Inspection on 18/06/07 for Jaffray Nursing Home

This inspection was carried out on 18th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jaffray Nursing Home 27/11/06

Jaffray Nursing Home 05/12/05

Jaffray Nursing Home 09/06/05

Jaffray Nursing Home 16/12/04

Jaffray Nursing Home 20/07/04

Jaffray Nursing Home 14/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Jaffray Nursing Home 19 - 31 Jaffray Crescent Erdington Birmingham West Midlands B24 8EG Lead Inspector Kerry Coulter Key Unannounced Inspection 18 & 19th June 2007 11:20 th Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 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 Jaffray Nursing Home DS0000024859.V337860.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 Adults 18-65. 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. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jaffray Nursing Home Address 19 - 31 Jaffray Crescent Erdington Birmingham West Midlands B24 8EG 0121 382 1383 0121 382 9278 jaffraycaresociety@btinternet.com 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) Jaffray Care Society Sukhwinder Thandi Care Home 18 Category(ies) of Learning disability (18), Physical disability (18) registration, with number of places Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 18 persons with a learning disability and physical disability. That the home can continue to accommodate four named services who are over 65. That Jaffray Nursing Home apply for variation on behalf of future service users who reach the age of 65. That details regarding how the specific care and social needs of people over the age of 65 will be met must be included in the service users plan. 27th November 2006 Date of last inspection Brief Description of the Service: Jaffray Nursing Home comprises of four bungalows and each bungalow accommodates 4 - 5 people up to a total of 18 people who have a learning disability, physical disability and additional nursing needs. All bungalows are well maintained internally and externally. There is parking to the side of the property plus a pleasant garden with seating to the rear. All the bungalows have level access throughout and are fully accessible to people without full mobility. Each bungalow has a dining room and lounge area and one has a conservatory. All bedrooms are single with a wash hand basin and call bell system. There is a separate toilet and bathroom, which are fully adapted and suitable for people with mobility problems where assistance is required. They also have a range of hoists for people with mobility problems and pressure relieving equipment for people who are at risk of developing pressure sores. A copy of the service user guide is available in each bungalow, which provides information about the facilities. The information provided by the home indicates that fees vary depending on individuals needs and can range from £331 - £2292 per week. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the fieldwork visit took place a range of information was gathered that included notifications received from the home and a completed pre-inspection questionnaire (AQAA). One inspector carried out the unannounced fieldwork visit over two days. This was the homes key inspection for the inspection year 2007 to 2008. The people living in the home, Manager, the staff on duty, Maintenance Manager, visiting Therapist and the Operations Manager were spoken to. Time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. One survey form was received from a relative of someone who lives at the home. All information looked at was used to determine whether peoples varied needs are being effectively met. What the service does well: Staff are generally good at helping people live the lifestyle of their choice. This includes attending learning, leisure or staying in touch with people important to them. The staff are friendly and helpful. People are supported by staff they know, and who are familiar with their needs. People are supported to undertake personal care to a high standard. All were individual in presentation with make up and jewellery where appropriate to reflect their gender, culture and preferences. There is enough staff employed so that the people living in the home can be supported to do most of the things they want to do. The bungalows that people live in are very well presented and maintained to a good standard providing a pleasant and safe place for people to live. All the people have a single bedroom. These are all very different, and each person’s room contains the things that are important to them. There is a range of equipment for moving and handling people to ensure their safety. There is also a range of equipment for use to prevent the risk of pressure sores and all areas of the home are accessible to people whose mobility is restricted. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 6 In all the bungalows there was a good stock of food with a range of fresh vegetables and fruit, menus were varied providing people with a nutritious diet. What has improved since the last inspection? What they could do better: Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 7 Some peoples risk assessments needed to be reviewed and updated so that they do not conflict with information recorded in the care plan to ensure people receive the care they need. Some areas of healthcare planning and monitoring needed to improve so that people get the care they need to stay healthy. A review is needed of the way in which soiled laundry is transported through kitchen areas to ensure people who live at the home are not put at unnecessary risk of infection. Information provided to people who live at the home needs to be in a format they can understand. Arrangements for access to community activities need to improve to ensure all people living at the home have enough opportunities to participate in community activities. A protocol on the use of the oxygen kept at the home should be developed to ensure staff know when and how to use it. Staff at the home should receive formal recorded supervision at least every other month so that they are fully supported in their role. The quality assurance process needs improvement to include feedback from people who live at the home and other stakeholders and an annual development plan drawn up to show peoples views have been taken into account. 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. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with most of the information they need to make a decision about moving to the home but further information in alternative formats needs to be provided to ensure an informed choice can be made. EVIDENCE: At the last inspection it was identified that development of the Service User Guide and Statement of Purpose was needed. These have since been reviewed and are now separate documents rather than the previous combined information. Copies of the Guide were observed to be available in each bungalow. To enable people who live in the home to have a better understanding of the guide pictures had been used to help explain how a complaint can be made and staffing arrangements were also in a picture format, (numbers and roles). Other information in the guide was typed and this may not be in a suitable format to help people who cannot read understand the contents. Copies of terms and conditions of residency were available in the files sampled of people who live in the home, however these did not include full information on the fees. This information needs to be added so that people are fully aware of the costs of their stay at the home. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 10 At the last inspection it was identified that someone new had moved into the home without a full assessment being completed. Since then, there have been no new people admitted to the home so it has been difficult to assess current practice. However, observation of the admission policy shows this has recently been reviewed to reflect that assessments should be completed. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs, wishes and risks are generally well assessed and documented, to ensure their needs are met in the way they prefer. EVIDENCE: The care plans of three people who live at the home were sampled. The plans to deliver care and to reduce risks are generally clear, concise and regularly evaluated, they refer to the choices and likes of people and detail what staff do to meet the assessed need. Plans covered areas such as health, mobility, manual handling, advocacy, diet, activities, communication, likes and dislikes, personal care and night time needs. Where needed plans were seen to be in place to help staff manage challenging behaviour. There was some very good detailed information in some plans, for example recording in which hand one individual preferred to hold his cup. However other plans needed more detail, for example information on the type and size of incontinence pad needed. Care review meetings are held and it is good that people have the opportunity to attend their own meeting, relatives are also invited if this is appropriate. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 12 It has previously been identified that people need a copy of their plan in a format that is easier for them to understand. Progress has been made towards achieving this. Person Centred Planning (PCP) is being used to achieve this and the home has a co-ordinator who is leading the process. Some people who live at the home now have their own PCP, this is a plan that focuses on their likes and dislikes and what is important to them. The plans are completed in both pictures and words making them easier for people to understand. It is good that people have a copy of their plan in their bedroom. Throughout the inspection staff were observed to support people who live at the home to make day to day decisions, this included what people wanted to do, where they wanted to sit and what they wanted to drink. Staff consulted with people about what they wanted to watch on television and one staff was observed giving one person the remote control so that they could change the channel themselves. The Manager has tried to access advocacy support for people who live at the home not everyone at the home has involved relatives or is able to fully communicate their views. Unfortunately the advocacy group approached only has the capacity to offer an advocate in crisis situations. People’s care plans had information on how to access the advocate if needed. Discussion with the Manager indicates that she and one other staff has recently attended training on the new ‘Mental Capacity Act’. This is a new Act that will protect the healthcare, financial and legal rights of people living in care homes and makes clear in what circumstances to involve an Independent Mental Capacity Advocate. There are systems in place to consult with people who live at the home, this includes regular weekly meetings for each bungalow. Minutes sampled for some of the bungalows were very repetitive in content and did not always show that people had been consulted, often focussing on the activities they were looking forward to. On several occasions staff had recorded that people were looking forward to going to the weight clinic or seeing the GP. In some bungalows the meeting minutes also showed that people had been involved in deciding the menu for the week. The agenda for the meetings had a section for complaints but this was often left blank. The Manager said that a new format for the recording of meeting minutes had been devised and this was observed to be on an individual basis for each person but is not yet in use. Consideration needs to be given of how to make the best use of the meetings to ensure that the views of people are sought across a wide range of topics and not just a few areas. People living in the home all have risk assessments to underpin risks they face and are exposed to. These were generally comprehensive, and control measures in place were reflective of the risk assessed. However some of the information in the assessments were not up to date and some had not been Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 13 reviewed in line with the guidance in the individuals care plan. For one person their moving and handling assessment recorded that two staff were needed to assist in changing their pad but this was not consistent with the care plan. The Nurse on duty said only one staff was now needed. One risk assessment for pressure sores had not been reviewed monthly as recorded as required on the care plan. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of interesting and varied activities is offered most of the time with opportunities for personal development to stimulate people and enhance their lifestyle. People are offered a nutritious diet that is varied including a range of fresh produce that meets their special dietary needs. EVIDENCE: The opportunity for people to undertake activities was assessed. The records of activities held in each home and what was on offer to people on the day of the inspection were looked at. People are generally offered a varied range of activities. It was pleasing to see this included opportunity for personal development, such as college courses as well as leisure including eating out, going to places of interest, shopping and the cinema. The home employs three staff who work as drivers / carers on a rota basis to assist other care staff in supporting people to do activities. Discussion with staff indicates that it can sometimes be a problem to get access to a driver. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 15 Staff in one of the bungalows said there were no community activities planned that day as the driver was allocated to other bungalows as they had the driver on previous days. The pre inspection questionnaire completed by the Manager stated that getting more drivers is something the home would like to do. While people do generally have a good lifestyle for some people records showed they did not always have lots of opportunity for community activities. For one person there were eight entries over twenty days in June where no activity was recorded except ‘stayed at home’. This will need to be looked at to make sure everyone gets an equal chance to participate in activities. One person spoken with was excited, she said she is getting a new computer for her bedroom (staff said it will be touch screen.) This will help her with the office skills course she is doing at college. One person was going shopping for personal items in the afternoon, staff had given them a brochure to look through of things they might like to buy. Another person was looking through a newspaper, staff later gave them a car book. This was good as their care plan said they had a special interest in cars. Therapeutic activities including aromatherapy and exercise to music is provided on a regular basis. Some people were having aromatherapy on the day of the inspection. There was little information about how activities are evaluated as staff do not often record if the activity was enjoyed or not. One staff said they were in the process of doing photographs of activities to assist people in choosing activities they enjoy. People who live at the home have the opportunity to go on holiday. One person had recently been to Blackpool. Photographs of the holiday showed them having a good time. Other people were going on a holiday the next week to a hotel in Devon. It was evident in daily notes that family contact is encouraged and maintained. Staff said one person had just had his 70th birthday, a big party was organised to celebrate, which their relatives attended. The food available in all the bungalows was plentiful and varied. Fresh fruit and vegetables were available in all the bungalows. The menus showed a very varied diet had been planned. Staff were observed supporting people at breakfast and at lunchtime. Staff were patient offering support as needed. One person said she was taking a packed lunch to college of beef sandwiches ‘my favourite’. Another person said the food was good, especially the cakes. Staff said that people choose the menu in advance and that picture cards are used for people with communication difficulties. Choice of what to eat and drink was offered to people. Unfortunately for one person they were given something they had not chosen at lunchtime but this seemed to be an unusual occurrence as other Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 16 evidence indicated choice is usually respected. One of the student nurses who was on placement at the home said the meals on offer were good and that healthy eating had improved since some staff had done portion control training. Staff spoken with were aware of the dietary needs of individuals to include who was on a special diet, who was at risk of choking and the particular food allergies of one person. Some people are fed enterally by tube. Evidence of review with the dietician, and care plans to underpin this were in place. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive personal support in the way they prefer and require. Most health care needs are well planned for and met. Some specific needs tracked need further development to ensure peoples healthcare needs are fully addressed. Medication management is generally safe, and systems showed people had received the right medication at the right time. EVIDENCE: Staff had supported individuals to pay attention to their personal care to encourage their self-esteem and their feeling of well being. All were individual in presentation with make up and jewellery where appropriate to reflect their gender, culture and preferences. The gender care preferences of people had been taken into account. One person gets upset if supported by a female so he has an allocated male staff 1:1 during the day. Health action care plans are available that refer to the involvement of primary and secondary healthcare services, contact with these services are well recorded and include GP, optician, dietician, dentist, chiropodist and hospital appointments. The specific healthcare needs of people were tracked. One Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 18 person was observed to have a sore eye, staff had already taken action and arranged for the GP to visit. All of the files assessed generally contained detailed plans that provided staff with clear guidance on how to meet the detailed needs. There were some requirements made regarding health care needs at the last inspection and most of these had been met. There were still some healthcare issues that needed improvement. One care plan stated that for one person their risk assessment for pressure care needed review monthly but this was being done every three months. One person has hay fever but there was no plan as to the care needed for this, such as prescribed medication in the summer months. Records did show dental appointments are offered but this was not always at the frequency recorded as required in the care plan. In some bungalows the completion of bowel monitoring charts for those at risk of constipation was to a good standard. However, in one bungalow for the three people tracked the records did not show this was being monitored effectively in line with their care plan. This puts people at risk of suffering from constipation. Whilst there are some healthcare issues that need improvement it is good that action has been taken to try and address these issues. A new role has been created of Nursing Support Manager. A nurse has been promoted to this role in the last month and will offer support and advice to team leaders, supervise staff and ensure all care, health and medication practices are regularly audited. The home uses a monitored dose medication system and on inspection it was found that the monitored dose system was adequately managed. The medication administration systems was assessed in bungalows 19 and 31. Medication was stored in locked trolleys. Medication Administration Records (MARS) had been signed appropriately. The MARS cross-referenced with the blister pack indicating that medication had been given as prescribed. It was identified at the last inspection that creams had not been dated when opened. It was observed at this inspection that this is being done most of the time, out of five opened creams sampled four had been dated. They all need to be dated when opened and discarded after a designated period due to the risk of bacterial infection. Protocols for the use of ‘as required’ PRN medication had been reviewed and updated to ensure staff have clear guidelines for the use of the medication. As required at the last inspection the GP has been consulted about the use of homely remedies to ensure there are no contraindications to its use. One of the bungalows has oxygen available in case of an emergency. As required previously this has now been secured to the wall. Discussion with one of the Nurses indicates the protocol on its use is still under development. This is needed so that staff are clear about when and how it should be used. A variety of audits are completed to ensure medication practice is safe. The supplying pharmacist did an audit in April 2007 and identified there were no Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 19 discrepancies in record keeping. Nursing staff do a weekly stock check of medication prescribed on an ‘as required’ basis. There is also an internal system for auditing medication, one Nurse said this is done monthly but in one bungalow it had last been done in March 2007. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are sufficient to ensure that the people living in the home feel their views are listened to and acted on. Arrangements are generally sufficient to ensure that people living in the home are protected from abuse, neglect and self- harm. EVIDENCE: The Manager stated she had not received any complaints since the last inspection. The Commission have not received any complaints about the service. People who live at the home are provided with a copy of the complaints policy, it is included in the service users guide with illustration to aid people’s understanding. A copy is also on display in the entrance hall to each bungalow. One relative indicated they were aware of the home’s complaints procedure. Since the last inspection a new leaflet has been developed for compliments, concerns and complaints, people visiting the home can use it to comment on the service provided. It is available in the hallway and can be sent to Jaffray Care anonymously if preferred. It is intended for use by visitors to the home and people who live there. However the format of the leaflet is not very accessible to people who cannot read. A Therapist visiting the home said she had not raised any concerns recently but when she had done so in the past they were always acted on by the Manager who let her know what had been done about them. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 21 There are policies and procedures in place for the protection of people who live in the home in the event of an allegation of abuse. One staff spoken with said she would always report any suspicions of abuse to her Manager or the Social Services. The staff team have received training regarding adult protection and this training is included within the organisations training programme to ensure new staff also undertake the training. Records sampled included a checklist of the individual’s property. These are dated so staff can track what personal property people have and identify if anything goes missing. Staff support people to look after their money. The money for two people were sampled, receipts were available for all expenditure. Jaffray has systems to safeguard peoples monies this includes staff counting and checking peoples monies at shift handover to make sure it is correct, checks on monies are also done by the Operations Manager as part of their monthly visits. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are sufficient to ensure that people live in a homely, comfortable and safe environment that meets their individual needs. EVIDENCE: The Jaffray Nursing Home bungalows were all very well presented and well maintained. There were photographs of the people living there displayed around the home making it look homely. Systems are in place for regular redecoration and refurbishment, which ensures the home remains presented to a high standard. It was a warm day and in some bungalows staff had put fans on to try and maintain a comfortable temperature. Discussion with the Manager and staff indicates there are some new furnishings on order, staff said people had been involved in choosing them by looking at brochures. Each of the bungalows has a lounge and dining areas, separate kitchen plus toilet and bathing facilities, which are accessible to people with mobility problems. One of the bungalows also has a conservatory. The lounge carpet in bungalow 21 was very stained, staff were unsure if a new one had been Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 23 ordered as part of the new furnishings. If not, the carpet will need deep cleaning to remove the stains or a new carpet ordered. There was a loose radiator cover in bungalow 21, this had been reported to the maintenance department eight weeks before but had yet to be repaired. Bedrooms were personalised and discussion with staff and a visitor showed that individuals had chosen the colours that their bedrooms were decorated in. All bedrooms have a call bell system, lockable facilities, locks to doors, carpet/appropriate flooring, curtains furniture and adequate lighting to meet people’s needs. They were noted to have been well personalised to include peoples personal interests such as cars or Elvis pictures providing a homely environment. Since the last inspection gutters, sofits and facia boards have been replaced and paving slabs to the rear have been replaced with tarmac to reduce any risk of falls. The garden is very well maintained, with lots of garden furniture available for people to use. A small water feature makes the area very relaxing. The main office is in the garden. It is small in size, the Manager said Jaffray Care is awaiting the outcome of a planning application to extend it. Staff spoken with said they had the equipment they needed to meet people’s needs. They have a range of hoists for people with mobility problems and pressure relieving equipment for people who are at risk of developing pressure sores. Staff said that as required at the last inspection new slings had been purchased for use with the hoists. Some people had their own electric armchairs that assist them to stand up. One person was asked about her chair, she said it was ‘comfy’. Kitchens in each bungalow were clean and tidy, all foods were stored correctly. Fridge and freezer temperatures were recorded most days ensuring good food hygiene standards. Where fridge temperatures had been high staff said the fridge had been replaced. The home was clean and free from offensive odours throughout. The fridge was clean and food opened had been labelled and dated with the date opened. It had been wrapped appropriately to ensure it did not become contaminated. Colour coded chopping boards were available in the kitchen so that foods could not be contaminated by other foods when food is being prepared. Staff were observed wheeling a trolley overflowing with soiled laundry through the kitchen area to get to the laundry situated in the garden. Staff who were asked if there was an infection control procedure covering the transportation of the laundry through the kitchen were unsure if there was one, despite the majority of staff having received recent infection control training. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing the home, their support and development were generally sufficient to ensure that the needs of people living in the home are met. There is a robust recruitment system in place, which protects people from harm. EVIDENCE: Records showed that just under 50 of staff had achieved NVQ level 2 or above in Care, which does not meet the standard. At least 50 of staff need to achieve this qualification to ensue the staff team have the skills and knowledge to meet the needs of the people living at the home. Other staff are currently undertaking NVQ 2 or 3 in Care to ensure they have these skills and knowledge. The staff team during informal discussions were able to demonstrate they had an understanding of the peoples needs. During the visit some very positive interactions between staff and people who live in the home were noted. One relative said ‘they do a wonderful job’. Rotas and discussion with staff showed that there were enough staff on duty to meet the needs of the people living there. Two regular agency nurses were Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 25 being used to cover nurse vacancies to ensure people are supported by staff who know them well. Four staff recruitment records were sampled, it was evident that the process was comprehensive including a full application form, an interview, and evidence of required checks including criminal records bureau disclosures, two references and health screening. Initially there was no evidence that the Personal Identification Number (PIN) had been checked for a newly recruited nurse to show they were still on the nurse register. However, the Manager arranged for this information to be faxed from headquarters. The manager provided a copy of the training plan for 2007. The plan included topics such as fire safety, health and safety, food hygiene, first aid and manual handling. Additional training to meet the specific needs of residents was also on the plan including social role valorisation and vulnerable adults, epilepsy and makaton. Several requirements were made at the last inspection regarding training for staff, it is good that staff have now had the training they need or it has been booked. Training undertaken has included fire, infection control, manual handling, Makaton (sign language), adult protection and portion control for healthy eating. Induction records were sampled for two new staff. Both had fully completed the homes induction. However, the induction programme knowledge base did not appear to meet the standards of the Social Skills Council. The Manager said that the induction format was being changed and was able to evidence that a new staff commencing work that week was trialling the use of a new induction package, linked to Skills For Care standards. Staff spoken with said they felt supported. The Manager and nurses undertake formal supervision of staff in order to monitor staff progress and training needs etc. and records are retained in the home. On Inspection it was noted that it was not always undertaken at least every other month. Staff meetings are held fairly regularly in each bungalow to ensure staff be kept informed about important issues. A new staff consultancy group has been established since the last inspection. This is intended to act as a forum for staff across Jaffray Care services to raise issues that are important to them without the presence of their manager. The Manager said that there has only been one meeting so far, this was to discuss the role of the group. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements generally ensure that people who live at the home benefit from a service that is run in their best interest. Arrangements are sufficient to ensure that the health, safety and welfare of the people living in the home are promoted and protected. EVIDENCE: The home has a manager who is registered with the CSCI. She advised that she meets regularly with other managers to discuss organisational policies and good practices. It appeared that the outcomes for people who live at the home had improved since the last inspection. At the last inspection some outcomes were poor, outcomes are now adequate or good. The Annual Quality Assurance Assessment was sent to the Manager to be completed before the inspection was completed and returned within the set timescale. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 27 The Operations Manager visits the home on a regular basis and provides the Manager and the Commission with a report of these visits. The visits often include interviews with people who live at the home and staff, viewing records for example complaints, budgets, staff training, management of money and also assessing environmental standards. The report also includes where needed an action plan for improvements. Sometimes the information from more than one visit is included on one report. This means for example, where the information from the visit in March is included on the April report there is a delay in the Manager receiving the information for March. This could result in improvements needed being delayed. Each report should cover one month so that the Manager receives up to date information. The home does have a manual about quality standards including policies and procedures, however there is not a clearly defined system or process for evaluating the quality of services provided to people at the care home to include their views and the views of their representatives. This has been identified at previous inspections. The health and safety of people who live at the home, staff and visitors is generally very well protected by robust servicing and testing of equipment and fittings. All fire safety tests and routine tests of electrical, gas and lifting equipment had been undertaken. In November 2006 the West Midlands Fire Service visited the home and said fire precautions were satisfactory. Staff have undertaken recent fire training and a member of staff questioned was aware of the evacuation procedure. During the inspection visit the alarms were being serviced by an engineer. It was disappointing that the Inspector or the people living in the home were not informed that the fire alarms were going to be sounded. People living in the home need to be informed about tests of the alarms as it gives confusing signals if the alarms sound but there is no evacuation of the bungalow. This could potentially mean that people do not react in the event of the alarms sounding for a real fire. Records sampled showed that the nurse call system was due its annual service. Discussion with the Jaffray Care Maintenance Manager indicates this will be serviced by the due date. Hazardous products such as cleaning materials are stored securely so that they are not misused. Data sheets are available for hazardous products used so if they should be misused staff would know what action to take to ensure the person’s safety. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 29 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4) Requirement Timescale for action 30/07/07 2. YA19 12(1) 3. YA19 15(1) 4. YA19 13(1) Ensure individuals risk assessments are reviewed and updated where necessary and do not conflict with information recorded in the care plan to ensure people receive the care they need. Outstanding requirement from 30/12/06. Where people have been 30/07/07 assessed as at risk of constipation suitable systems must be in place for monitoring that people have opened their bowels and appropriate action taken when necessary to ensure they stay healthy. Outstanding requirement from 30/12/06. Where specific health needs 30/07/07 have been identified for people there must be a care plan in place that guides the staff on what care the person needs to stay healthy. Staff must ensure that people 30/07/07 are supported to attend the dentist regularly, in line with their assessed needs. DS0000024859.V337860.R01.S.doc Version 5.2 Jaffray Nursing Home Page 30 5. YA30 13(3) A review is needed of the way in which soiled laundry is transported through kitchen areas to ensure people who live at the home are not put at unnecessary risk of infection. 30/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA5 Good Practice Recommendations The format for the Service Users Guide should be further reviewed to ensure it is easier for people who live at the home or who are thinking of moving there to understand. Information on the fees paid by, or on behalf of people who live in the home need to be added to the terms and conditions of residency so that people are fully aware of the costs of their stay at the home. Continue with the development of person centred plans so that all people who live at the home have a plan they have been involved in, in a format that is easier for them to understand. Review the format and agenda’s of the weekly meetings for people who live at the home to ensure their views are fully sought across a wider range of topics. Review the arrangements for access to community activities to ensure all people living at the home have enough opportunities to participate in community activities. The systems for auditing medication should be improved to ensure staff date topical creams and ointments on opening and discarded after a designated period due to the risk of bacterial infection. A protocol on the use of the oxygen kept at the home should be developed to ensure staff know when and how to use it. Staff at the home should receive formal recorded supervision at least every other month so that they are fully supported in their role. Reports of monthly visits to the home by the Operations Manager should be completed in a timely manner with one report covering only one month to ensure the Manager of DS0000024859.V337860.R01.S.doc Version 5.2 Page 31 3. YA6 4. 5. YA8 YA13 6. YA20 7. 8. 9. YA20 YA36 YA39 Jaffray Nursing Home 10. YA39 11. YA42 the home receives an up to date report. The quality assurance process needs improvement to include feedback from people who live at the home and other stakeholders and an annual development plan drawn up to show peoples views have been taken into account. People living in the home need to be informed about tests of the fire alarms as it gives confusing signals if the alarms sound and there is no evacuation of the bungalow. This could potentially mean that people do not react in the event of the alarms sounding for a real fire. Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Jaffray Nursing Home DS0000024859.V337860.R01.S.doc Version 5.2 Page 33 - 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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