Inspection on 19/12/05 for Jah Jireh

This inspection was carried out on 19th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Jah Jireh 10/10/06

Jah Jireh 16/02/06

Jah Jireh 01/02/05

Jah Jireh 05/08/04

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

CARE HOMES FOR OLDER PEOPLE Jah-Jireh 7 Beechfield Court Leyland Lancashire PR5 2WA Lead Inspector Pauline Randles Unannounced Inspection 19th December 2005 09:15 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 Jah-Jireh DS0000005936.V263936.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. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Jah-Jireh Address 7 Beechfield Court Leyland Lancashire PR5 2WA 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) 01772 623710 Jah Jireh (Charity) Homes Mr Russell Charles Baker Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 01/02/05 Brief Description of the Service: Jah-Jireh is situated in a residential area in Leyland, close to local shops and facilities. The home provides 24-hour personal care for up to 36 older people. Jah-Jireh homes have been established and are run wholly and solely to give accommodation and care to members of the community of Jehovah’s Witnesses. The home provides accommodation throughout two floors in both single and shared rooms, and the majority have an en-suite facility. The communal areas are situated on the ground floors. The home has a passenger lift. The grounds to the house are extensive, and private for the residents to enjoy. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over an eight-hour period. There were thirty-six residents living at the care home at this time. During the course of the inspection the registered manager, four staff, five visitors and eight residents were spoken to, of which three were case tracked. In addition policies, procedures and records were examined, activities observed and relevant parts of the building viewed. Information from a pre inspection questionnaire contributed to the findings. What the service does well: What has improved since the last inspection? All requirements and recommendations from the previous inspection had been addressed including a revision of procedures relating to needs assessment, adult protection and recruitment and selection to ensure their robustness. Systems for care planning, checking water temperatures and installation of bed rails had been extended to protect the health, safety and welfare of residents. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 6 Reports from the homeowner had been sent to the commission submitted confirming that a responsible individual had made monthly quality assessment visits to the care home. The lounge and dining room had been decorated, the dining room carpeted and six bedrooms decorated to provide added comfort for residents. Also the peeling wallpaper in one bathroom had been attended to as previously required. 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. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The written information provided prospective residents and their representatives with full details of the home’s services and facilities enabling an informed choice to be made about possible residency. Improvements had been made to the pre admission assessment process that ensured only those people who could have their needs effectively met were accepted for admission to the care home. EVIDENCE: The Statement of Purpose and Service User Guide had been revised in June 05 as required following the previous inspection. These documents were written in an easily read format that enabled resident access and included a copy of the inspection report. Fire precautions and associated emergency information had been extended as requested. A DVD film was also available to inform prospective residents about the services and facilities of the care home. Three case files were examined that indicated pre admission assessments were thorough encompassing all requirements. Also, evidence was seen that confirmation of whether or not a place could be offered was sent in writing to Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 9 prospective residents following their assessment. A Local Authority needs assessment and Care Management Plan was held on file where this was applicable. In such cases a pre admission assessment had also been completed to further enhance the information available. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 10 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 and 9 The health and personal care of residents was well met. Good records had been maintained to ensure that staff were aware of individual needs. EVIDENCE: Care plans had been extensively revised in accordance with previous inspection requirements. The plans were now extremely thorough reflecting the assessed needs of residents and providing an effective guide to care practice. Risk and nutritional assessments had been introduced and were seen on the files of three residents. It was recommended that wherever practicable the risk assessment should be signed by the resident or their representative. Weight records were being regularly maintained and it was noted that a recent weight fluctuation had been followed up. The three residents case tracked were spoken to which confirmed the relevance of their current care plans. Records indicated that health needs were met through effective multi disciplinary working, for example with the pharmacy, general practitioners and through daily district nursing visits. Residents confirmed that personal health needs in relation to optical, dental and chiropody requirements were well met. More than one resident said if they were unwell they would be enabled to rest Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 11 and meals would be brought to their room. The bed rails risk assessment procedure had been extended as requested although there were no rails installed at the time of inspection. The practice of taking blood glucose tests had ceased since the previous inspection with suitable alternative arrangements made via district nursing services. Medication policies and procedures were in keeping with legislation and professional guidance. Requirements made by the Pharmacy Inspector had been acted upon as confirmed in a local pharmacy report dated the 2nd December 05 that stated “temperature checks ok, fridge well maintained,” and medical administration sheets “well filled.” Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 12 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 and 15 The procedures relating to activities and outings do not adequately evidence that consultation has taken place and that the resulting arrangements are resident led. Residents were enabled to see visitors of their choosing in private if they so wished. . A wholesome diet is provided that aids appetite and nutrition. EVIDENCE: Residents spoken to confirmed that they were enabled to exercise choice in relation to meal and bed times. Files indicated that social needs and preferences had been recorded during the initial assessment. In regard to recreational activities some residents said, for example “ not much activities would like outings particularly in the summertime,” and “ perhaps it would be nice if one or two could be taken out.” A member of staff held particular responsibility for activities. In recent months these had included a garden party for residents and their relatives and the establishment of a shop facility. Shop accounts had been crosschecked and were found to be correct when examined. A local outfitter had brought some clothes in for residents to choose from at the time of inspection. There was evidence that a range of Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 13 entertainment had been advertised however there was no record consultation with residents, the levels of participation or satisfaction. of To ensure that residents were enabled to exercise choice in regard to going out for their shopping and choosing social and recreational activities it was required that consultation takes place with records maintained. Residents confirmed that visitors were made welcome and offered refreshments when calling at the care home. One visitor spoken to, who had been given a cup of tea, said there was “ always someone quick to answer the door” whilst another visitor said “ staff are friendly and caring.” Residents were enabled to see visitors in private if they wished. All residents were of the Jehovah’s Witness faith therefore the church community provided pastoral care and support. Also residents were provided with transport should they wish to attend the local Kingdom Hall for worship and meetings. Menus indicated that balanced and nutritious meals were provided with choice and alternatives available. The cook when spoken to demonstrated an understanding of the special dietary needs of the residents for example five residents who were diabetic. In discussion about liquidised diets it was recommended to the cook that items of pureed food should be pureed separately to maintain attractiveness of the meal and stimulate appetite. Residents had been consulted about menus as evidenced in meeting notes and changes to menus had been made accordingly. One resident who said she “loves it,” in relation to living at the care home spends time each day going round with menus to enable other residents make an informed choice about their meals. As noted from residents’ files nutrition is monitored and any fluctuations in the weight of a resident were acted upon. Cooks were available at all meal times which made it possible to serve a hot meal in the evening and a lighter lunch thereby meeting the preference of residents. When asked about meals residents said, “very good,” and “well looked after and well fed.” Also a visitor said, “Meals were excellent when I worked here.” Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 14 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): 18 The policies and procedures of the care home ensured that residents were protected from the potential of abuse occurring. EVIDENCE: Robust adult protection procedures were in place that included whistle blowing and dealing with verbal or physical aggression. Department of Health Guidance No Secrets in Lancashire provided underpinning guidance. The policy clearly defined types of abuse and made reference to data protection, storing of cash and valuables and acceptance of gifts procedures. At the time of inspection formal training of a staff group was taking place. During a brief observation of the training event it was noted that the topics being covered included protection and safety, dealing with fear, anxiety and verbal or physical aggression. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 15 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, 21 and 26 The premises were suitably fitted, furnished and hygienically maintained providing a safe and homely environment for residents. There were adequate bathing and toilet facilities for the benefit of residents that were readily accessible. EVIDENCE: The lounge, dining room and six bedrooms had been redecorated since the previous inspection. Also a new carpet had been laid in the dining room. Peeling wallpaper in the bathroom had been replaced as previously required. A business plan outlining the proposed maintenance and refurbishment tasks for the coming financial year was provided for examination. The plan had been submitted to head office for approval following which an agreed priority list will be available for inspection. The premises and grounds were observed to be generally well maintained and evidence was seen that the service had complied with fire and electrical safety requirements. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 16 There were adequate toilet and bathing facilities suitably located for the benefit of residents and easy access. Of the five bathrooms, three have aids to assist bathing. A lockable sluice facility that was not used to store chemical products was clearly signed and separate from general facilities for residents. Water temperature records indicated that water temperatures in bathrooms were maintained, around 43 degrees. At the time of inspection the premises were clean and odour free. There were detailed policies and procedures for control of infection that included safe handling of clinical waste, sharps and needle stick procedures. Discussion with a domestic assistant confirmed her understanding of the safe use of materials and knowledge of good practice relating to the control of substances that might be hazardous to health. Observation of cleaning tasks being undertaken indicated attention to detail. It was again recommended that confirmation that the premises comply with the Water Supply (Water Fittings) Regulations 1999 should be obtained to ensure safety. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 17 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): 28, 29 and 30 The available training initiatives had enabled staff to develop additional skills, competence and gain relevant qualifications. Procedures of the care home for confirming criminal records checks were not sufficient to verify that only people suitable to work in a care home environment were recruited. EVIDENCE: Records indicated that staff members had participated in a range of training initiatives including food hygiene, fire safety, moving and handling, health and safety and caring for people with dementia. More than 50 of care staff held a National Vocational Qualification at Level 2. Training and development needs of individual staff members had been assessed and responded to in training and career development plans. A training session was taking place at Jah Jireh at the time of inspection. It was observed that the learning environment was enabling to staff and there was clear evidence of relevance of material and suitable participation. A resident said, in relation to staff training, “younger staff need to learn, they are doing very good because of training,” Personnel files of three staff members spoken to were examined. Each file held proof of identity, two references and confirmation of Criminal records Bureau (CRB) clearance. The procedures stated that any concerns around clearance would be referred to the Commission for Social Care Inspection for advice. The actual CRB clearance documents were held at the head office of Jah Jireh. A Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 18 basic record of dates of submissions made and clearances received was held at the care home. On request the unique number of the three CRB records for the staff being tracked was forwarded by fax from head office to evidence validity. It is required that CRB recording systems at the care home be extended to ensure the unique reference number is available for all staff in order to meet regulatory purposes. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 19 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): 36, 37 and 38 The home was well managed and promoted the interests of the residents. Supervision procedures need some development to adequately cover all recommended topics. EVIDENCE: Supervision of care staff had been provided at regular intervals and had covered topics of relevant significance. However the main topics recommended for discussion had not been addressed as a routine framework for discussion. It was therefore again recommended that supervision should include reference to philosophy of care, care practice and career development needs. Staff members said they felt supported and more than one staff member said “we work as a team.” Records were generally maintained in very good order, for example residents and personnel files were well structured and clear to read. Evidence was seen Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 20 that residents had been advised in regard to accessing their records and guidance had also been given at a residents meeting. Also where possible residents had signed their care plan indicating their involvement and agreement to the content. Food temperature records had not been fully completed by catering staff and current kitchen cleaning records were not available for inspection. It is required that these records be maintained effectively at all times to ensure safe food handling and a hygienic environment. Examination of records and discussion with staff members confirmed that induction training had taken place that included the mandatory training topics of moving and handling, food hygiene, fire safety, health and safety and first aid. Policies and procedures examined were underpinned by relevant health and safety legislation. The fire risk assessment had been reviewed annually and all safety certificates were up to date and available for inspection. Safety procedures were suitably posted and accident and incident records adequately maintained. Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 21 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X 3 X X X X 2 STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 2 3 Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Timescale for action 16 (2) (n) Residents must be consulted 31/01/06 about the programme of activities and outings to be arranged. Records must be maintained of the consultation participation and satisfaction levels. 19(b)(1) Evidence of completed Criminal 15/01/06 Sch(2) (7) Records Bureau checks must be available for inspection at the care home. 17 (2) Records relating to food 15/01/06 temperatures and kitchen cleaning must be effectively maintained. Regulation Requirement 2 OP29 3 OP35 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 OP8 OP15 Good Practice Recommendations Wherever practicable, risk assessments should be signed by the service user or their representative. Food items should be pureed separately when providing a liquidised diet. DS0000005936.V263936.R01.S.doc Version 5.0 Page 23 Jah-Jireh 3 4 OP26 OP36 Confirmation that the premises comply with the Water Supply (Water Fittings) Regulations 1999 should be sought. Supervision should cover all elements as outlined in standard 36.3 Jah-Jireh DS0000005936.V263936.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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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