CARE HOMES FOR OLDER PEOPLE
Jalna Care Home 285b Manchester Road Burnley Lancashire BB11 4HL Lead Inspector
Mr Jeff Pearson Unannounced Inspection 4th October 2005 09:50 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.V252836.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. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 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 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.V252836.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. There must be a suitably qualified manager, who is registered with the National Care Standards Commission in post at all times. 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. There is a sluicing facility installed in the home within 6 months of registration. The repairs outlined in the letter dated 1st December 2003 are completed within 3 months of registration and any further repairs are completed to agreed timescales. 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. 9th February 2005 3. 4. 5. Date of last inspection Brief Description of the Service: Jalna is registered to accommodate 22 older people over the age of 65 who require help with personal care. People who live here are either privately or local authority funded. The home is a semi-detached Victorian property, with surrounding gardens and paved areas. Jalna was extended in 1999 to provide additional accommodation and improved facilities. The home offers 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. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 8 hours and was carried out over one day by one inspector. There were 22 residents accommodated. 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, a relative and staff were spoken with. A tour of the premises was carried out. Records, policies and procedures were looked at. Completed comment cards were received from 2 residents, and 4 relative/visitors. What the service does well: What has improved since the last inspection?
Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 6 New chairs and curtains had been provided in the large lounge. The residents were being supported to use wheelchairs properly and safely. More was being done to find out what the residents and others thought about the home and what improvements could be made. More care staff had completed NVQ (National Vocational Qualifications) in care. The format for interviewing new staff had been further developed to provide better questioning. 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. Jalna Care Home DS0000054471.V252836.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 Jalna Care Home DS0000054471.V252836.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): 3 The admission process ensured the residents’ were properly assessed, their needs and wishes known and planned for prior to moving into the home. EVIDENCE: The residents case files included assessment information from Social Services as appropriate and pre admission assessments had been carried out by staff at the home. The assessment details included much relevant information. Each resident had a care plan in place. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 9 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): 7,8,10 Some progress had been made in improving residents care plans, but not all needs/wishes had been noted, staff were not being fully instructed to respond to the residents’ individual needs and abilities. The health needs of the residents were being appropriately managed, with the involvement of health care professionals. Support with personal care was provided sensitively in a way which promoted the resident’s privacy and dignity. EVIDENCE: The care plans seen as part of case tracking, did not include all care needs. Details in the action plans did not provide clear instructions for staff on what they needed to do for each resident. Entries in residents’ individual daily records were brief, some read ‘care plan as plan’ which did not always provide an accurate reflection. Risk assessments had been carried out, however the actions to be taken in response were not fully detailed in the care plans.
Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 10 Residents spoken with had an awareness of their care plans, some had signed in agreement with them. Records indicated residents were receiving attention from health care professionals and that general health was being monitored, this was confirmed in discussion with residents and staff. Health related policies were available. One relative spoken with described how the home had enabled her mother to receive medical attention. Care staff were assisting the residents with personal care and promoting self-care. However, such actions were not fully noted within the care plans. Residents said they were treated with dignity and respect, this approach and maintaining privacy, was observed within care practices, care plans and records. Screening was available for shared bedrooms. All four comment cards received from residents indicated that their privacy was respected. Staff spoken with expressed a sound knowledge of ensuring residents privacy within their work. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 11 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 Flexible lifestyles and activities were being encouraged in response to individual and group needs, abilities and wishes. Visiting times were flexible so residents could continue relationships with relatives and friends. Some community contact was being maintained to enable the residents to retain links with others. Residents were being given the opportunity to make choices and decisions, to enable them to have as much control over their lives as possible. EVIDENCE: There was information on display in the home, outlining the activities available each afternoon. Residents spoken with described the various activities available, including dominoes, bingo, sing-a-longs, visiting entertainers and celebrations such as birthdays and the annual barbeque. A trip to Blackpool was being planned. Routines in the home appeared flexible. Residents said they were able to go to bed and get up, whenever they wished, and were seen spending time in their rooms. A Christian praise and worship session was being held each week. Newspapers and books were available.
Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 12 The visiting arrangements were detailed in the homes guide. Relative/visitor comment cards received, indicated that staff welcome them into the home and that arrangements could be made for privacy. A visitor spoken with said she was always made to feel welcome and refreshments were always offered. Some residents said they occasionally go out with families. Children from a local school had visited at Christmas and representatives from various Churches made regular visits to the home. The residents had been encouraged to bring their own personal possessions and furniture with them, they were seen to be supported and enabled, to make their own choices and decisions. Financial arrangements were outlined in the homes guide. Residents spoken with felt they still had a degree of control over their lives. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 13 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 The complaints processes needed further attention, to make sure any complaints are appropriately acted upon. Satisfactory arrangements were in place for protecting the residents from abuse, but guidance for managers and staff needed developing to ensure an appropriate response. EVIDENCE: The complaints procedure was included in the home’s guide a copy had previously been displayed in the entrance hallway. The Manager explained she makes a point of seeing visitors and relatives to make sure things are okay. The Manager said there had not been any complaints made at the home. The complaints procedure did not include details of expected timescale for dealing with complaints. There was no specific system for recording any complaints or issues raised. Residents spoken with implied they would feel confident in raising any concerns. The homes protection/abuse policies included relevant information based upon the ‘No Secrets ’ guidance. Procedures for reporting allegations, suspicions or incidents of abuse were seen. Staff had been given written instructions on their none involvement with residents wills and accepting gifts. Guidance and procedures were available on dealing with aggressive behaviour. A brief policy on restraint had been devised. Some staff had covered protection and abuse matters as part of NVQ (National Vocational Qualifications) training. The comment cards received from residents’ indicated that they felt safe in the home.
Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 The standard of the accommodation was good; providing the residents with an attractive and homely place to live, some matters needed attention to ensure the residents have comfortable surroundings and appropriate facilities. EVIDENCE: The home was found to be clean and free from unpleasant smells. The cleaner spoken with explained how rooms were cleaned in response to each residents’ needs and wishes. The lounges and dining room were appropriately furnished and provided pleasant living areas. New curtains and new chairs had been provided in the main lounge. The gardens were accessible to the residents, attractive and well kept. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 15 The residents spoken with said they were happy with the accommodation provided at Jalna and expressed an appreciation of the garden. One first floor bathroom did not have any form of heating and the bath was not accessible to most of the residents. A sluice was yet to be provided in the laundry, the home owner said arrangements were being made to upgrade the laundry by including a sluice and a gas dryer. One bedroom carpet was seen to be in need of replacement, arrangements were being made to attend to this matter. There was no written refurbishment programme to show which areas of the home had been identified for attention and planned for. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 16 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 Staffing arrangements were sufficient in aiming to ensure the resident’s needs are effectively and safely met. Progress had been made in enabling staff to gain recognised qualifications to improve the quality of service for the residents. Staff recruitment practices indicated improvements needed to be made for the protection of the residents. EVIDENCE: The required numbers of staff were on duty. Staff rotas and records of hours worked, indicated that appropriate staffing levels were being kept with extra staff also being on duty when needed. The staff rota needed to include each persons’ role and the on call arrangements. Residents spoken with were appreciative of the staff team; all comment cards from residents indicated that staff treat them well. Comment cards from relatives/visitors indicated that they considered sufficient numbers of staff were on duty when they called at the home. There were a sufficient number catering and cleaning staff employed at the home. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 17 More than 50 of the care team had NVQ level 2 qualifications and 4 carers were doing NVQ level 2. Staff had individual development plans which were being updated following their annual appraisal. Staff records checked were found to have some discrepancies. Employment histories did not include enough detail and there were no records to show gaps in employment had been looked into. The source of one reference required further attention and another reference needed to be requested. Medical histories were brief. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 18 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): 32, 33, 35 The management and leadership approach had helped create a supportive, positive environment for the residents and staff. Progress had been in developing quality assurance systems to help ensure the home is run in the best interest of the resident, but the home owners were not fulfilling their legal responsibilities in this process. Appropriate systems were in place to manage residents’ monies, charges and payments. EVIDENCE: The atmosphere in Jalna was friendly and supportive, relationships between residents and staff were good. The residents spoken with expressed an appreciation of the management team and homeowners. Relative/visitor comment cards included positive statements
Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 19 about the running of the home. One member of staff spoken with said the manager was approachable and helpful, and that the homes’ general philosophy was “the residents come first, they can have what they want”. The manager said new resident surveys were to be introduced. Some consultation had been carried out with relatives and residents had been asked about meals. A survey was being devised for GP’s and District Nurses. A newsletter had been produced to keep people up to date on at the happenings at Jalna. The homes’ guide included information about financial matters. Records seen indicated accountable systems were in place to manage residents’ pensions, monies and charges and payments. Secure storage was provided. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 20 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 3 X X X Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 15 Requirement 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. Instructions following specific assessments and risk assessments must be included in care plans. The complaints procedure must include the expected timescales for dealing with any complaints made. The timescale must be in accordance with regulations. Appropriate heating must be provided in the first floor bathroom. Suitable equipment, which meets the needs of the residents, must be provided in the first floor bathroom. A sluicing facility must be provided. (Timescale of 31/3/05 not met) Timescale for action 27/01/06 2 OP16 22 31/12/05 3 4 OP22 OP22 23 23 31/12/05 31/01/06 5 OP26 13, 16 03/02/06 Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 22 6 OP29 17, 19 7 OP33 26 The recruitment of staff must include the obtaining and checking of full employment histories, with records kept. (Timescale of 31/3/05 not fully met) The homeowners must arrange for unannounced visits to be made to Jalna a report of the findings must be given to the manager and sent to the commission. (Timescale of 31/3/05 not fully met) 04/10/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The review of resident’s care plans should be carried out where possible, with their involvement. They should be enabled to sign in agreement with the review/changes to their care plan. This could be introduced as a one to one activity. 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. An appropriate form should be produced to ease the recording and management of any complaints made. A copy of the complaints procedure should be displayed in the home. The allegation/suspicion/referral of abuse procedures could include telephone contact details of relevant agencies. The restraint policies and procedures could be further developed to provide more thorough guidance. Staff training on protection and abuse matters should be ongoing. 2 OP16 3 OP18 Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 23 4 5 OP19 OP29 A written programme of refurbishment and redecoration should be produced, which identifies matters in need of attention and shows timescales for action. Requests for applicants’ medical histories should be further developed to obtain more extensive information. Careful consideration should be given to the suitability of references and referees. Jalna Care Home DS0000054471.V252836.R01.S.doc Version 5.0 Page 24 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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