Inspection on 19/01/07 for Celia Johnson Court Residential Home

This inspection was carried out on 19th January 2007.

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

Celia Johnson Court Residential... 31/05/06

Celia Johnson Court Residential... 15/12/05

Celia Johnson Court Residential... 12/07/05

Celia Johnson Court Residential... 30/01/05

Celia Johnson Court Residential... 02/08/04

Celia Johnson Court Residential... 12/12/03

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Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Celia Johnson Court Residential Home Gregson Close Studio Way Borehamwood Hertfordshire WD6 5RG Lead Inspector Hazel Wynn Key Unannounced Inspection 19th January 2007 10:00 19/01/07 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.V327980.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. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 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.V327980.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 Brief Description of the Service: Celia Johnson Court is a care home providing personal care and accommodation for 37 older people. Aldwyck Housing Association owns the home, 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. The statement of purpose, service user guide and previous CSCI inspection reports are available at the mangers office at Wilton House (a copy of the service users guide will be provided to prospective service users by the home) CSCI inspection reports are also available on the CSCI web site. The fee range is currently £400 - £435. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains the outcomes of the unannounced inspection carried out by a regulation inspector of the CSCI on 19th January 2007. The evidence gathered during the inspection including observation, discussion with service users, care staff and the manager and examination of records maintained in the home has been drawn together in this report. All of the key standards were assessed during this inspection. Care plans, the medication, recruitment, financial and health and safety records, and health and safety records were inspected. A tour of the home was undertaken. All service users spoken to expressed satisfaction with the home, and the service provided. A service users meeting was in progress during the inspection with issues being debated regarding meals. Service users praised the service and the way they were treated and the standard of care that they receive. Staff felt that they were encouraged to and enabled to acquire and update the training that they need to provide care for the service users. What the service does well: What has improved since the last inspection? Quotes were obtained to provide shading to the conservatory but a report on subsidence has resulted in nearby homes being vacated and currently the conservatory at Celia Johnson Court is under assessment regarding the possibility of subsidence; therefore, the proposed shading for the conservatory Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 6 to meet the requirement made at the last inspection is on hold pending the outcome of the surveyors investigation. A programme of refurbishment has been drawn up to refurbish and re-carpet various areas of the home over the next few months. 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. Celia Johnson Court Residential Home DS0000019311.V327980.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 Celia Johnson Court Residential Home DS0000019311.V327980.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 3. Standard 6 does not apply to this service. A full assessment is carried out in order to establish the needs of individual service users prior to them moving into the home. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: A sample of four full and comprehensive assessments, undertaken prior to service users moving in were seen on the individual service users files examined at this inspection. The assessment forms part of the care plan and is continuously reviewed to ensure the home can continue to meet changing needs. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10 The plans of care set out the health, personal and social care needs of the individual service users and health care needs are fully met. Medication is appropriately and safely managed. Service users are treated with dignity and respect and their right to privacy guarded. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: Four care plans were sampled during this inspection; the care plans record the individual’s, health, personal and social care needs. The progress records showed that the service users’ health care needs were being fully met. A check of the medication system, including storage was being managed appropriately with protocols in place for individuals who can self medicate. There were no gaps on the Medication Administration Records seen at this inspection and medication was observed to be appropriately administered and stored. Service users spoken with during this inspection stated that they felt very well cared for and that they are treated with dignity and respect, and they are afforded privacy. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 10 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 –15 The lifestyle matches the expectations and preferences of the service users with a range of activities being provided. Contact with family, friends and community is actively supported. Service users are supported to exercise choice and control over their lives. The food served is wholesome, balanced and appealing. Dining arrangements are in pleasant surroundings and although mealtimes are at set times, alternative arrangements can be made so that beverages and snacks can be served throughout the day. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: Service users stated that there is a good programme of activities and they can choose to take part in any of these. One service user has been able to maintain their placement at a day centre, which they had enjoyed prior to admission. A service users’ meeting was taking place and the main item on the agenda was the lunchtime meal; the service uses were not happy with the quality of the liver served and wanted to provide feedback to the chef. Speaking with the service users at the meeting evidence was gained that they are very comfortable with lodging a complaint. Two visitors stated that visitors are made very welcome and said there was a happy relaxed atmosphere in the home. Service users provided feedback that family members are welcomed Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 11 into the home and can visit at times convenient to them. Some of the service users said they are still able to get out and about; one service user said they just comes and goes as she pleases. Service users views are gained through the quality assurance system and actions are taken to satisfy the service users regarding how the home is run in respect of individual and joint needs (the service users’ meeting held during this inspection was one example of this). The manager stated that the religious needs of the service users are met by visiting clergy who visit the home on two separate occasions per month. Through observation and discussions with service users evidence was gained that dignity and respect, alongside the upholding of the right to privacy are high on the homes agenda. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Complaints are listened to, listened to, taken seriously and acted upon. The service users are protected from abuse. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: The registered manager has dealt with one complaint in this inspection year and dealt with this complaint in accordance with the homes’ policies and procedures; the home had identified that a service user’s needs could not be met due to progressively changing needs that were beyond the home’s capacity. The service user’s representative did not want the service user to move from the home; the registered manager’s decision was appropriate. There had been no other complaints; the registered manager stated that the service users views are gained on an ongoing basis and issues are generally dealt with before they progress to an official complaint. All service users are issued with a copy of their contract/terms and conditions and a copy was available for each service user in the home’s office. Training in abuse awareness is provided to all staff and evidence of this was gained from staff files and discussions with staff during this inspection. Protocols were in place to protect service users and individual risk assessments were seen during this inspection to protect service users who are at risk from self-harm and to ensure protection from neglect. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. The home is well maintained and provides a safe environment although the use of the conservatory is under review. Good hygiene is practiced in the home and it is kept fresh and clean. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: The registered manager explained that quotes were obtained to provide shading to the conservatory but a report on subsidence has resulted in nearby homes being vacated and currently the conservatory at Celia Johnson Court is under assessment regarding the possibility of subsidence. Therefore, the proposed shading for the conservatory to meet the requirement made at the last inspection is on hold pending the outcome of the surveyors investigation. The requirement made at the last inspection has not been brought forward to this inspection report as this cannot be met until the outcome of the surveyors report is known. The registered manager should keep the CSCI updated Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 14 regarding progress in this matter. A programme of refurbishment has been drawn up to refurbish and re-carpet various areas of the home over the next few months. A tour of the building was undertaken as part of this inspection and all areas of the home were clean and fresh. A sample of the homes health and safety records including fire safety, lift and hoists maintenance, Portable Appliance Testing, Water Safety checks and whole building check provided evidence that the service takes health and safety matters seriously. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 –30 The service users’ needs are met by an adequate number of staff who have a good skill mix between them. The service users are protected by the home’s recruitment policy and practices and the home takes all reasonable steps to ensure service users are in safe hands. There is a training programme for staff and staff do not carry out tasks they have not been deemed competent to undertake. The quality in this outcome group is excellent; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: Staff spoken with said they had attended various training courses during the inspection year and the records provided evidence that staff had attended all mandatory training courses and other courses, which will be of benefit in their work with service users. The home has a good profile of staff with NVQ at level 2 and new starters will commence the planned NVQ programme in February 2007. The policies, procedures and practices observed during the inspection, together with staff training ensure that the service users are in safe hands at all times. A sample of recruitment files for staff recruited since the last inspection were examined and were found to contain all of the documents required for good Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 16 recruitment practice; these contained proof of identity, CRB and POVA checks, two references, completed application form and other recruitment data. A programme of induction commences immediately at the start of employment and competence is assessed prior to staff undertaking tasks allocated to them. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 17 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, 37 and 38. The manager is registered by the CSCI. She is fully able to discharge her responsibilities and runs the home in the best interests of the service users. The financial interests of the service users are well managed and transparent. The health, safety and welfare of the service users and staff is safeguarded. The quality in this outcome group is excellent; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: The manager was robustly checked and interviewed during the registration of manager process and has been in post for many years. The registered manager holds Level 4 NVQ (National Vocational Qualification at management level) and is competent, having managed the home successfully during her service to the home. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 18 The service carries out surveys of service users’ opinions and wishes about the management of the home. Questionnaires are carried out concerning the quality of food and the choice of activities; a service users meeting was in process during this inspection and was observed by the inspector. Service users’ meetings take place approximately every six weeks, and service users bring up suggestions and concerns there. The outcomes of surveys are posted on the notice board. Service users spoken with during this inspection said that they felt the staff are keen to listen to their views, are comfortable about complaining and that staff do act on any concerns they have. A sample of service users financial accounts was seen during this inspection; the system is transparent and balances checked were correct; receipts for transactions reconciled with entries. Policies and procedures are in place to safeguard service user’s financial interests. Records seen at this inspection were well maintained and included health and safety practices in the home, regular tests of fire alarms and equipment, electrical and equipment maintenance. Other records mentioned earlier in this report were well maintained. Risk assessments are in place for activities within the home, and appropriate risk assessments were seen for individual service users. All incidents in the home are recorded appropriately, and Regulation 37 reports are forwarded to the CSCI. The supervision record provided evidence that staff receive formal supervision on a regular basis, and an annual appraisal of their work. Staff stated that communication and support is good and this included handovers at every shift change and regular staff meetings. Staff and service users praised the efforts and support provided by the manager. Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 19 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 3 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 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X 3 4 Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 20 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. Standard Regulation Requirement Timescale for action 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 Standard Good Practice Recommendations Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Celia Johnson Court Residential Home DS0000019311.V327980.R01.S.doc Version 5.2 Page 22 - 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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