CARE HOMES FOR OLDER PEOPLE
Ella & Ridley Jacobs House 19-25 Church Road Hendon London NW4 4EB Lead Inspector
Rebecca Bauers Unannounced Inspection 21st October 2005 09:00 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 Ella & Ridley Jacobs House DS0000010428.V251241.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. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ella & Ridley Jacobs House Address 19-25 Church Road Hendon London NW4 4EB 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) 020 8203 5368 020 8201 5254 Jewish Care Natasha Jane Carson Care Home 48 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (48) of places Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Limited to 48 adults of either gender over the age of 65 years some of whom may have dementia. 17th May 2005 Date of last inspection Brief Description of the Service: Ella and Ridley Jacobs House, which is operated by Jewish Care, is registered to provide personal care for up to 48 older people some of whom have problems associated with dementia or confusion. The home is purpose built and is located in a busy suburban area known as ”The Burroughs” near Hendon Town Hall. It is very convenient for local shops and transport services. The stated aims of the home are to meet the needs of 45 elderly frail Jewish service users and provide respite care to up to three service users. Service users, relatives and friends are invited to parties at Jewish festival times. There are two friends committees who regularly hold events and raise money to ensure that service users have the best possible care. There is also a small group of volunteers who undertake training to help staff with aspects of social care and manage an in-house shop for the service users. The home aims to encourage service users to live life to the full, ever mindful that they have rights. Dignity and care of service users, support and development of staff, the views of relatives, volunteers, and religious leaders are all monitored by Jewish Care’s Quality Assurance team. The environment and lifestyle arrangements reflect the Jewish culture and way of life. The home is a large building that has been extended and modified over the years to meet the changing needs of service users. It is organised over five floors. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on the 21st of October 2005 as part of the annual inspection programme to identify progress with previous requirements and to check the standards of care against the core standards. The inspection took five and a half hours to complete. A partial tour of the home took place; four service users were spoken to on an individual basis. No relatives requested to speak to the inspector. Care records, staff records, complaints records and health and safety records were examined. Staff were spoken to intermittently throughout the inspection and the inspector was able to speak to the manager throughout the inspection. Further information was obtained from the homes newsletter and through general observation of service user and staff interaction. What the service does well:
Service users benefit from good assessments of need prior to admission and informative guidance about the home to enable decisions to be made about the home. Service users social and emotional needs are understood. Service users say the staff are ‘great’, ‘very caring and kind.’ Service users benefit from having an activities co-ordinator and a wide range of activities that meet cultural and spiritual needs. Service users continue to benefit from healthy, wholesome food that meets their cultural and dietary needs. Service users say ‘the food is very good here and it’s all Kosher which is the most important thing’ Service users benefit from a stable, competent, well-trained staff team that understand their needs fully. Staff morale is good which promotes good positive team working. Service users continue to benefit from having open forums to discuss the issues that affect them and to influence change in the running of the home to their own advantage. Good links have been developed with relatives through regular meeting and the development of the homes newsletter. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 6 Service users know how to complain and have been given the relevant contact information to enable them to complain both internally and externally. All complaints no matter how minor are taken seriously. The home is comfortable and homely. Service users felt that their bedrooms were comfortable and personalised. Communal areas are conducive to promote conversation. What has improved since the last inspection?
Fourteen requirements were made at the last inspection twelve had been met at this inspection. The manager and staff must be commended on their efforts to achieve this. The manager demonstrated that during the last five months in post she has developed a good knowledge of where the shortfalls in the service are and has clear objectives to address these. These have included staff capabilities, training needs and regular support for staff to facilitate continuity in service. All service users have been assessed for the risk of pressure sores and actions to minimise risk have been documented. Service users are now having annual reviews, health outcomes are being consistently and fully documented to ensure that service users are receiving the care that they need and that it is monitored appropriately to identify if service users needs change. PRN guidelines are in place for service users who have prescribed PRN and for service users to be enabled to access the local community. The outcome and actions of the investigation into a complaint received by the Commission from a relative had been satisfactorily investigated and the outcome had been sent to the Commission. Environmental requirements made to promote the personal care and safety of service users had been partially addressed although maintenance still remains an issue. A new bath had been fitted on the top floor although it was still not operational because the lifting chair was still on order. This is still a requirement so that there are adequate washing facilities for service users who are currently only using their own wash-hand basins. Service users who wish to have their bedroom doors open have had approved fire door release mechanisms fitted. The condemned tumble dryer had been removed but not replaced. A maintenance plan was sent to the Commission to identify all works identified and the timescales for completion, this work is ongoing.
Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 7 Service users are benefiting from additional staff on duty in the mornings to meet their needs and to ensure that their safety is promoted. Staff are now receiving regular documented supervision, which promotes continuity in care and the overall service provided to service users. The manager commented that staff have clarity about the importance of supervision and how these support sessions can influence their work practice which ultimately benefits service users. The homes fire risk assessment has been reviewed. What they could do better: Five requirements were made at this inspection two requirements were restated and one recommendation was made. Service user risk assessments still require ongoing work, detailed assessments need to be in place with clear actions to be taken by staff to minimise risk to service users, for example, falls and the use of cot sides as this is a restrictive practice. Service user individual plans require further development to ensure that clear support needs are in place to manage behaviour due to dementia care needs and to ensure that service users who are diabetic are supported appropriately by staff with regard to their nutritional needs. Individual plans must be reviewed monthly to ensure that changing needs are reflected in the plans and that service users continue to receive and benefit from the support they receive from staff. Although service users do access a wide variety of activities both in the local community, across London and in the Home Counties these are not evident when reading individual files, it is recommended that the service users chosen pursuits be documented fully. Staff files are still incomplete and do not demonstrate that the homes recruitment procedure is being followed nor do they demonstrate that staff are inducted appropriately, this must be rectified to safeguard service users and was a requirement from the last inspection. Environmental requirements are made with reference to maintenance and how this is handled and prioritised. There seems to be no sense of urgency that service users remain without an adapted bath on the top floor for almost six months, this is completely unacceptable and the process of dealing with maintenance must be reviewed to ensure that service users basic needs are a real priority and that they are met.
Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Service users are provided with good information about the home prior to choosing to live in the home. Service users move into the home in the safe knowledge that their needs have been fully assessed and can be met by the home. EVIDENCE: There have been eight new admissions since the last inspection in May. Three files examined contained detailed initial assessments from either the social worker or the home or both. On this basis the service users can feel assured that the home has accurate understanding of their needs and that these will be met. Service users spoken to confirmed that they had been given a copy of the homes service user guide and statement of purpose prior to admission so that they and their families could make an informed choice about where to live. The home does not provide intermediate care. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 11 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): 7,8,9,10 The service users health and personal needs are still not set out clearly in their individual plans of care. Social care needs are. Service users health needs seem to be fully met and are fully documented. Service users are protected by the homes medication policy and procedures. Service users state that they are treated with respect and their right to privacy is upheld. EVIDENCE: A requirement made at the last inspection for the registered provider to ensure PRN medication guidelines were documented to safeguard service users had been fully progressed. PRN guidelines were agreed by a GP and in place. Most service users health and personal care needs are still set out using the ‘standex system’, which is more geared to a nursing environment. These care plans have been more recently updated to include more detail but still do not reflect a holistic picture of service users, nor are their support needs clearly identified. A new care plan format is being introduced across all ‘Jewish Care
Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 12 homes’, which has been implemented so far with all new service users admitted into the home. Of the five individual plans examined two were using the new care plan format and three were using the ‘standex’ system. There were gaps in the individual plans meaning that not all areas concerning service users health and welfare were covered. For example a service user who was diagnosed, as diabetic did not have a nutritional assessment in place or an individual plan to reflect the dietary needs of the individual and support required by staff. Other service users who exhibit some behaviour that challenge the service due to their dementia care needs had not been reflected in their individual plans. This must be rectified to enable staff to manage effectively, consistently and in agreed ways to benefit the support received by service users from staff. As mentioned previously five service user files in total were seen. A requirement made at the last inspection for the health records to be documented fully with clear outcomes of appointments, when and how personal care was given and monitoring of weight had been fully progressed. However the requirement made for the actions to minimise risk of falls had not been progressed only a general risk assessment was in place. Risk assessments for pressure sores had been documented and assessments had been fully completed. The risk assessments for falls and cot sides must be fully documented to demonstrate appropriate care is being given to service users and that staff are working in ways to minimise risk to service users. Service users did make very positive comments with regard to the care they receive saying that ‘the staff are very kind, that they agree their personal care needs with staff and that staff always respect their wishes, privacy and dignity’. Service users spoken to knew whom their key worker was and had been involved in the development of their individual plans. All service users are now having documented annual reviews to ensure the home is able to continue to meet their needs. However there was no evidence that service users individual plans are being reviewed monthly this must be rectified to ensure that service users changing needs are identified and are being met by the home. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 13 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): 12,13, 14,15 Service users benefit from living in a home that meets their social and cultural expectations and preferences. Family and friend contact is promoted and access to the community is more frequent although not documented. Service users exercise choice and control over their lives and enjoy a wholesome, varied diet in small dining rooms or in their own rooms when requested. EVIDENCE: Service users continue to find the lifestyle experienced in the home matches their preferences and satisfies their social, cultural, religious and most recreational interest needs. These had been documented in service users individual plans. Service users were observed talking to each other and to staff. The home has an activities co-ordinator who arranges weekend trips and day trips for service users including activities in the home. Service users described their enjoyment during trips to the synagogue to celebrate recent festivities such as Rosh Hashana, Yom Kippur and Sukkot. Requirements made for service users to be given more opportunity to access the local community had been progressed although these had not been documented. This must be rectified to show a clear indication of the activities service users enjoy and to
Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 14 monitor if they are being offered fulfilling activities. Service users confirmed that they had their own telephones in their rooms to contact family and friends. Several service users were seen with relatives during the day and explained that relatives can visit at any time. Relatives are involved in three monthly meetings and a monthly newsletter is sent out to relatives to ensure that they are kept up-to–date with activities and events in the home. Service users spoken to were positive about the food provided in the home and said that the kitchen staff were flexible when and if they wanted alternative meals. Some special diets and diabetic alternatives are provided and the meals are kosher to reflect the culture of the service users. Service users have regular meetings where issues are discussed; service users now have separate meetings to discuss menus and food generally. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 15 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 Service users and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse by well-trained staff and the home adult protection procedures. EVIDENCE: Service users are protected from abuse, all staff have received adult protection training and a clear adult protection policy and procedure is in place. There has been one adult protection issue since the last inspection the home informed all agencies as appropriate. A requirement made at the last inspection for the registered person to keep the Commission informed of the outcome and action of an investigation into a complaint had been fully progressed. The investigation into the complaint had been investigated appropriately and was found to be partially substantiated. Eighteen complaints had been made since the last inspection these were generally minor all complaints had been logged appropriately and clear outcomes had been documented. All complaints had been dealt with satisfactorily. Service users stated that they knew who to complain to and felt that their views were listened to and acted upon. None of the service users spoken to wanted to complain about anything in the home they were generally positive about the care received, the staff and the new manager. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 16 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): 19,22,26 The home is clean, pleasant and hygienic. Service users live in comfortable surroundings although continued maintenance work is needed to improve the environment for service users. Service users still have not got sufficient washing facilities on the top floor. EVIDENCE: Service users benefit from a clean, pleasant and hygienic living environment. One service user who had moved into the home two weeks ago stated ‘the home is very clean and I have a nice room’. Two of the floors of the home were seen and a sample of service users bedrooms were visited. Service users had been given the freedom to choose colour schemes and to bring furniture and personal items with them. Six of the bedrooms had been decorated since the last inspection three more bedrooms were due to be decorated. Service users can be reassured that there are plans to continue to refurbish many
Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 17 parts of the home. A maintenance plan has been forwarded to the Commission addressing the areas raised during the last inspection and from the homes own audit. Service users spoken to said that their bedrooms were very comfortable. Some service users had been supplied with specialist beds to enable elevation of their feet to help guard against water retention. A requirement made at the last inspection for the service users on the top floor to have an assisted bath or shower facility fitted had been partially progressed. The new bath had been fitted although the ‘lifting seat’ was on order and would not be installed for at least six weeks. This is not satisfactory, maintenance issues must be dealt with more promptly, six months waiting time for a bath to be installed is not satisfactory and is not of benefit to service users. It is very disappointing that service users are still waiting for the lifting chair to arrive. This means that service users are still needing to go to other floors for personal care. Self- closing door devices as approved by the fire brigade have now been fitted to safeguard service users in the event of a fire. There is also a record of the batteries of these door guards being checked weekly. The condemned tumble dryer in the laundry room had been removed since the last inspection. To ensure the safety of service users, relatives and staff. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 18 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): 27,29 Service users needs are now being fully met by the numbers of staff on duty. The homes recruitment policy and procedures are being followed although the staff files still do not demonstrate that service users are wholly protected. EVIDENCE: The inspector was pleased to discover that in the last month service users needs are being met by the numbers of staff on duty in the morning. This is good progress following a requirement made at the last inspection. Two staff are now on duty between the hours of 7.30 am and 11.30 am in the dining areas. This means that those service users with greater dementia care needs and a propensity to wander off during breakfast is now being managed more safely. Service users stated that staff seem to spend more time talking to them as opposed to being hurried carrying out tasks. A requirement made at the last inspection for staff files to contain two references, contracts, start dates, inductions or application forms had not been fully progressed. Only one of the five staff files examined contained all the relevant information. There had been two new staff start since the last inspection appropriate checks had been carried out and they were in the process of their induction. All files must contain the listed documents to safeguard service users and to demonstrate that the homes recruitment procedures protect service users. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 19 Service users stated that ‘the staff are always kind, helpful and understand my difficulties.’ Others said ‘I can’t fault the staff.’ ‘The staff are very friendly’. Two key members of staff are currently undertaking training in the development and review of risk assessments. Once complete all staff will be shown how to monitor and review risk assessments and each service users risk assessment will be held in their own bedroom so that staff are consistent in their practices when supporting service users with for example manual handling and lifting and minimising their risk of falls. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 20 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): 31,33,36,38 Service users are living in a home that is well run and are positive with regard to the changes the manager has implemented. The home positively promotes service user involvement and is run in the best interests of the service users. Staff are now supervised regularly. Service users health, safety and welfare are promoted and protected by the homes safety checks EVIDENCE: Service users and staff were very positive with regard to their comments about the manager. They said that she listened and continues to be approachable and open. The acting manager has undertaken her registration interview with the Commission to become registered and is awaiting her certificate of registration. She commences her NVQ level 4 in care and the registered managers award this month.
Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 21 Service users said that there are several forums in which they are able to discuss idea and issues to affect the running of the home and in their best interests. Staff are now receiving supervisions every two months to promote continuity in service provision for service users. Five supervision records examined contained detailed information with regard to work practice issues discussed, training needs and further actions to improve work practice. The health, safety and welfare of service users is protected by the homes regular safety checks, since the last inspection the fire risk assessment had been reviewed in June 2005. All relevant safety certificates were in place. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 22 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 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 13(4)(b) (c) Requirement The registered person must ensure that service users risk assessments identify in detail ways to minimise risk and actions to be taken by staff. For example, cot sides and risk of falls. This requirement is amended and restated from the last inspection. The registered person must ensure that staff files include a contract of employment, two references, application form, training certificates and a completed induction. This requirement is restated from the last inspection. The registered person must ensure that individual plans are reviewed monthly and there must be evidence to demonstrate this on file. The registered person must ensure that individual plans cover all aspects of a service users health and welfare. In particular support needs must be in place for nutritional needs (diabeties) and behaviour where
DS0000010428.V251241.R01.S.doc Timescale for action 01/12/05 2 OP29 17(2) Schedule 3 31/12/05 3 OP7 15(2)(b) 30/11/05 4 OP7 15 (1) 31/12/05 Ella & Ridley Jacobs House Version 5.0 Page 24 5 OP19 23 appropriate management. The registered person must ensure that maintenance issues are dealt promptly, specifically when the issue concerns aids and adaptations in the home to benefit service users. 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The registered person should ensure that all activities undertaken by service users are documented in their individual plans to enable a clear indication of the activities service users enjoy participating in. Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Ella & Ridley Jacobs House DS0000010428.V251241.R01.S.doc Version 5.0 Page 26 - 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!
