful to remind the service users of the complaints procedure occasionally, perhaps at service users’ meetings. There were no complaints recorded since our last inspection. We noted that the address of CSCI was not up to date, the procedure should be reviewed and amended to reflect the change. At the last inspection we required that the Registered Manager liaise with the local authority safeguarding department to ensure that the home’s procedures were consistent with their own. We were told that a copy of the procedure had been forwarded to the Safeguarding Co-ordinator for comment but no response had been received. This should be followed up further by the home. The home has had appropriate contact with safeguarding authorities and the Registered Manager is aware of her responsibilities. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 17 At the last inspection we required that some improvements be made to the way in which the home manages service users’ finances on their behalf, we found that these requirements have been met and this has increased the protection available to residents. Access to finances is limited to senior staff and two staff sign to verify items of expenditure. At the time of our visits the home was not looking after any valuable items on behalf of service users. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 18 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): 19, 20, 21, 23, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from a comfortable and well maintained home which has facilities appropriate to their needs. So that they are sure that the best practice in infection control is being followed an assessment of their procedures should be conducted by the home. EVIDENCE: The home is a large semi-detached house in a residential area of Streatham. There is plenty of on—street parking available. There is adequate communal space for the service users. One end of a communal room has had folding doors added and this has created a small room which can be used for private meetings or individual activities. There is some sensory equipment in the room and this creates a relaxing atmosphere. This has improved the facilities available to service users. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 19 The communal areas are now decorated with items relevant to the service users. The staff notices previously on display have been removed to the hallway of the home and areas specifically for staff. There is an accessible garden to the rear of the home and the Registered Manager said that she has plans to develop raised beds with sensory items there so that service users can benefit more from the space. There is a shower room on the ground floor of the home, and a bathroom which cannot be easily used. On the first floor is another shower room. It is intended that the ground floor bathroom will be converted to a wet room. We were told about this plan on our inspection of the home in 2008, so anticipate that this year the goal will be achieved. Bedrooms were in good condition and personalised. The rooms vary in size. Service users said that they are happy with their rooms. Some redecoration of bedrooms has been undertaken and this has improved the appearance of the rooms. The home is adequately clean and laundry facilities are appropriate for the needs of the home. We learned from the AQAA that nine of the staff have received training on infection control matters. We recommend that the home conduct an assessment of their procedures using the Department of Health guidance (‘Essential Steps’) to ensure that they are meeting best practice guidelines in this area. See recommendation 1. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29, 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 adequately trained staff to meet service users’ needs. The home should consider using the Common Induction Standards developed by Skills for Care, this will improve the induction training for new staff. Staff with a specialist role should be provided with appropriate training. EVIDENCE: In addition to the Registered Manager and the Deputy Manager the staff team consists of nine care workers and an Activity Co-ordinator. All of the care staff are qualified to NVQ level 2 or above. The staffing levels are for there to be two staff on duty throughout the day with an additional member of staff on duty between 8am and 11am. This allows service users to have flexibility about the time they rise from bed and still have any necessary assistance. In addition there will be at least one of the managers and the activity co-ordinator on duty during the weekdays. At night time a member of staff is on night duty and another member of staff on sleep in duty at the home, available to be called to assist. There is a support staff team consisting of a cook and a cleaner and the Deputy Manager deals with administrative functions. Training in a range of issues has been provided over the last year, including health and safety and care issues. The activity co-ordinator received induction to the home but the Common Induction Standards which have been developed by Skills for Care are not used. They set down the minimum expectations about the learning outcomes that need to be met so that new workers know all Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 21 they need to know to work safely and effectively. We recommend that these standards are used by the home. It is also recommended that the Activity Coordinator receive training in activities for older people. See recommendations 2 and 3. The file of a newly recruited member of staff was examined to make sure that legal requirements are met. The file included the appropriate checks. Changes required at the last inspection have been introduced. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems will be improved by an effective quality assurance system being introduced. Advice on this issue is recommended. Residents’ finances are safely managed. Although many aspects of health and safety are good risk assessments need further development. EVIDENCE: The Manager of the home has been registered for many years and is very familiar with the operation of the home and the residents. She and the Deputy Manager have begun work on the Registered Manager’s Award. They have both undertaken training over the last year in a range of relevant issues, particularly care planning systems. This has led to improvements in the home which were identified as necessary at the inspection of January 2008. We saw questionnaires which have been used over the last year to survey the opinions of service users, staff and relatives. These are useful documents but it Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 23 has been noted on several previous inspections that a systematic quality assurance system is required. This will assist the Registered Manager to assess the performance of the home and to establish an agenda for future improvements. In the AQAA completed in July 2007 it was stated that it was intended that the AQAA would be used to formulate a quality assurance system. This has not been achieved and the AQAA completed in 2008 demonstrated that there had been little progress in this area. It is recommended that the Registered Manager seek advice in how to establish a quality assurance system. See recommendation 4. The Registered Manager said that discussions are on-going to confirm a suitable person to carry out visits to the home under Regulation 26. Such visits should provide an opportunity for service users and staff to raise issues with an external person and act as an additional form of protection. When this has been finalised reports of the visits must be available for inspection. The home looks after the finances of a small number of service users. We examined records about these. Cash, which builds up at the home, is deposited in a bank account specifically for this purpose. Records are kept to ensure that there is clarity about to whom the money belongs. We checked these records and they were satisfactory and accurate. Access to the funds is limited. We found on our first visit that payments to the hairdresser should be recorded on receipts issued by the hairdresser rather than just on petty cash slips. When we returned on this action had been taken, and the amount spent was confirmed by the signatures of two members of staff. Overall the financial records were in good order. We looked at the health and safety records. They showed that checks of equipment in the home are carried out at appropriate intervals. This included the gas appliances, electrical appliances and the fire safety systems. The fire risk assessment was reviewed in March 2008, as required by the last inspection. An area that we saw needed improvement is in the area of risk assessment. We saw risk assessments for a number of issues relating to specific service users, including falling, wandering and inappropriate behaviours. These documents did not adequately address the issues and need development. However we did not see a risk assessment relating to the use of bedsides, which were being used at the time we visited. We provided information on this issue after the inspection. See requirement 3 and recommendation 5. Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 24 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Timescale for action So that service users to maintain 01/04/09 as much independence as possible it is required that service users who wish, and are deemed capable of self medicating, are supplied with lockable storage facilities. The Registered Manager must 01/04/09 request that the GP look at the list of products specified as homely remedies and be asked to sign to indicate agreement or otherwise. So that risks to service users are minimised, assessments must adequately describe the risks and the action to be taken to minimise them. Full and detailed risk assessments for the use of bedsides and moving and handling tasks must be conducted. 01/04/09 Requirement 2. OP9 13(2) 3. OP38 13(4)(c) Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 26 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 OP26 Good Practice Recommendations We recommend that the home conduct an assessment of their procedures using the Department of Health guidance (‘Essential Steps’) to ensure that they are meeting best practice guidelines in relation to infection control. We recommend that the Common Induction Standards developed by Skills for Care are used by the home to induct new staff into their role. It is recommended that the Activity Co-ordinator receive training in providing activities for older people. It is recommended that the Registered Manager seek advice in how to establish a quality assurance system. It is recommended that the staff responsible for undertaking risk assessments receive training in this area. 2. OP30 3. 4. 5. OP30 OP33 OP38 Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Joybrook DS0000022738.V374137.R01.S.doc Version 5.2 Page 28 - 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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