Inspection on 12/04/05 for 9-10 Jutland Place

This inspection was carried out on 12th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

9-10 Jutland Place 22/08/07

9-10 Jutland Place 05/04/06

9-10 Jutland Place 10/10/05

9-10 Jutland Place 03/11/04

9-10 Jutland Place 10/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 9/10 Jutland Place Pooley Green Egham Surrey TW20 8ET Lead Inspector Megan McHugh Unannounced 12 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 9/10 Jutland Place Version 1.10 Page 3 SERVICE INFORMATION Name of service 9/10 Jutland Place Address 9/10 Jutland Place, Pooley Green, Egham, Surrey. TW20 8ET 01784 436647 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap Society Ms Jan Tregelles CRH (PC) 8 Category(ies) of Learning disability (LD) 7 registration, with number of places Learning disability over 65 years of age LD(E)) 1 9/10 Jutland Place Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be: UNDER 65 YEARS OF AGE. One named service user who is over the age of 65 years, may be accommodated in the home. Date of last inspection 03 November 2004 Brief Description of the Service: Jutland place is located in a residential area of Egham. The home is a detached property formed from two semi detached houses and is in keeping with the surrounding area. The home is close to local amenities and service users are assisted to access these as much as possible.The home provides accommodation for eight service users, male and female, with a learning disability. Service users attend day services and learning facilities Monday to Friday and the staff provide activities on the weekends. There is a secure garden to the rear of the property and communal parking to the front of the premises. 9/10 Jutland Place Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours with two inspectors. A tour of the premises was undertaken and staff and care records were sampled during the day. Staff were spoken with during the course of their duties and six of the eight residents were spoken to during the day. What the service does well: What has improved since the last inspection? What they could do better: The staff still need to be given chances to attend specialised training relating to the work they do in the home with the residents. For example: training in ageing and dementia in people with learning disabilities, epilepsy, managing behaviours. 9/10 Jutland Place Version 1.10 Page 6 All care plans must be updated on a more regular basis, especially in relation to the older resident. The kitchen needs to be refurbished as the work surfaces next to the cooker are worn and split in areas and one cupboard door was hanging off its hinges. The staff stated that the manager has already requested this work to be done, however this matter should still be pursued to ensure the request is being dealt with. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 9/10 Jutland Place Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 9/10 Jutland Place Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Residents have the information they need to make an informed choice about where to live, although the information could be more user friendly. The home has an appropriate admission procedure in place that includes a needs assessment of an individual and offers the person an opportunity to visit the home on several occasions. Contracts were in place for residents whose files were looked at. EVIDENCE: The statement of purpose was updated last year following the new manager in post. Both the statement of purpose and the residents guide could be made more user friendly for residents in the home. The home has not had any new admissions since it opened and the procedure is based on what the home would like to do should a place become available. The admission procedure talks about pre-admission assessments that must be carried out and offers trail visits to the home on numerous occasions. Staff stated that the current group of residents would be actively involved in the process of choosing a new resident. This was not discussed with any of the residents, as we did not wish to cause any confusion or upset. Residents’ files that were looked at contained contracts between the home and the resident and some were signed by the residents, acknowledging their understanding of the agreements. 9/10 Jutland Place Version 1.10 Page 9 9/10 Jutland Place Version 1.10 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10 The systems for service user consultation were good, with a variety of evidence that indicated that residents views are sought in relation to their needs and aspects of their lives in the home. There was clear care planning and risk assessing in place but these were not kept under consistent review. EVIDENCE: The staff are still in the process of changing over to person centred plans and evidence of the work done was available. This included a great deal of input from the residents who have helped make large charts and have given staff their life histories. These plans, although full of information are not reviewed every 6 months as required. One resident falls under the older people Standards and must have his care plan reviewed on a monthly basis, which is not being done at present. This resident has been unwell recently and must have their plans kept under constant review in relation to their needs and with the regular reviews being held Residents informed the inspectors that they were involved in the running of the home, they helped decide the menus, helped choose new staff, decided on what paint colours should be used in redecoration and more. Residents stated that they were aware of risks to themselves inside and outside the home and 9/10 Jutland Place Version 1.10 Page 11 that was why the staff were there, to help them. The written risk assessments were not kept under consistent review: some were up to date and others were not, especially in relation to the resident who has been unwell and whose needs have changed. One resident commented that he had a key for his bedroom door that he kept locked but that he did not want a key for the front door, as he preferred to ring the doorbell. Staff confirmed that those residents who are able to safely hold the front door and/or bedroom key are asked if they would like to have one. However, all the residents preferred to ring the doorbell, even those who have keys. 9/10 Jutland Place Version 1.10 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17. Links with the local community are good and through this the residents are well supported in social and educational aspects. The menus are chosen by the residents and offer variety and take into account any preferences or dietary needs. EVIDENCE: Residents stated that they have an activity programme in place, which included a home day. They said they choose the activities they like to take part in and these included karaoke, pottery, life skills, drama, makatron choir, selfadvocacy, cookery, make the most of yourself, coping with an emergency and many more. On their home day they usually go out with their key worker and the residents on home day on the day of the visit stated that they had bought a desk each, one for his computer, the other for his drawings. There was evidence that residents are offered the opportunities to attend church although many do not wish to attend. One resident attends some evening classes with their parent and all relatives are encouraged to be involved in the home and the residents’ lives. One resident stated that another 9/10 Jutland Place Version 1.10 Page 13 resident’s brother had helped put their new desk together and their family often visited them. It was disappointing to note that the weekend staffing levels, which were commended in the previous report, have now been decreased. Residents commented that there were less people around at the weekend now. The menu choices involve consultation with residents and staff try to encourage residents to join in with the cooking and meal processes by laying the tables, chopping vegetables and stirring the food. Residents commented that they have jobs they like to do and do them every day. One resident stated that he empties the bins, while another always packs the dishwasher. 9/10 Jutland Place Version 1.10 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, and 21 The staff have a good understanding of the residents support needs and have good interpersonal relationships with the residents. The health needs were being met with evidence of multi disciplinary working taking place. Improvements could be made in relation to specialist staff training. EVIDENCE: Residents stated that staff help them when needed, usually when they have put on clothing not appropriate to the weather outside. All residents are assisted when they are in the bathroom although the amount of support needed varies from resident to resident. Staff stated and this was backed up in the individual residents records that residents visit the GP when required and that other health needs are met. On the day of the visit the district nurse was leaving as the inspectors arrived and staff stated that she had been in to pick up a continence assessment. Staff stated that they have not received any additional training in ageing, illness or dying of a resident. In light of the ageing of the resident group and that one resident has been unwell and required a hospital stay, this is an important issue in this home. 9/10 Jutland Place Version 1.10 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Complaints are responded to appropriately and staff are aware of that residents must be protected from abuse, neglect and self-harm. EVIDENCE: The complaint policy was available in written and picture format making it accessible to the residents. Residents were aware that if they are unhappy they could complain to a number of people as shown on the ‘letter’ given to them. Residents are very vocal and were heard to be talking to staff about what they like and anything that they do not like. A resident was observed talking to a staff member about some one they did not like at one of the day services. The staff member reacted positively and asked appropriate questions to ensure that the resident’s safety was not at risk. This was seen as a positive relationship that has been formed between staff and residents. Staff stated that they have received training in the protection of vulnerable adults and try to pass on the information, including the dangers, to the residents to make them more self aware and so they know what to watch out for and what to report to the staff. 9/10 Jutland Place Version 1.10 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 The general standard of the environment within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: Residents stated that they like their home and that they were involved in choosing the colours used to paint during the last redecoration. Residents bedrooms were individually decorated and reflected the individual person’s tastes and needs. One resident said he had his own key to his bedroom and locked it when he was not there. He also stated that he had recently had his room redecorated and had chosen the new furniture and had bought himself a desk and a computer. There were photos of family and friends in each bedroom and one was decorated in the resident’s football team colours with the official team duvet cover and curtains. 9/10 Jutland Place Version 1.10 Page 17 The ground floor shower room has finally been completed and is in use and all residents stated that they were very happy now that it was done. The upstairs bathrooms have had the baths resealed and tiles replaced. The kitchen worktops next to the stove had holes in them and areas were peeling away. A cupboard door was missing and staff stated that they had tried, unsuccessfully, to re-attach this. Staff stated that the manager had put in a request for this area to be redone but they were unaware of any outcome to the request. Residents stated that this was ugly and it would be nice to have new cupboards and worktops. 9/10 Jutland Place Version 1.10 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 and 33 The staff team in place offer consistency of care and support to residents within the home. Staff are clear about their roles and mandatory training is now in place. There has been no progress in the areas of specific additional training, such as care of the ageing and epilepsy. EVIDENCE: Staff have a book of ‘duties for the day’ and each one was aware of what duties they were expected to do for that day. It was observed that the staff on duty worked well as a team and supported each other when they had completed their assigned tasks. On the day of the visit the manager was off sick and staff had assigned senior role to one care worker for the shift. This showed good planning and initiative. Staff stated that they had attended all their mandatory training and an ongoing training schedule was seen. Two staff are due to start their NVQ level 2 training later this year. This is seen as a huge improvement as less than a year ago the whole staff team was new and many had not worked in the care home setting before, therefore no one had any previous training in place. 9/10 Jutland Place Version 1.10 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health, safety and welfare of residents are promoted and the one concern brought up on the day was dealt with as an immediate action. EVIDENCE: Residents stated that staff look after them well and are concerned about their safety. Staff have completed environmental risk assessments these were observed by residents and staff. A new risk assessment was in place with concerns about the walk-in shower and cleaning and drying the floor immediately after use, as one resident had slipped on the wet floor. This was being done when the visit started. It was noted that the dishwasher tablets were kept in a kitchen cupboard and no risk assessment was in place. Staff immediately removed the tablets and locked them in the COSHH (Control of Substances Hazardous to Health) cupboard until a risk assessment is completed. Staff and residents stated that they knew that the tablets were only used in the dishwasher. 9/10 Jutland Place Version 1.10 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 9/10 Jutland Place 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x x x Version 1.10 Page 21 16 17 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x 1 Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x 9/10 Jutland Place Version 1.10 Page 22 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 YA 21 Regulation Requirement Timescale for action 30/05/05 2. YA 6 3. YA 9 4. YA 24 5. YA 42 6. YA 42 18(1)(a)(c Staff must recieve training in ) ageing and dying. THIS REQUIREMENT IS OUTSTANDING FROM TWO PREVIOUS REPORTS. (Previous timescale of 29/06/04 and 13/12/04) 15(2)(b) All care plans must be kept under review, 6 monthly for younger adults and monthly for older people. 13(4) Risk assessments must be kept under review, especially for the resident who falls under the Older People National Minimum Standards. 23(2)(b)(c A refurbishment plan must be ) sent to the CSCI office, setting out timescales for the planned work in the kitchen. This is to include replacement of worktops, cupboards and regrouting or replacing of the kitchen tiles 13(3)(4) All COSHH items must be locked away or risk assessed against all residents to ensure residents safety. All food products that are removed from the original packaging must be dated. 12/05/05 30/04/05 12/05/04 12/04/05 12/04/05 9/10 Jutland Place Version 1.10 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA 17 YA 19 YA 29 YA 33 Good Practice Recommendations A record should be kept of what each resident has in their packed lunches. The accident report records should be kept in the same place, either in the residents files or the accident file. The home should consider further pressure care input from the relevant professionals, for the resident who falls within the older people standards. The home should reconsider the staffing levels at the weekend, in view of the recent reduction since the last inspection. 9/10 Jutland Place Version 1.10 Page 24 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey. TW20 8ET 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 9/10 Jutland Place Version 1.10 Page 25 - 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!