Inspection on 31/05/06 for Celia Johnson Court Residential Home

This inspection was carried out on 31st May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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... 19/01/07

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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Oak Ridge

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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 31st May 2006 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.V295214.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.V295214.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.V295214.R01.S.doc Version 5.2 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. 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 fee range is currently £400 - £435. Celia Johnson Court Residential Home DS0000019311.V295214.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 two regulation inspectors on 31st May 2006 using available evidence gathered during the inspection including observation, discussion with residents, care staff and the manager and examination of records maintained in the home. All of the key standards were assessed during this inspection and the overall outcome was very positive, with just one requirement for blinds/shading to be installed in the conservatory in the interest of health, safety and the residents’ comfort (previously, trees, which have been felled, had offered natural shading). All residents spoken to expressed satisfaction with the home, and the service provided. Medication, recruitment, care plans and health and safety records were inspected. Residents 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 residents. Based on this inspection visit and information received since the last inspection visit, the overall quality of this service is good. What the service does well: The service provides comfortable, clean and safe accommodation and residents spoke highly of the way in which their personal care, social care and support is delivered. An example of this was a resident who had expressed a wish to be served alternative foods and several approaches to meet her expectations had been tried; the resident is now enjoying meals purchased in (ready meals) as an alternative, whenever the menu is not to her satisfaction. This resident offered every praise for the staff and service. The importance of consulting with residents appears to be a priority, and action is taken when residents views dictate the need. The staff organise a range of activities, and residents 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.V295214.R01.S.doc Version 5.2 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.V295214.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.V295214.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable to this home. Prospective residents are provided with sufficient information to make a choice regarding the suitability of the home to meet their need. A full assessment is carried out in order to establish the needs of individual residents prior to them moving into the home. The service does not provide intermediate care. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: An updated Statement of Purpose and Service User Guide are available to prospective residents, copies of these documents have been provided to CSCI. Examples of full and comprehensive assessments, undertaken prior to residents moving in were seen on the individual residents files examined at this inspection. Celia Johnson Court Residential Home DS0000019311.V295214.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 The plans of care set out the health, personal and social care needs of the individual residents and health care needs are fully met. Those service users who self medicate are safeguarded by protocols in place. Service users feel that they are treated with dignity and respect and that their right to privacy is upheld. 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 staff team had worked very hard to provide new streamlined formats for individual care plans; the care plans examined during this inspection, set out within them, the personal and social care needs of the residents for whom they were drawn up and the meeting of the health care needs was being fully met; four residents’ health, personal and social care needs were tracked during this inspection with positive outcomes. Medication was being managed appropriately with protocols having been put in place for individuals who can self medicate; there were no gaps ion the Medication Administration Records seen at this inspection and medication was observed to be appropriately administered and stored. Residents stated that they are treated with dignity and respect with their privacy guarded. Celia Johnson Court Residential Home DS0000019311.V295214.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 The lifestyle matches the expectations and preferences of the residents with a range of activities being provided. Contact with family, friends and community is actively supported. Residents 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 where necessary and beverages and snacks are 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: Residents stated that there is a good programme of activities and they can choose to take part in any of these. Activities were observed taking place during this inspection. One gentleman said he very much enjoys his visits to the pub. A good example of service users being supported to exercise control over their lives was of a resident spoken with who said that they didn’t always want what was on the menu and the home has purchased in ready meals of very good quality for her which she can chose from as an alternative to the menu provided. 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 manager stated that the religious needs of the residents are met by visiting clergy who visit the Celia Johnson Court Residential Home DS0000019311.V295214.R01.S.doc Version 5.2 Page 11 home on two separate occasions per month. Residents provided feedback that family members are welcomed into the home and can visit at times convenient to them. Celia Johnson Court Residential Home DS0000019311.V295214.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 The residents and their relatives can be confident that complaints will be listened to, listened to, taken seriously and acted upon. The residents’ legal rights are protected. The residents 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 manager stated that she fully investigates all complaints and is keen to resolve any concerns. Two complaints received prior to the last inspection were resolved by 31st March 2006 (since the last inspection took place). Both had been relating to the same resident and made by 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. Documentation in relation to complaints examined during this inspection verified was observed that the procedures within the company policy are adhered to. 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.V295214.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 The environment is safe and there is a schedule in place to refresh/redecorate the environment to ensure it is well maintained. The conservatory is used and enjoyed communally but needs blinds/shading to ensure it can be used safely. The home was clean and comfortable on the day of the inspection. With the exception of the need for blinds/shading to be provided in the conservatory, 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 manager stated that work is scheduled to commence in the forthcoming months to redecorate worn areas of the home. The inspectors discussed with the manager that the wide and practical hallways could be more aesthetically pleasing, if consideration was given to a more modern choice of lighting at the time of redecoration. Some trees have been felled in the garden and these had previously provided natural shading for the conservatory; this has led to a need to provide blinds/shading for the conservatory, which is enjoyed as an alternative lounge by the residents. A requirement is made, as an outcome of Celia Johnson Court Residential Home DS0000019311.V295214.R01.S.doc Version 5.2 Page 14 this inspection, for blinds/shading to be provided in the conservatory to ensure that the residents can use this safely and comfortably. The home was observed to be fresh (with the exception of some redecoration needs already scheduled), clean and odour free during this inspection. Celia Johnson Court Residential Home DS0000019311.V295214.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 The residents’ needs are met by an adequate number of staff who have a good skill mix between them. The residents are in safe hands at all times and are protected by the home’s recruitment policy and practices. The staff are trained and competent to do their jobs. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: All longer standing staff have gained or are in process of obtaining NVQ’s in care and the records showed that all staff update their mandatory training needs as required and also attend additional training courses to equip them to meet the needs of the residents. Staff spoken with said they had attended some very useful training courses. The policies, procedures and practices observed during the inspection, together with staff training ensure that the residents are in safe hands at all times. The recruitment files of all staff recruited since the last inspection were examined and were found to contain all of the documents required for good recruitment practice; these contained proof of identity, CRB and POVA checks, two references, completed application form and other recruitment data. As stated above the staff receive the training they need to meet the needs of the residents (individually and collectively) with competence. Celia Johnson Court Residential Home DS0000019311.V295214.R01.S.doc Version 5.2 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): 31, 33, 35 and 38 The home is run and managed by a manager who is of good character, fit to be in charge and who is fully able to discharge her responsibilities. The home is run in the best interests of the residents. The financial interests of the residents are safeguarded. The health, safety and welfare of the service users and staff are promoted and protected. 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 manager was robustly checked and interviewed during the registration of manager process by the Commission and found to be fit and competent and has managed the home well during her service to the home. The home 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, evidence of this is aforementioned Celia Johnson Court Residential Home DS0000019311.V295214.R01.S.doc Version 5.2 Page 17 in this report and the outcomes of survey were posted on the notice board. Service users’ meetings take place approximately every six weeks, and service users bring up suggestions and concerns there. Service users stated that they felt the staff are keen to listen to their views and to act on any concerns they have. Policies, procedures and protocols were in place at the home to protect the financial interests of service users. 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 are aforementioned earlier in this report and were observed to be 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. Staff spoken with stated that they have supervision every six weeks, 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 residents praised the efforts and support provided by the manager. Celia Johnson Court Residential Home DS0000019311.V295214.R01.S.doc Version 5.2 Page 18 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 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 X X X X X 3 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 3 X 3 X X 3 Celia Johnson Court Residential Home DS0000019311.V295214.R01.S.doc Version 5.2 Page 19 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 OP19 Regulation 16(2)(c) Requirement In the interests of health and safety and the comfort of the service users blinds or other form of shading must be provided in the conservatory to protect service users from the heat of the sun projected through the glass. This must be actioned within a very short time frame. Timescale for action 30/06/06 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 OP19 Good Practice Recommendations Consider providing modern and more aesthetic lighting for the hallways as part of the current redecoration schedule. Celia Johnson Court Residential Home DS0000019311.V295214.R01.S.doc Version 5.2 Page 20 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 © 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.V295214.R01.S.doc Version 5.2 Page 21 - 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. 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