CARE HOMES FOR OLDER PEOPLE
Jalna Care Home 285b Manchester Road Burnley Lancashire BB11 4HL Lead Inspector
Mr Jeff Pearson Unannounced Inspection 09:45 18 October 2006
th 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 Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Jalna Care Home Address 285b Manchester Road Burnley Lancashire BB11 4HL 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) 01282 431182 01282 416119 www.jalna.co.uk Botany House Limited Mrs Margaret Simpson Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Staffing levels in the home must be in accordance with the guidance issued by the previous registration authority and reflect the number and needs of the service users. Within the registration of the home 22 older people requiring personal care, there are 2 service users with a mental disorder MD(E) and 4 with dementia DE(E). These numbers apply only whilst these named service users reside in the home. Date of last inspection 8th February 2006 Brief Description of the Service: Jalna is registered to accommodate 22 older people over the age of 65 who require help with personal care. The home is a semi-detached Victorian property, with surrounding gardens and paved areas. There are 18 single bedrooms, 10 with en-suite toilets and 2 shared bedrooms, 1 with en-suite toilet. Various adaptations to assist with self-help and mobility are provided. The upper floors are accessed by a chair lift. There is a large lounge/dining room with adjoining conservatory, a separate dining area and a small quiet/visitors lounge area. The residents have access to the paved area to the front of the home, with garden furniture being provided. There is car parking space available at the front of the building. Jalna is approximately 1 mile from Burnley town centre and is on a bus route. There are some shops, public houses, churches and a post office quite close to the home. A local park is within reasonable walking distance. Various activities are available including mini bus trips. Jalna is a non-smoking residence. At the time of this inspection visit the range of fees was £320.00 to £360.50 there were additional optional charges for hairdressing and extra newspapers. Written information about Jalna was available in the dining room entrance. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a visit to the home, was conducted at Jalna on the 18th, 19th and 20th of October 2006, the visit took 16½ hours and was carried out by one inspector. There were 21 residents accommodated. Prior to the inspection visit, survey forms were sent to the home for the residents and their relatives/representatives to complete. Four were received from residents, two from relatives/visitors. Information was gathered from a pre inspection questionnaire completed by Mrs Simpson, registered manager. The files/records of 3 residents were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. During the inspection, the residents, manager, homeowners, staff and visitors were spoken with. The records of the most recently recruited staff were looked at. Some policies and procedures were seen. A tour of the home was carried out. What the service does well: Jalna had a welcoming and supportive atmosphere. The staff were friendly and enthusiastic. One resident said, “I like the homeliness” and considered staff to be “marvellous and very thoughtful” “They have done marvels with my mum, they really looked after her and sorted her needs” commented a relative. There were some good care practices at Jalna. One resident stated, “ I was really down last week, but the girls talked with me and I felt better” Routines in the home were flexible, so people had some freedom in how they spent their time. Privacy and dignity was being promoted, “The staff always abide by what I say” “I find the staff very helpful” residents said, another explained that before entering the bedroom “they knock and wait until I shout “come in” The residents were mostly satisfied with the activities and entertainment provided at the home. One resident explained “An entertainer is coming tonight, he plays our tunes, we have a sing-song and those that can dance get up and dance” “I think things are okay with activities, we have enough going on” said another. The residents expressed an appreciation of the food saying, “ The food is good” “the meals are very good, no faults, we can have what we want” and “Plain wholesome food, nicely cooked and nicely served” Choice menus were available and mealtimes were seen as a social occasion.
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 6 Visiting times were flexible so friends and relatives could call at different times, the residents could see people in private. Relatives indicated they were always made to feel welcome at the home, one said “I am treated as family when I come here” “They are very sociable with people who come to visit” said a resident. The residents appreciated the staff and homeowners; relationships between everyone in the home were good. “The management do everything they can to make you comfortable and I don’t think you can ask for more than that” one resident said. “ The owners are very nice,” said another. The home was clean and fresh smelling. The communal areas were nicely decorated and furnished in a homely way; the front garden was attractive well maintained and appreciated by the residents. “What nicer place can we have, than overlooking the garden?” said one. The residents expressed an appreciation of their private space saying “I love my bedroom” and “ I have my own things with me” What has improved since the last inspection? What they could do better: Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 7 To find out and properly respond to people’s needs, abilities and wishes, the assessment system needed to be further developed. All needs identified on assessment are to be included in the residents initial care plan. The resident’s individual care plans still needed to include full details of all their health and social needs and how they are to be met, to ensure staff know exactly what to do for each person. Any changes in care needs must be written in care plans, to provide clear up to date instructions for staff. The residents should be more involved when their care plans written and reviewed they should where possible, sign in agreement with them. Medication management, policies, practices; training, recording systems and assessments needed further attention for the protection of residents and staff. Better records needed to be kept of meals served to the residents to show they are getting a proper diet and choices. The protection procedures needed changing to provide clearer instructions for staff, to make sure they do the right thing. Staff then needed to be made aware of the updated procedures. The quality assurance system still needed more work to make sure everyone is consulted and to show plans are being made to make improvements for the benefit of the residents. Better records should be kept of staff training to show and they are being supported to develop their skills and update their learning for the benefit of the residents. 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. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 8 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 Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 9 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): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems for assessing peoples’ needs and abilities did not sufficiently ensure all needs are known and planned for. EVIDENCE: The records of the three most recently admitted residents showed assessment, and initial care plan information had been obtained, as appropriate, from Social Services. The manager said potential residents were always visited in their own environment. New residents had received letters assuring them of a place at the home, they made positive comments about the home and staff and said they had settled well.
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 10 The document used by the home for assessing people covered various health and social care needs and abilities, however, it had not been fully completed and it was not clear all needs had been properly considered. One Social Services initial care plan indicated a specific care need, but this had not been included in the homes care planning system, the manager said the identified need was “not a problem”, but there was no written evidence in support of this, which suggested the matter had not been properly reviewed. Two of the new residents said they had not seen the homes’ guide, the manager was to ensure copies were provided. It was also advised the service user guide be reviewed and updated, to include the requirements of the amended regulations. Intermediate care is not provided at Jalna. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were not sufficient in fully addressing the residents’ health, personal and social care needs. Medication management practices needed some attention for the protection of the residents and staff. Support with personal care was provided sensitively in a way which promoted the resident’s privacy and dignity. EVIDENCE: Progress had been made in care planning. A new care planning system had been introduced. Care plans seen as part of ‘case tracking’ included details of action to be taken by staff to meet needs and were sensitively written. Care plans provided summaries of peoples’ preferred daily routines and their background histories. However, the care plans had not been dated and it was not evident the residents had been involved defining, or reviewing their care plans. Following discussion with residents, it was apparent some care planning matters had not been updated in response to changing needs. Social care
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 12 needs had not been fully included in care plans. This more informal approach to care planning means that continuity of care is largely dependant upon staff memory and good communication systems, with a potential for care needs not being properly met and care being reactively rather than proactively planned. Risk assessments on the use of bedrails, did not fully identify and consider all potential hazards. Daily care notes included entries stating “care as plan” which did not always provide an accurate reflection of peoples life and situation. The residents’ surveys indicated they ‘always’ or ‘usually’ get the medical support they need. Dietary needs had been considered and responded to as appropriate, weight was being monitored. Moving and handling assessments had been carried out as appropriate. There were records of residents receiving attention from health care professionals, such as District Nurses and GPs. Various health care policies and procedures were available. Relatives spoken with considered the residents were looked after well. Staff responsible for administering medications, had received some training and additional training was being arranged. Medication management policies procedures were available. Storage was satisfactory. Records and stock checked as part of ‘case tracking’ were mostly satisfactory, there were some discrepancies, for example, there were some gaps in recording which had not been properly followed up, one bottle of eye drops had not been dated when opened. The homes written procedures for administering medication were not being properly followed, in that the medication was not being taken to the resident in its original container. There were no individual protocols for ‘when required’ and ‘variable dose’ medication. Assessments for residents administering their own medication did not fully consider all potential risks. Residents spoken with felt they were “treated with respect”. Care practices observed, showed privacy needs were being promoted, for example residents were supported to see visiting professionals in the privacy of their own rooms. One resident said, staff always knocked and waited for a reply before entering the room. A system was in place which linked residents to a named member of staff, who was responsible for overseeing aspects of their care. There was a telephone for residents in the dining room, it was suggested a mobile handset be provided so people could make/receive calls in the privacy of their rooms. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents had a degree of independence, opportunity to take part in activities, make choices and decisions and keep in touch with families and friends. The catering arrangements were sufficient in providing for the residents tastes, choices and diet. EVIDENCE: Routines in the home appeared flexible, for example, the residents said they could get up and go to bed when they wished and do “whatever they wanted” and meals were not served at a set time. There had not been any residents meetings held for some time, therefore less opportunity to make group decisions and be involved with day-to-day matters. Most residents were satisfied with the activities on offer, which included dominoes, cards, bingo; entertainers visited the home every two weeks. The arts and crafts session held one afternoon was well attended and enjoyed by the residents. Some residents said they preferred not to join in with activities and their wishes were respected. Newspapers were being delivered each day and various books were available. An outing to Blackpool Illuminations had been arranged. Staff spoken with said they usually had time to spend with the
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 14 residents. Seasonal events had been celebrated; Remembrance Sunday was to be observed. The residents had been encouraged to bring their own personal possessions and furniture with them, some were managing their own affairs; relatives were supporting others. The visiting arrangements were outlined in the homes guide. Residents spoken with said they could have visitors at anytime. Several relatives visited the home during the inspection visit, those spoken with said they were always felt welcome at the home and that they could stay for meals if they wished. All the residents spoken with said they were generally happy with the quality, quantity and choice of meals provided, this response was also reflected in the majority of residents surveys. A two- week seasonal menu system was in place, it was suggested this be increased to four weeks to increase variety. Choices were being offered within each course. Hot and cold drinks were provided throughout the day and fruit squash was available in the main lounge. Specific diets, such as fat free and diabetic, were being catered for. The meal times observed were unhurried and relaxed, staff were seen to be courteous and attentive when serving meals, independence was being encouraged, for example the residents who were able were supported to pour their own drinks. Ways of involving residents with menu planning and promoting further choice and independence at meal times were discussed with the manager. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems and procedures were in place to provide for the management of complaints. Safeguarding adults policies and procedures, were not robust enough to fully protect the residents. EVIDENCE: The residents spoken with said they had ‘no complaints’, but had an awareness of the complaints procedure. The complaints procedure was included in the home’s guide and was displayed in the home; it had been updated to include timescales and met with the National Minimum Standards and Regulations. The complaints processes were discussed with the manager. Records showed there had been two complaints made at the home, both had been dealt with and resolved by the manager. A system had recently been introduced for senior staff to log and respond to any ‘minor’ issues raised. Some staff had covered protection and abuse matters as part of NVQ (National Vocational Qualifications) training. The manager said there had been some ‘inhouse’ training on protection matters and a questionnaire had been devised to evaluate learning. Staff spoken with had an awareness of indicators of abuse and safeguarding procedures. The home had several proactive policies and procedures in relation to protection, however, there was an implication that allegations, suspicions, or incidents would be investigated by the home and the reporting bad practice procedure for staff did not provide clear referral details
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 16 or reassurances for staff raising concerns. There were no procedures for making referrals to the Protection Of Vulnerable Adults Register. The policies and procedures for restraint had not yet been updated, to include current best practice guidance. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 17 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): 19,21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided the residents with an attractive and ‘homely’ place to live. EVIDENCE: The residents spoken with were satisfied with the accommodation provided including their bedrooms, communal areas and gardens. The lounge and dining areas were pleasantly decorated; furnishings were ‘homely’ in style. Improvements in the home were ongoing. New carpets had been fitted in the hallway and lounge, the lounge was being decorated. Maintenance records showed matters needing attention and indicated when works had been completed. A radiator had been provided in the bathroom without heating. To provide further assistance for the residents, additional mobility adaptations had been provided in two bathrooms. It was suggested the suitability of this equipment
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 18 be reviewed to enable people, to use bathing facilities closest to their bedrooms. The home was found to be clean and free from unpleasant odours, all the residents completing surveys, indicated the home was always clean and fresh. Appropriate laundry equipment was available. Liquid soap was provided in bathrooms and toilets. Most staff had undertaken infection control training. Alcohol based had rub was provided, for staff and visitors to cleanse their hands. Several staff were seen to access the food preparation kitchen, it was suggested this practice be reviewed to promote food safety. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements were sufficient in aiming to ensure the resident’s needs are effectively and safely met. An improvement in staff recruitment practices, showed attention was being given to protecting the residents. Induction training and ongoing staff development, promoted effective support and care for the residents. EVIDENCE: Residents spoken with were complimentary about the staff team. One of the residents’ surveys indicated staff were ‘always’ available when they needed them, three suggested staff were ‘usually’ available. Two relative/visitor comment cards indicated that in their opinion, sufficient staff were not always on duty. Staff spoken with considered, although some days were busier than others, they had enough time to care for the residents. Staff rotas and records showed that previously agreed staffing levels were in place. Arrangements were in place to cover catering and cleaning duties. Action was being taken to provide support for residents with appointments. The recruitment records of the two newest employed staff showed the required information had been obtained and initial clearance checks carried out. The application form had been developed to ensure a full employment history is requested, gaps in employment had been explored. Staff had been provided
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 20 with contracts of employment. Arrangements had been made for new staff to be supervised as required. Records were seen of completed and ongoing induction training, new, unqualified staff were being supported to start NVQ (National Vocational Qualifications) training as a matter of course. More than 60 of the carers had NVQ in care, level 2. One member of staff was to commence NVQ level 3, it was suggested that al senior staff be supported to undertake this course of learning. Some staff had accessed specialised training, for example ‘falls reduction’ Staff spoken with confirmed training and development was ongoing, however, individual staff training records were not up to date. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements were satisfactory in promoting the smooth running of the home, for the benefit of the residents and staff. EVIDENCE: The atmosphere at Jalna was found to be relaxed, supportive and welcoming. The residents, visitors and staff spoken with expressed an appreciation of the manger and homeowners; everyone seemed to get on well together. Lines of accountability were clearly defined within the homes organisational structure and reflected upon the staff rota. The manager had more than two years experience in her role, she had previously attained City and Guilds care management qualifications and had
Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 22 re-commenced the Registered Managers Award. The manager considered the homeowners to be supportive and said informal meetings were ongoing. However, it would be good practice for the manager to receive a more structured appraisal. Senior staff meetings were said to have been held, but no records had been kept, there had not been a full staff meeting at the home for some time; the manager said she was proposing to arrange and lead a staff meeting following the inspection. The homeowners were fulfilling their responsibilities to visit the home unannounced and had forwarded reports of their findings to the Commission, the reports were sincere, interesting and informative. Systems for monitoring the quality of the service were informal. Residents’ views were being sought during various discussions; for example, they had been consulted about menus and colour schemes for their bedrooms. Some questionnaires had previously been given out. Quality assurances were discussed with one of the homeowners who said they were proposing to start a more formal process of collecting information, and development planning. The homes’ guide included some information about financial matters. Records seen indicated accountable systems were in place to manage residents’ pensions, charges and payments. It was advised that two people sign to verify transactions of residents’ personal monies. Secure storage was available. Most records seen were found to be satisfactory, however, the record of meals served did not include details of the food provided at breakfast and supper and therefore did provide a true reflection of the diet taken. The home was found to be free from any obvious hazards to health and safety. The pre-inspection questionnaire showed equipment had been serviced and that installations and maintenance checks were ongoing. Records were seen of various checks. A fire drill had been carried out but not dated. Fire risk assessments were in the process of being completed. Health and Safety risk assessments had been completed and health and safety policies were available. Training in safe working practices was ongoing, or being arranged, however, the manager said carers had not up-dated their basic food hygiene training. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 31/12/06 2. OP9 13,18 3. 4. OP9 OP18 13,17 13(6) Care plans must include all identified needs and be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents health and welfare needs. (Timescale of 31/03/06 not fully met) Care plans must be reviewed and updated in response to changing needs. Staff authorised to administer 31/05/07 medicines must receive accredited medicines management training and have an assessment of their competence to complete these tasks. (Timescale of 30/06/06 not fully met) Records of all medication must 17/11/06 be kept, including the date they were administered to residents. The protection of vulnerable 08/12/06 adults procedures must include appropriate clear details of the action to be taken on suspicion or allegations of abuse. Staff must be made aware of this revised procedure.
DS0000054471.V309295.R01.S.doc Version 5.2 Jalna Care Home Page 25 5. OP18 13(6) 6. 7. OP31 OP33 10(3) 24 8. 9. OP37 OP38 16 18 The reporting bad practice (whistle blowing) procedure must include appropriate referral details. Staff must be made aware of this revised procedure. The Registered Manager must obtain recognised care management qualifications. The quality assurance process must result in the production of an annual development plan. (Timescale of 31/06/06 not met) Records of meals served must be in sufficient detail to show whether diet is satisfactory. Arrangements must be made as appropriate, to ensure all staff receive training and updates, in the safe working practices as specified in 38.2 of the National Minimum Standards for Older People. 08/12/06 31/05/07 23/02/07 17/11/06 17/02/07 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 OP3 OP7 Good Practice Recommendations The homes assessment process should ensure full consideration is given to peoples’ needs, wishes and abilities. Resident’s should be enabled to sign in agreement with the review/changes to their care plan. The care plan format should ensure all needs/abilities/wishes are identified and responded to. The care plan should be as used as a working document and made available to all relevant staff. Care notes should be concise, accurate and reflective of the residents’ daily lives and circumstances. Assessments for the use of bedrails; should ensure all
DS0000054471.V309295.R01.S.doc Version 5.2 Page 26 Jalna Care Home 3. OP9 4. 5. OP12 OP18 6. 7. OP27 OP33 possible risks are considered and planned for. Individual protocols should be defined for residents prescribed ‘when necessary’ and ‘variable dose’ medication. Eye drops should be dated when opened to provide an indication of the ‘use by’ date. Assessments should be carried out on all residents’ capacity to manage their own medication. The assessment should fully consider all potential risk areas, with any support strategies being included in the care plan. Residents group discussion meetings should be reintroduced as an activity. Physical intervention/restraint policies and procedures should be further developed in line with current guidance. The reporting bad practice (whistle blowing) procedure should include reassurances for staff should they raise concerns. Procedures should be defined for making referrals as appropriate, to the Protection Of Vulnerable Adults Register. Staffing arrangements should continue to be reviewed and adjusted accordingly, in response to the needs and abilities of the residents accommodated. The quality assurance process should include more formal consultation with residents, and appropriate others. The process should review all aspects of service provision at the home and identify strengths and development needs. Jalna Care Home DS0000054471.V309295.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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