Inspection on 08/02/06 for Jalna Care Home

This inspection was carried out on 8th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Jalna Care Home 03/07/07

Jalna Care Home 18/10/06

Jalna Care Home 04/10/05

Jalna Care Home 09/02/05

Jalna Care Home 08/07/04

Jalna Care Home 17/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Jalna Care Home 285b Manchester Road Burnley Lancashire BB11 4HL Lead Inspector Mr Jeff Pearson Unannounced Inspection 8th February 2006 09:30 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.V281403.R01.S.doc Version 5.1 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.V281403.R01.S.doc Version 5.1 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.V281403.R01.S.doc Version 5.1 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. 4th October 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.V281403.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took 7 ½ hours and was carried over one day by one inspector. There were 22 residents accommodated. The 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, registered manager, home owners, relatives and staff were spoken with. Policies, records and documents were looked at. A tour of the premises was carried out. Comment cards were received from relatives. A pre inspection questionnaire was completed by the manager. What the service does well: Jalna had a welcoming, supportive and friendly atmosphere. The home was ‘homely’ and was pleasantly decorated; residents said they liked the accommodation provided, including their own rooms, shared rooms and the grounds. The home was clean and had no unpleasant odours. One relative wrote “Overall Jalna is a well run home – It is lovely and clean and there are no unpleasant odours. Staff really care and do all they can to help. Service users are treated with dignity” The catering arrangements were good, all the residents spoken with appreciated the food provided one said, “I’m very happy with he meals, the food is good” The programme of staff training and development was well established. The residents appreciated the staff and relationships between everyone in the home good. One resident commented “I like it here its lovely, everybody is so kind” The registered manager had experience and had trained for her role. Staff meetings were being held, the home owners were supportive to the manager. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Several requirements and recommendations were outstanding from the previous inspection. The registered persons therefore needed to give these matters their attention. The home owners should develop a more proactive approach to the inspection process and liaise more effectively with the Commission. The resident’s individual care plans still needed to include all details of all their needs and how they are to be met, to ensure staff know exactly what to do for each person. The residents should be more involved when their care plans are reviewed and should sign in agreement with them. Medication management, records, policies, and training needed further attention. The procedure for making complaints still needed to include a timescale, so people know how long it will take to get things sorted out. A complaints form should be produced, which makes sure good records are kept and complaints are properly dealt with. To make sure managers and staff do the right thing if there is an incident, allegation or suspicion of abuse, telephone number should be included in the procedures. All staff should be trained on protection and abuse issues. To protect residents and staff, the guidelines for physical intervention must be developed to include more, up to date information. By keeping plans to show which areas of the home are due to be upgraded and when, the home owners would explain their future intentions, so the Commission would know matters are in hand. So the residents are kept warm, a suitable heating must be provided in one upstairs bathroom. To make sure people can use the upstairs bath suitable equipment must be provided. To make sure soiled clothing/linen and commodes are properly dealt with, a sluice needed to be installed. When recruiting staff, the managers must ensure all necessary checks are fully completed and records kept, for protection of the residents. To make sure the home is being properly run, and to show this is the case, the homeowners must arrange for surprise visits to be made to Jalna with reports of their findings being sent to the Commission, an annual development report must be produced to show how the home is developing. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 7 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.V281403.R01.S.doc Version 5.1 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.V281403.R01.S.doc Version 5.1 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): None of the above standards were assessed at this inspection; please refer to the previous inspection report dated 4th October 2005. EVIDENCE: Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 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): 7,9 Progress in improving residents care plans was ongoing; therefore staff were still not being fully instructed to respond to the residents’ individual needs and abilities. Medication management practices were in need of improvement for the protection of the residents and staff. EVIDENCE: The registered manager explained that the residents care plans were being updated to provide more detailed and appropriate information. A ‘draft’ care plan seen, showed this matter was being given attention. The care plans in current use were as previous, details in the action plans did not provide clear instructions for staff on what they needed to do for each resident. Discussion took place with the manager and Mrs Lane, home owner, about the care planning process, including that care plans should be used continually as a working document. Medication storage facilities were satisfactory, clean and secure. Medication policies were available. Medication guidance material was available. One Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 11 residents’ medication had been administered but not signed for. Paracetamol had been entered onto one MAR (medication administration record) but the dosage instructions had not been included. There were gaps in MAR charts with no reason given. Several residents had been prescribed medication on a ‘when necessary’ but there were not instructions on when this was to be offered. Not all senior staff with responsibilities for medication had attended accredited training. There was no policy or procedures for medication leaving the home with residents, for example when taking a holiday, or going out for the day. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 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): 15 The catering arrangements were good, offering residents choice and variety. Specific diets were being catered for. EVIDENCE: The residents spoken with said they were happy with the quality, variety and choice of meals provided. Three full meals were being offered daily. A two week menu system was in place; the cook said the menus had been reviewed three weeks ago. Choice menus were available, the options being discussed with residents each day. Diets such as diabetic and low fat were being catered for. Drinks and snacks were readily available. Fresh produce was being obtained from local sources. Fresh fruit was seen to be readily available. At lunchtime the service was good meals were served sensitively with attention being given to individual preferences. The breakfast menu was not written out or on display it was suggested this matter be given attention. Relatives spoken said they were always offered a drink when visiting and had often been invited to stay for meals. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 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): The complaints processes still needed further attention, to make sure any complaints are appropriately managed. No progress had been made in developing the restraint policy and abuse referral procedures; therefore guidelines and instructions were lacking in conveying an appropriate response for the protection of the residents. EVIDENCE: Residents and relatives spoken with said they had no complaints, and had an awareness of the procedure for making complaints and raising concerns. The manager said there had not been any complaints made at the home. The complaints procedure was included in the home’s guide. A notice in the entrance hall way advised people to speak to the home owners or manager ‘if these something your not happy with’. The complaints procedure had not been updated to include expected timescales for dealing with complaints and a system for recording any complaints or issues raised had not been introduced. The manager said that the homes’ protection and abuse policies and procedures were as previous and that the policy on restraint remained the same. Records showed new staff were being guided to familiarize themselves with the protection and abuse policies, as part of their induction training. Some staff had covered protection and abuse matters as part of NVQ (National Vocational Qualifications) training. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 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 residents spoken with said they were happy with the accommodation provided at Jalna and expressed an appreciation of the garden. The home was found to be clean and free from unpleasant smells. A liquid hand sanitizer dispenser had been provided in for visitors. The lounges and dining room were appropriately furnished and provided pleasant living areas. The dining room had been redecorated and new windows had been fitted in the conservatory. Heating had not been provided in the first floor bathroom, the bath was not accessible to most of the residents but a bath seat had been ordered. A sluice was yet to be provided in the laundry. 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.V281403.R01.S.doc Version 5.1 Page 15 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, 29, 30 Staffing arrangements were sufficient in aiming to ensure the resident’s needs are effectively and safely met. Recruitment practices had improved, but further attention was still needed to protect the service users. The staff induction training and programme of ongoing staff development, aimed to promote effective support for the service users. EVIDENCE: Residents and visitors spoken with were complimentary about the staff team. 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 person’s role. Comment cards from relatives indicated they considered sufficient numbers of staff were on duty. The records of the most recently recruited staff members were checked. Appropriate clearance checks had been carried out and satisfactory written references were available. The application form in use requested an employment history for the past 10 years, as apposed to a full history, however the manager said a full history had been asked for. There were no interview notes available. Medical declarations did not include sufficient information to make an informed judgement about health matters. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 16 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. Records were being kept of staff development and training and copy certificates were available on staff files. More than half of the care staff team had attained NVQs in care. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 17 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, 38 The manager of Jalna had the ability, experience and qualifications to effectively manage the service for the benefit of the residents. Quality assurance systems to help ensure the home is run in the best interest of the resident were ongoing, but the home owners chose not to fulfil their legal responsibilities in this process. Health and safety was being promoted for the benefit of the residents, staff and visitors. EVIDENCE: The atmosphere in the home was found to be relaxed, supportive and welcoming. The residents, staff , manager and home owners seemed to get on well together. Margaret Simpson, registered manager had been in post two years and had attained NVQ level 4 in management and care and was Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 18 proposing to undertake the Registered Managers Award. Lines of accountability within the management structure were clear. Staff meetings were being held and the homeowners were accessible and supportive to the manager. The manager said that satisfaction surveys had recently been given to the residents, also that relatives and others such as District Nurses, were soon to be contacted. It was suggested that staff should also be surveyed. The home had attained Investors In People accreditation. The Commission had not received any monthly reports from the home owners. There were no annual development plans available. The home was found to be free from any obvious hazards to health and safety. Health and Safety policy statements were available. The pre inspection questionnaire showed equipment had been serviced and that installations and maintenance checks were ongoing. Fire drills were being carried out, fire equipment was being checked and tested. Several staff had completed First Aid training. Training in safe working practices, such as moving and handling and infection control was ongoing, or being arranged. Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 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 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 3 Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 20 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. (Timescale of 27/01/06 not met) Full and accurate records must be kept of all medicines received and administered. Staff authorised to administer medicines must receive accredited medicines management training and have an assessment of their competence to complete these tasks. The complaints procedure must include the expected timescales for dealing with any complaints made. The timescale must be in accordance with regulations. (Timescale of 31/12/05 not met) Timescale for action 31/03/06 2. 3. OP9 OP9 13,17 13,18 10/02/06 30/06/06 4. OP16 22 31/03/06 Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 21 5. OP18 13 6. OP22 23 7. OP22 23 8. 9. OP26 OP29 13, 16 17, 19 10. OP33 26 11. OP33 24 Physical intervention/restraint policies and procedures must be further developed in line with current guidance. Appropriate heating must be provided in the first floor bathroom. (Timescale of 31/12/05 not met) Suitable equipment, which meets the needs of the residents, must be provided in the first floor bathroom. (Timescale of 31/01/06 not met) A sluicing facility must be provided. (Timescale of 03/02/06 not met) The recruitment of staff must include the obtaining of a more detailed medical health declaration. 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 30/11/05 not met) The quality assurance process must result in the production of an annual development plan. 31/03/06 28/07/06 31/03/06 28/07/06 24/02/06 31/03/06 30/06/06 Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 22 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. Individual criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all residents prescribed such items. The when necessary medication policy should guide staff to define/refer to individual criteria for when necessary and variable dose medication. Policies and procedures should be defined and introduced in respect of medication leaving the home with residents and their representatives. 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 should include telephone contact details of relevant agencies. Training on protection and abuse matters should be ongoing for all staff. A written programme of refurbishment and redecoration should be produced, which identifies matters in need of attention and shows timescales for action. The staff application form should request the details of full employment histories. Records should be kept of all recruitment interviews. 2. OP9 3. OP16 4. OP18 5. 6. OP19 OP29 Jalna Care Home DS0000054471.V281403.R01.S.doc Version 5.1 Page 23 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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