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Inspection on 09/06/05 for Jaffray Nursing Home

Also see our care home review for Jaffray Nursing Home for more information

This inspection was carried out on 9th June 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Jaffray provides a very homely environment in which to live. The premises are well maintained and presented to a high standard. People who live in the home are able to help choose furniture and colour schemes. People who live at Jaffray are well supported with their personal care. This includes wearing clothes they like, wearing makeup, and having their hair styled as they like. Jaffray ensures staff employed to work in the home receive full checks before being allowed to start work. They try to ensure that the same people provide care all the time. The food available at Jaffray looked and smelt nice. People that live in the homes told inspectors they liked the food, and were observed to enjoy eating it. Plenty of food was available, and it was of a good quality. The friends and family of people that live in the home are able to come and visit. Inspectors found that people who live at the home receive their medication at the right time in the right dose.

What has improved since the last inspection?

The records of care on two of the bungalows have caused the CSCI concerns in recent inspections. Staff had worked to improve these since the last inspection. The home has decreased in number by two people. This means that every one who lives at Jaffray has a single bedroom.

What the care home could do better:

Progress has been made towards meeting a large number of the requirements previously made. Work must continue to fully meet these. The home must ensure they have enough staff to meet the needs of people that live in the home. The home must ensure there are interesting and varied things for people who live in the home to do.

CARE HOME ADULTS 18-65 Jaffray Nursing Home 19-31 Jaffray Crescent Erdington Birmingham B24 8EG Lead Inspector Alison Ridge Unannounced 9 June 2005 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 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 Stationary 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 E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Jaffray Nursing Home Address 19-31 Jaffray Crescent Erdington Birmingham B24 8EG 0121 382 1383 0121 255 2356 Telephone number Fax number Email 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 21 Category(ies) of Learning Disability - Physical Disabillity registration, with number of places Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1.21 persons with a learning disability and physical disability 2. That the home can continue to accommodate three named services who are over 65. 4. That Jaffray Nursing Home apply for variation on behalf of future service users who reach the age of 65. 5. 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. Date of last inspection 16 December 2004 Brief Description of the Service: Jaffray Nursing Home comprises of four bungalows. The home accomodates 18 people who have a learning disability, physical disability and additional nursing needs. The bungalows have level access throughout and are fully accessable to people without full mobility. Each bungalow is home to four or five people. Each service user has a single room, none of these have ensuite facilities, but all have a wash hand basin. Each bungalow has supported bathing facilities. The home has a range of hoists and mobility equipment. Each bungalow has a kitchen, dining room and lounge area. One bunglaow has a conservatory. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on one day by two inspectors. The inspectors spent time in each of the four bungalows, talking with service users and staff, observing care practice and reading care records. Mandatory records including staff files and those relating to health and safety were also inspected. Inspectors were also pleased to meet with the homes manager and the responsible individual. What the service does well: What has improved since the last inspection? The records of care on two of the bungalows have caused the CSCI concerns in recent inspections. Staff had worked to improve these since the last inspection. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 6 The home has decreased in number by two people. This means that every one who lives at Jaffray has a single bedroom. 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. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 Prospective service users do not have an opportunity to visit the home prior to admission so they can decide whether or not they would like to live there and whether the home can meet their needs. EVIDENCE: The home has a stable service user group, there are no residential vacancies, and there have been no new admissions since the last inspection. The work undertaken with one service user who has moved from one of the Jaffray Bungalows to another was tracked. It was not evident from the service users file that a new assessment of need or any trial visits had been undertaken. It was of concern that the service users file had not been reviewed or updated to reflect the new care environment, and any new or additional needs or risks. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9,10 Records of care have improved since the last inspection, however they still do not fully underpin the service users needs or provide clear guidance to staff. The home has not consulted with service users regarding their plan of care. The home has developed risk assessments. These require further work to underpin key areas of service users needs. EVIDENCE: Each service user has an individual plan of care. Four of the plans were assessed at this inspection. It was evident that since the last inspection work to review these and develop the documents further had been undertaken. The care files had been rationalised as previously recommended and information regarding service users current needs was easier to locate. The daily care notes were being completed in a more structured manner, and the information contained in them generally gave a greater impression of the person’s day, and how their needs had been met. It was pleasing to hear that training in Person Centred Planning (PCP) had been provided to some staff, and that this is the care planning model the home attends to adopt in the near future. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 10 At present care files do not show any liaison with service users. Risk assessments again show signs of review and development. Further work continues to be required to fully underpin service users needs. It was reported after the inspection that risk assessments to underpin service users undertaking community activities had been completed. These were not presented for inspection. Risk assessments for eating and drinking were tracked. It has been required that the document and practice regarding choking be reviewed. At present it is recorded that meat must be liquidised. The inspectors tracked other foods, being offered and eaten that also present a choking hazard. It was not evident if these had been assessed. Risk assessments must be kept under review, and show how the review has been undertaken. Some risk assessments had not been reviewed in the past six months. Review dates set by the home had not all been met. All care records observed were safely stored. No breaches of confidential information were noted. Staff liaised with service users and among themselves in a professional and friendly manner. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,17 Opportunities to undertake leisure and developmental activities are provided at the home. The range and frequency of these are not consistent with the peers of service users who do not live in a care home. EVIDENCE: It was evident that service users in all of the bungalows have been supported to undertake a range of leisure and developmental activities. Some of the service users accommodated attend local day services. Other service users undertake all activities in, or from the home. The inspector has recommended that the purpose of activities be explored with each service user. This would enable staff to plan and establish the effectiveness of the activity, and the individual’s development. The range of activities undertaken was appropriate to the culture and age of the service users accommodated. Activities undertaken included meals out, theatre trips, visits to places of interest and local walks and local shopping. The frequency of the activities was not consistent with the service users peer group. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 12 The home accommodates some service users with very complex needs. It was disappointing to find that entries previously identified as inappropriate continue to be used. These include, ”played with toys” for one of the service users on some of the days sampled. The staff work pattern has had both positive and negative effects on the delivery of activities. Staff work until 8pm, which results in service users being able to undertake some activities into the early evening. The inspector’s noted one recent theatre trip, on which service users attended an early evening performance, this ensured they had returned to the home by 8pm. The inspectors commented it would be usual for adults to attend the later evening performance. Opportunities appear to cluster around the day a driver is available for the home. At the time of inspection service users on one home had been out in the afternoon and the evening, as a driver was available. Other days proceeding this no community activity had been achieved. The manager provided evidence with the response to the report, of the work undertaken with staff to address this. Service users are enabled to access the local community, including attending local churches and using community health and leisure facilities. The food stocks, record of food, menus, and discussion with service users about the food all identified that a nutritious and varied diet is served within the home. Food stocks were plentiful, and included fresh fruit and vegetables. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Service users are supported to undertake personal care to a high standard. Medication management was good. Specific healthcare needs are not well planned. Consistent evidence that healthcare needs have been met was not available. EVIDENCE: Service users accommodated at Jaffray all appeared to have been well supported with their personal hygiene. Inspectors were pleased to meet with service users in all the bungalows who appeared very individual in appearance. Inspectors commended the home for the detail in which care records on bungalow 29 had been completed. Service users accommodated at Jaffray Nursing home have a wide variety of health care needs. Learning Disability nurses employed at the home over see and plan care, with the support of the multi disciplinary team. The healthcare offered to each service user is plotted on a matrix, and recorded in the nursing notes. Records made do not evidence that chiropody, dental or optical care is given on a regular basis, or as assessed for the service user in their plan of care. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 14 Some service users require support with their mental health. The plans of two service users were assessed. The plans did not evidence how well-being is identified for these people, or the indicators of change. The care plan for one service user identified as having a low body mass index (BMI) was assessed. The plan did not state the current BMI, how the person was being enabled to increase weight, or the goal BMI the person was aiming for. The care plan had been reviewed monthly and no changes made. The inspectors identified that as no weight had been gained, and the BMI remained unchanged, the plan was not working and required amending/development. It was of concern that the review process had not identified this. One service user who can display some difficult to manage behaviour was tracked. A plan to underpin his needs in this area was available. Inspectors have commented previously that the plan must also contain proactive strategies to reduce/minimise the impact of the behaviour, as well as reactive plans. Some service users require total support to evacuate their bowel. In one of the homes sampled records of bowel movements, enemas and suppositories did not evidence that the protocol regarding the use of these “As required” (PRN) medicines had been followed. Service users with epilepsy prescribed rescue medicines all had a plan to underpin the use of this. Not all strategies had been signed, or dated or showed agreement with the GP. It is recommended that liaison with the Epilepsy nurse be undertaken to ensure the protocols contain all the required information, and reflect current best practice. These documents continue to require development to reflect the action to be taken in the community or if a nurse is not available. Care plans sampled all showed review in the past six months. In some cases a shorter review period had been identified by the nurse writing the plan. In many instances this review was overdue. The home was reminded of the need for all service users to have a Health Action plan in place for all service users by June 2005. Medication was assessed in bungalow 29. This is an area in which the home continues to perform well. Medication management was good. Minor shortfalls were identified, which were made requirements at the time of inspection. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has robust procedures and practices regarding the investigation of Complaints and Adult Protection concerns. EVIDENCE: It was reported that the home has received no complaints since the last inspection. The CSCI received a complaint about this home in January 2005 regarding infection control and medication. The provider investigated the complaint. The outcome was that the complaint was not upheld. The CSCI was involved in an Adult Protection investigation in April 2004. The provider investigated this matter. Training and support was given to staff involved in the incident. The inspectors assessed work undertaken to develop the care plan of the affected service user. It was not evident that this had been undertaken, to ensure the future safety and wellbeing of the service user. It was required at the time of inspection that this be undertaken. The manager has since informed the inspector that the required work has been undertaken. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27,28,30 The premises of Jaffray Nursing Home are presented and maintained to a high standard. Service users reported being happy with the facilities provided, and the inspectors observed them to meet individual needs. EVIDENCE: The premises of Jaffray Nursing home are presented and maintained to a very high standard. Since the last inspection curtains, and lounge furniture had been updated. These areas appeared very attractive. The conservatory in Bungalow 31 has been completed and is in full use. This appears to be a very valuable space, and a number of service users reported enjoying sitting in there. It has been recommended that thermal ceiling blinds be fitted to ensure service users comfort throughout the year when using the facility. Areas of the home identified as requiring attention were, • The redecoration of the wc in bungalow 21. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 17 The inspector was pleased to meet with one service user who had just had his room painted, and a new carpet fitted. He reported choosing the colour scheme and was obviously very pleased with the result. Jaffray nursing home has reduced the number of service users accommodated by two, resulting in all of the service users having a single bedroom. Work to redecorate and arrange these rooms was underway. The areas of the home inspected were clean. Some food products that had passed the best before date, and some mouldy bread was observed. These items were discarded at the time of inspection. Hygienic hand washing and drying facilities were generally available, with the exception of the laundry, and one communal bathroom. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35,36 The number of staff on duty was not adequate to meet the needs of service users. Staff employed at the home receive training in areas relevant to service users needs, enabling them to deliver the required care and support. Robust checks are made on staff prior to them starting work in the home, which safeguards service users from harm. EVIDENCE: Training delivered since the last inspection was assessed from the homes training Matrix. Training in the area of Adult Protection remains outstanding. Staff had received training in Diabetes care. The manager was asked to ensure all staff working with service users who have diabetes (recently changes as one service user has moved homes) have received the training. It was reported that staff working with service users that use Makaton have received training in this area. Learning Disability Award Framework (LDAF) induction is not available to new staff and must be provided. The training given to one recent staff starter was assessed against the requirements of Standard 35 of the National Minimum Standards. It was evident the person had been supported to undertake training in Food Hygiene, Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 19 Risk assessment, Health and Safety, Adult Protection, Manual Handling, CPI, and Epilepsy awareness. Training in care planning, personal care, medication, security, escort duties pressure care, and dying remained outstanding. The manager provided inspectors with a revised copy of the induction checklist which will cover the majority of these topics. The number of staff on duty did not appear to be adequate for the service users accommodated. Both inspectors noted long periods of time when service users sat unsupported or supervised by the staff on duty. Staff reported it is usual to have two care staff on duty in each bungalow, with a nurse working between two bungalows. The home employs three day service staff, who work in turn on each home. The inspectors were previously informed the working of long days would result in greater numbers of staff on shift. This does not appear to be the case in practice or on the rota. The recruitment practices employed by the home were assessed and found to be robust. Staff had been thoroughly checked prior to starting work in the home, and staff are subject to a trial period. Staff supervisions were assessed. Supervisions have been undertaken, though not with great enough frequency to meet the six times a year target, or to ensure staff are fit to meet service users ongoing needs. An example of good practice, following up on concerns about staff performance was observed during the inspection. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 The management and operation of the home had improved. The management still does not ensure outcomes for service users are consistently met. EVIDENCE: The management arrangements at the home appear to have improved since the last inspection, with the manager being supernumerary. The inspectors remain concerned that key areas of the homes function, including meeting service users needs continue to require development. Health and safety records were sampled Fire safety records showed that routine testing of the alarm and emergency lights had been undertaken. The fire risk assessment has previously been required as requiring review. This remained unchanged. Inspectors observed staff manually lift baskets of wet washing from the bungalow to the laundry. It is required this be explored and alternative means of moving the load obtained. Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 2 2 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 2 Standard No 11 12 13 14 15 16 17 2 2 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x 3 1 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Jaffray Nursing Home Score 3 1 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 22 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 1 Regulation 4 Requirement Not assessed at this inspection. The categories of service users accommodated must be reviewed, as the Statement of Purpose details this to be people aged 18-65, and to include service users with mild challenging behaviour. The detail given in some of the sections of the Statement of Purpose requires further development to fully inform the reader. Assessment must be undertaken 1/8/05 of new service users. The home must evidence they can meet the individuals needs. Individual contracts must be 1/9/05 signed by the registered person and where possible the client. All contracts must include the cost of the placement. The contract must be further 1/9/05 developed to include, - The fees charged - Rights and responsibilities of both parties - Elements of the Care management Care plan to be provided outside if the home Version 1.30 Page 23 Timescale for action 2. 3 14 3. 5 5(1) b, c 17(1) a 4. 5 5(1) Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc 5. 6 12(1) a, b 14(2) a, b 15(1)(2) 17(1) a, schedule 3 6. 6 12(1)(a) (3) and 15 12(1) a, b 13(4) a, b, c Health and Safety at Work Act 1992 13(4) 7. 9 Requirement partly met. (Elements met have been deleted.) The plan must also include any aids/ adaptations used by the resident and a record of service/maintenance of such equipment kept. The plan must include restrictions on choice and freedom that have been agreed with the service user. Activity plans appropriate to the aims of the home should also be within individual care plans, to include how residents will be supported to participate in the day to day running of the home, and empowered to make choices about aspects of their lives. The plan must include details of how individuals communicate. Service users must be called by their preferred name. Service users plans must evidence consultation with service users. Resident’s risk assessments must be written, reviewed and updated where necessary. Risk assessments must then be subject to regular review and a record of this kept. Risk assessments must be developed to fully reflect the in house and community activities undertaken by service users. Risk assessments and practice regarding eating and drinking must be reviewed. Service users must be offered skills relevant to greater independence. Communication systems to support the spoken word must be provided as required by 1/9/05 1/8/05 1/8/05 8. 9 1/8/05 9. 10. 9 11 13(4) 12(1)(ab)(2), (3) 14/8/05 1/9/05 Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 24 service users. 11. 12 16(2)(mn) Service users must be offered a choice of valued and fulfilling activities at a time of their choosing. 1/9/05 12. 13. 17 12(4)(a) and 23(2)(n) 14. 15. 16. 18 19 19 17. 19 18. 19. 19 19 20. 21. 19 19 Not assessed at this inspection. Crockery suited to the needs of service users, and consistent with ordinary living principles must be used. 12(1)(aStaff must provide sensitive and b) required care and support to service users. 13(1)(a) Nursing care must be reviewed to ensure service users health care needs are being fully met. 12(1)(a) Requirement partly met. and Elements met have been 13(1)(a) deleted. Health care needs of service users must be urgently reviewed to include the provision of the following; Care plans to fully reflect the needs of the service user, and to be kept under review. A record of contact made with the multi disciplinary team. 13(1)(b) Service users must be supported to receive treatment from chiropody and dental services as required. Evidence of this must be maintained in the home. 12(1)(aCare plans must be updated and b) amended as service users needs change. 12(1)(aClear care planning and guidance b) and must be provided for service 13(4)(a-c) users with epilepsy. This must include access to the community. 12(1)(aMental health needs must be b) planned as required. 12(1)(a) Health action plans must be developed with service users as E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc 1/8/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/10/05 Page 25 Jaffray Nursing Home Version 1.30 22. 20 13(2) 23. 20 13(2) 24. 23 13(6) and 18(1)(b) 25. 24 26. 27. 28. 29. 24 30 30 30 13(4)(c) and 23(2)(ab) 23(2)(ab) 13(3) and 23(2)(k) 16(2)(J) 13(4)(c) and 23(5) 30. 31. 33 33 18(1)(a) 18(1)(a) 32. 33 18(1)(c )(i) identified in the white paper,Valuing People A protocol regarding service users who require medication while out on activities must be developed. PRN (As required) protocols must be kept under review. PRN protocols must be available for all as required medications. Medications no longer required must be removed or marked on the MAR chart. Five staff still require this training. All staff must receive training in Adult protection policies and procedures. Uneven paving slabs in the garden must be levelled to reduce the risk of residents and staff tripping. Redecoration of one toilet must be undertaken. Hygienic commode washing facilities must be made available. Paper towels and liquid soap must be provided in all toilets and bathrooms and the laundry. Food storage of dry good must be airtight Fridge and freezer temperatures must be taken and recorded daily. Adequate numbers of staff must be provided in all areas of the home. Staff must be available across the waking day to ensure service users are offered opportunities to undertake activities and a lifestyle consistent with their peer group. Learning Disability Award Framework induction must be undertaken with all new staff starters. 1/8/05 1/8/05 1/9/05 1/10/05 1/8/05 1/8/05 14/7/05 14/7/05 1/8/05 1/8/05 1/9/05 Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 26 33. 34. 36 39 18(2) 24 35. 42 13(5) and 18(1)(c)(i ) 13(4) 13(4)(c) and 23(4)(a) 36. 37. 42 42 Supervisions must be undertaken with all staff, at least six times each year. Not assessed at this inspection. A Quality Assurance system must be obtained and results of such audit made available for inspection. Facilities for the transportation of wet linen must be obtained, and staff trained to safely handle this load. Risk assessments must be developed for food, staff and the premises. The fire risk assessment must be further developed to accurately reflect the situation in the home. 1/9/05 1/8/05 1/9/05 14/8/05 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 Good Practice Recommendations Jaffray Nursing Home E54 S24859 Jaffray Nursing Home V232651 090605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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. 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