CARE HOMES FOR OLDER PEOPLE
Celia Johnson Court Residential Home Gregson Close Studio Way Borehamwood Hertfordshire WD6 5RG Lead Inspector
June Humphreys Unannounced Inspection 15th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 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. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Celia Johnson Court Residential Home Address Gregson Close Studio Way Borehamwood Hertfordshire WD6 5RG 0208 2073700 0208 3815221 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) Aldwyck Housing Association Limited Mrs Fiona Brown Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: Celia Johnson Court is a care home providing personal care and accommodation for 37 older people. The home is owned by Aldwyck Housing Association, which is a voluntary organisation. It was opened in 1992 and consists of a purpose built two storey building. The home is located in a modern housing estate on the outskirts of Borehamwood, near to the town centre. Public transport is easily accessible, and the home also has its own transport. All the homes bedrooms are single with en-suite facilities. There is a passenger lift. The home has attractive gardens on three sides that are well maintained and easily accessible. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted as an announced inspection. Those standards not assessed, had been assessed at the inspection carried out earlier in the year, in July. This was a positive inspection with nearly all standards inspected being met. All service users spoken to expressed satisfaction with the home, and the service provided. On the day of inspection the home was found to be comfortable and well maintained. The manager advised that the home is due for refurbishment, and inspector felt this would enable a greater ‘homely feel’ to the environment. What the service does well:
Celia Johnson Court is a residential care home providing personal care and accommodation for 37 older people. Service users spoken to said that they were very happy with the support, and quality of care provided. An example of this was a service user who was experiencing a medical problem she said” The staff have made every effort to make me comfortable, and have checked with me prior to making a referral for further assistance” The importance of consulting with service users appears to be a priority, and active in the care provided. The staff organise a range of activities, and service users have the option to participate or not. These activities include trips outside of the home. Meals are varied and nicely presented. They are at set times, but drinks and snacks are available throughout the day. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 6 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. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 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 Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Please refer to inspection report of 12th July 2005. Above standards not assessed on this occasion. (Standard 6 does not apply. There is no intermediate care service in operation.) EVIDENCE: Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 The quality of Personal care, and the level of assistance offered to service users is of a good standard. Care plans clearly identify service users needs, and take into consideration their wishes. The review of care plans is in the form of a journal, which although regularly completed, does not monitor adequately the goals set, or possible achieved outcomes. A great deal of progress has been made in the administration, and storage of medication since the pervious inspection. Several issues were raised in relation to the recording of medication. Service users who self-administer their own medication require a risk assessment. EVIDENCE: The current system of review does not adequately record service users changes in health, and personal care needs. On one care plan pressure sores were noted, but were not mentioned within the review process. A change in format, or staff training relating to significant information that should be included in the review is required.
Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 10 The service user relating to the above care plan was interviewed, and clearly was very happy with the support and intervention provided. She stated that staff had made every effort to make her comfortable. Appropriate intervention had been sought, and checked with her prior to referral. All requirements made as a result of the previous inspection have been met. The storage facilities for medication have been replaced, and medication reorganised. All medication has now been moved to a designated medical room, except for the controlled drugs cabinet. This is secure, and medication where checked was accurately recorded. Further examination of administering, and recording does however continue to present possible risks to service users. The recording of medication made auditing difficult. There was a lack of clarity in relation to the number of tablets that had been administered, as the recording was difficult to read. Inspectors made suggestions in relation to recording. MAR (medication and administration record) charts had been altered using tippex on several sheets. This caused further difficulty in reading the changes made. Two service users were identified as administering their own medication, but no risk assessments were in place to identify how this would be monitored. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Service users are given opportunity to choose the food they wish to eat from a variety of well-balanced meals. EVIDENCE: Service users are given choice in relation to selecting the food they wish to eat. A member of staff was observed assisting service users to choose/select from the menu, in a patient and caring manner. She did advise a service user who was diabetic of what was available on the menu to him. The food served on the day of inspection accurately reflected the menu on display. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Aldwyck housing association Limited has a comprehensive complaints policy, which is followed within all homes. The manager actively encourages service users, and their relatives to make complaints when necessary. EVIDENCE: The manager advised that she fully investigates all complaints, and that she is keen to resolve any possible concerns. There have been two complaints since the last inspection. Both have been relating to the same service user, completed by the same relative. Both complaints related to the standard of personal care offered by staff. On the day of inspection the standard of hygiene within the home, communal areas and peoples personal space i.e. bedrooms was of a very good standard. The documentation seen showed that the manager had dealt with complaints in a practical and prompt manner following the procedures within the company policy. She had responded in writing to the carer, and offered the opportunity to meet with them. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,26 The home provides a comfortable and well-maintained environment for service users to live. Staff provides a good level of support, maintaining a good standard of cleanliness and hygiene. EVIDENCE: Service users personal space (bedrooms) were personalised and individual in their appearance. The inspectors looked into numerous rooms and bathrooms all of which were clean and tidy; bedrooms displaying personal possessions and mementos. The carpet in room 33 was seen to be stained, and requires cleaning, or replacement. There is also on going concern relating to the odour in room 9. This was raised at the previous inspection and the manager has endeavoured to try to combat the issue by replacing carpet flooring with attractive lino. Electronic air fresheners have also been placed in the surrounding area. The inspector tried to speak to the service user concerned without success, but was advised by the manager that this is not an issue for the person, and that the individual has declined medical intervention.
Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 14 The overall environment whilst practical and safe, would benefit from a more ‘homely feel’. This is obviously difficult has there is large linking corridors which are excellent for wheelchair and frame service users. The manager advised that the home is due for refurbishment and that she would be trying to improve the overall appearance. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Please refer to inspection report of 12th July 2005. Above standards not assessed on this occasion. EVIDENCE: Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 The manager has worked hard to meet the standards relating to fire regulations i.e. door closures. There was some resistance from service users and the manager explained the need, and why it was important. EVIDENCE: Inspectors found no doors wedged on the day of inspection; automatic door closures are now in place. Window restrictors have also been fitted to all first floor windows. The manager has consulted with service users and carers to resolve concerns in relation to hot weather and windows not being open as wide as they would like. Adequate provisions of fans are now available for use in the warmer weather. Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 x x 3 x x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 3 Celia Johnson Court Residential Home DS0000019311.V271885.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15(2) Requirement The manager must ensure that service users care plans are reviewed and updated to reflect changing needs. Risk assessments must be completed for service users who self- administer medication. Alterations to MAR charts must not be made with tippex, and must be readable to prevent errors. An audit should be put in place to monitor this. The manager must ensure that the offensive odour in an individual service users room be eliminated. Where this is not possible a plan of monitoring must be identified in the service users risk assessment. Timescale for action 31/01/06 2. 3. OP9 OP90 13(4) (c ) 13(2) 21/12/05 21/12/05 4. OP26 16(2)(k)) 21/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
DS0000019311.V271885.R01.S.doc Version 5.0 Page 19 Celia Johnson Court Residential Home Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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