Inspection on 03/01/07 for James Terry Court

This inspection was carried out on 3rd January 2007.

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

James Terry Court 08/10/07

James Terry Court 13/02/06

James Terry Court 02/02/05

James Terry Court 14/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE James Terry Court 51 Warham Road South Croydon Surrey CR2 6LH Lead Inspector Lee Willis Key Unannounced Inspection 10:50a 3rd January 2007 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 James Terry Court DS0000019030.V311479.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. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service James Terry Court Address 51 Warham Road South Croydon Surrey CR2 6LH 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) 020 8688 1745 020 8688 0587 www.rmbi.org.uk Royal Masonic Benevolent Institution Mrs Diane Margaret Collins Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Total number of exclusively nursing beds = 13 Total number of dually registered beds =7 Total number of exclusively residential beds = 38 Date of last inspection 13th February 2006 Brief Description of the Service: James Terry Court is a Royal Masonic Benevolent Institute (RMBI) owned residential and nursing home that provides personal support for up to 58 older Freemasons and the dependent females of Freemasons. Mrs Diane Collins continues to be the registered manager of the service, a position she has held since January 2004. There have been no significant changes made to the physical environment of the home in the past twelve months, although the Commission is aware the RMBI are still planning to redevelop the entire site, subject to Local Council approvable. The building is currently set back from a busy thoroughfare in a suburban area of South Croydon and is within a mile radius of a wide variety of local shops, restaurants, cafes, pubs, and banks. The home is also on a main line bus route and within walking distance of several train stations with good links to central London and the surrounding areas. The home can be divided into distinct halves, comprising of a modern wing specifically designated for nursing care only and a much older wing primarily used for residential care. Most service users have their own single occupancy bedrooms, although two double rooms are also available for couples who choose to share. Communal space consists of a large open plan dining room with a conservatory attached and numerous lounges of varying sizes, which includes an activities room and library. The secluded enclosed garden at the rear of the property, which the majority of the bedrooms and communal spaces overlook, continues to be extremely well maintained. People who reside at James Terry have all been provided with copies of the homes Statement Of Purpose, Guide, and their terms and conditions of occupancy. These documents contain all the information people need to know about the facilities and services provided, as well as the fees charged, which currently stands at £450 per week for residential, and £735 for nursing. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process, which included a site visit to the home, the Commission for Social Care Inspection considers this to be a ‘good’ quality service that has a sustained track record of high performance ensuring good outcomes for service users. The site visit was unannounced and was carried out on Wednesday between 10.50am and 3.50pm. During the course of this five-hour inspection a dozen or so service users were met, of whom six were spoken with at length. The relatives of two service users were also met during this visit. Staff spoken with at length included the homes registered manager and her deputy; five support workers; a member of the catering staff; and a couple of laundry assistance. The remainder of the site visit was spent examining the homes records and touring the premises. The Commission prior to the site visit being carried out received no written feedback from service users or their representatives about the home, which was disappointing. What the service does well: What has improved since the last inspection? James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 6 Where weaknesses have emerged in the past the home has always tended to manage them well and the providers have also demonstrated a willingness to explore new ways of improving the service they offer. Since the homes last inspection it was positively noted that the relatively new concerns book has become an integral part of the services quality assurance system and is frequently used by staff to record any action that has been taken to resolve problems raised about its day-to-day operation. In addition to this, the home has also introduced a compliments book to record good practice points made by service users and/or their representatives. The providers have also introduced a centralised system for analysing the number of falls that occur in the home each week. It is hoped this practice will enable the providers to identify tripping hazards and those service users who are at a greater risk of falling more quickly than before. It was positively noted that despite the uncertain future of the building a limited program to start repairing and redecorating some of the more ‘worn’ out areas of the home has recently been reinstated. The Commission agrees with the manager’s comments that with the redevelopment of the home put back until at least 2009 prompt action must now be taken to address certain maintenance issues that cannot wait until a new home is built. Since the homes last inspection two external fire doors that were ‘sticking’ have both been replaced and more homely style light fittings installed in a lounge in the nursing wing. What they could do better: The positive comments made above notwithstanding there remains a number new and outstanding areas of practice that it is essential the service rectifies as soon as reasonably practicable. The manager accepted that the service could do better in a number of clearly identifiable ways: Firstly, all the homes call bells need to be fitted with suitably long pull cords to enable service users to active the alarm should they fall. Secondly, the providers will need to establish policies, procedures that will help staff deal more effectively with harassment in all its forms; either between service users; between staff; by staff; or by service users and/or their representatives on staff. Staff must also be suitably trained to implement the new policy. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 7 Finally, the manager must ensure the results of any stakeholder satisfaction questionnaires, which the provider should be undertaking on an annual basis, are available for any interested parties to examine on request. Failure to address this on going matter within the new timescale for action will result in the Commission considering taking enforcement action against the providers to ensure compliance. 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. James Terry Court DS0000019030.V311479.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 James Terry Court DS0000019030.V311479.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, 5 & 6 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficiently robust arrangements are in place to ensure needs and wishes of all new admissions, including those referred solely for respite care, are thoroughly assessed to determine whether or not the home is suitable. EVIDENCE: The manager explained that the home continues to have a large number of vacancies because the RMBI feel it would be unfair to admit any new referrals on a permanent basis while the future of the building remains uncertain. Consequently, no new service users have been admitted to the home in the past twelve months, although a disproportionate number of people referred solely for temporary respite provision have been accepted in this time. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 10 A pre-admission assessment was available on request in respect of the homes most recent respite referral and covered every aspect of the individual’s personal, social, and health care needs. Furthermore, this individual’s personal file contained a signed contract that set out their terms of conditions of occupancy, including the room they were to occupy, fees they and their representatives would be charged, and their rights and obligations. The relative of a prospective service user met during a tour of the premises said they had been invited to visit the home and assess its suitability for their loved one as part of the admissions process. Two senior members of staff met during the visit confirmed that no one is admitted for short-term respite care unless a suitably qualified member of staff has carried out a thorough assessment of their needs. The manager said the average length of stay for respite care is usually two weeks. The homes policy and procedures regarding respite admissions are included in the service users guide. James Terry Court DS0000019030.V311479.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, 10 & 11 Quality in this outcome area is good. This judgement has been made using all the available evidence. Suitable arrangements are in place to ensure service users physical and emotional health care needs are recognised and met. Sufficiently robust systems are in place to ensure medication records are appropriately maintained and monitored to safe guard and protect the service users ‘best interests’. EVIDENCE: The manager confirmed that only one service user referred solely for respite was currently residing at the home. A copy of their care plan was made available on request, which referred to their strengths and medical history, including a manual handling assessments that identified any risks associated with their mobility (i.e. history of falls). The four care plans inspected at random had all been reviewed within the last month and the recently introduced index system made accessing all the relevant information relatively easy. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 12 These care plans contain detailed records of all the medical appointments attended by these four individuals, including those with their GP’s and district nurses. The homes accident book revealed that two service users had been admitted to hospital in the past twelve months having injured themselves falling. The vast majority of significant incidents involving service users during this period also pertained to falls. It was positively noted that since the homes last inspection a record of all the falls involving service users is now sent off to RMBI’s central offices each week for the data to be analysed. The Commission agrees the new arrangements the providers have introduced to monitor falls will prove a far more effective way of identifying problems in the future. The manager said none of the service users are currently being treated for pressure sores. During a tour of the nursing wing a pressure-relieving mattress was noted to be in use in one service users bedroom. A member of staff advised the inspector that the mattress was used as a preventive measure to minimise the risk of pressure sores developing. One service users relative met during the visit said they were very impressed with all the health care support their loved one had received during their time at the home. No recording errors were noted on medication administration sheets currently in use for twelve service users. The recently promoted senior member of staff said monthly deliveries of new medication stocks are always checked in and appropriate records kept. The home uses a well known monitored dosage system, which all the senior staff met agreed reduces the risk of medication handling errors occurring. Most medication stocks are securely stored in lockable trolleys, although Controlled drugs continue to be kept in a metal cupboard fixed to the wall in the medical room. The senior nurse in charge of the nursing wing said staff appropriately maintain a separate controlled drugs register for the receipt, administration and disposal of this type of medication. Two suitably trained staff always sign the register each time a controlled drug is handled in the home. One relative met said they had spent a lot of time at the home over the Christmas period, including a couple of over night stays, and confirmed staff always knocked on peoples bedroom doors to ask permission to enter before doing so. This good practice was observed being carried out on numerous occasion during a tour of the building. During the visit the homes activities coordinator was observed supporting a service user get ready to go out. The manager said the coordinator had rearranged that day’s activity programme specifically to accompany this service user to their late spouses funeral. James Terry Court DS0000019030.V311479.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 & 15 Quality in this outcome area is excellent. This judgement has been made using all the available evidence. The social, leisure and recreational opportunities service users have to engage in, both at home and in the wider community, are well managed, ‘age’ appropriate, and provide people who use the service with daily variety and stimulation. Suitable arrangements are in place to enable service users to maintain appropriate relationships with their family and friends. Dietary needs and preferences are well catered providing daily variation, choice, and interest for the people who use the service. EVIDENCE: Three service users who allowed the inspector to join them for lunch said the activities on offer to them tended to match their preferences. Another group of three service users met relaxing in the conservatory after lunch said although they all preferred to spent most of their time in each others company and not participate in many of the activities on offer, they knew they could if they wanted to. One service user said they particularly enjoyed playing bingo, which James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 14 the staff regularly organised, and attending concerts given in the main dinning room. Another service user said they liked to just sit and watch the squirrels from the conservatory and chat to other residents who often frequented this area. Several service users said they were very impressed with the activities coordinator who was constantly organising social events. One relative met during the visit said they were extremely satisfied with the overall standard of care their loved one received during their time at the home at the home and they were particularly impressed with the homes very open and flexible approach to visiting times. This relative went onto say that staff had encouraged him to stay over night in one of the homes guests bedrooms in order for him to remain close to his wife over the Christmas period for which the home is highly commended. The overwhelming response of the half a dozen or so service users spoken with about the meals provided was also extremely positive. All three service users joined for lunch agreed the meals were always hot, well presented, and tasty. During a tour of the premises before lunch it was positively noted all the tables in the dining room, which seated a maximum of four people comfortably, were neatly laid out with all manner of condiments, napkins and cutlery for service users to help themselves too. A member of the catering staff met said service users are always asked what they would like to have for their lunch and evening meals the day before in order for the kitchen staff to start prepping it, although there was a degree of flexible if someone changed their mind at the last minute. This same member of staff went onto explain in the past few weeks a themed menu had been developed by the catering team and activities coordinator to co-inside with a number of British festivals and annual events, such as Burns night and Wimbledon for example. As advertised on that days menus all the people the inspector joined for lunch had a choice of roast pork or fish. The manager assured the inspector that service users who choose to eat in their bedrooms are also given a choice at meal times. Both the pork and fish dishes were well presented and cooked. All and all the service users met said they liked the idea that they could help themselves to as many potatoes and vegetables as they wished from the different side dishes staff brought to their table. The atmosphere in the dining room over lunch felt extremely relaxed and congenial. James Terry Court DS0000019030.V311479.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 good. This judgement has been made using all the available evidence. Suitable arrangements are in place for service users and their representatives to feel confident any complaints or concerns they may have about the way the home is operated will be taken seriously and acted upon. The homes measures for recognising, preventing and reporting abuse are sufficiently robust to minimise the risk of service users being harmed or neglected. EVIDENCE: All the service users and their relatives spoken with about staff working at the home said they were in the main approachable and always listened to you. The homes complaints log revealed that two formal complaints had been made about homes operation in the past year. The first of these pertained to a fall in which a service user sustained a serious injury. The complaint was up held following an internal investigation by RMBI and records showed that prompt action was taken by the provider to minimise the risk of a similar incident reoccurring in the future. The complainant later withdrew the second of these formal complaints after they agreed there had been some sort of misunderstanding with the home. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 16 It was positively noted that the home continues to record more informal concerns it receives about the service, as well as any action taken to resolve these matters. Since the homes last inspection the providers have introduced a compliments Book. The Commission considers the homes relatively new concerns and compliments books to be useful tools that will enable the providers to monitor its quality assurance more effectively. In the past year there has been one suspected incident of abuse which the home reported to all the relevant external agencies in a timely fashion in accordance with the local authorities vulnerable adult protection protocols. All the action agreed at the subsequent case conference has now been implemented by the home. James Terry Court DS0000019030.V311479.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, 22, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. The home, which is furnished and decorated to a reasonable standard, ensures service users live in a relatively safe and clean environment, although the physical layout still needs improving to make it far more homely. In the main service users have all the specialist equipment they require to maximise their independence, although suitably long pull cords need to be fitted to call bells to make them far more accessible. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 18 EVIDENCE: Although the home remains adequate for its stated purpose, many of the service users and their representatives, includes the homes senior management team, all agree that its vast size and layout of the building has never lent itself particularly well to the concepts of ‘warmth’ and ‘homeliness’. The manager advised the inspector that plans to redevelop the entire site have been delayed until 2009. Consequently a rolling programme for more urgent repair and redecoration work to be carried out on the existing home has been reintroduced. As a result lights in one of the communal lounges in the nursing wing have all been replaced with more domestic style fittings that are more in keeping with the homely surroundings and arrangements made for new lights to be installed in the main dining room by the end of the year. Furthermore, the rather ‘worn’ out carpets in both the nursing wing and large communal dining room are to be replaced with non-slip wood effect flooring in the next few months. Progress on all the aforementioned environmental issues will be assessed at the homes next inspection. The call bell in a lower ground floor toilet was activated at 1pm and a support worker was observed responding to the alarm with 30 seconds of it being sounded. However, it was noted the call bell system in this toilet was not fitted with a pull cord that would enable it to be used by someone who may have fallen over. The manager confirmed that none of the call bells in the home had been fitted with pull cords. Having tested the temperature of water emanating from a hot tap attached to a bath in the nursing wing it was found to be a safe 40 degrees Celsius at 12.30. Two laundry assistance met during a tour of the premises confirmed service users clothes are always washed separately and placed in individually labelled boxes before being returned to their rightful owner. Two very experienced assistance said the system worked relatively well and said very few items of clothing ever went missing. James Terry Court DS0000019030.V311479.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 all the available evidence. Sufficient numbers of suitably trained and competent staff are employed on a daily basis to meet the individual and collective needs of the service users. The homes recruitment policies and practices are suitably robust to ensure service users are not placed at risk of being harmed by individuals who are ‘unfit’ to work with vulnerable adults. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 20 EVIDENCE: In addition to the manager and her deputy, a registered first level nurse, two shift leaders, eight support workers, an activities coordinator, six domestics, and sufficient numbers of catering staff were all on duty in the home. The number of staff on duty at the time of this site visit matched the staff rota for that early shift and the manager said this level exceeded the minimum required to meet the needs of all the service users currently residing at the home. It was positively noted that despite having an unusually large number of bedrooms vacant because of the uncertain future of the building RMBI had decided not to reduce staffing levels. As a consequence, a couple of support workers spoken with during a tour of the premises said they had far more opportunities to spend ‘quality’ time with the service users. This was noted in practice when a couple of support workers were observed engaging a group of service users in a sing-a-long session in one of the communal lounges just before lunch. In line with National Minimum training targets for people working in residential care settings 50 of the homes current support worker team have now achieved a National Vocational Qualification in care (Level 2 or above), and a further five members of staff are enrolled on an NVQ or equivalent courses. The home continues to experience relatively low levels of staff turnover and consequently has only needed to recruit three new members of staff in the past twelve months. All the personal information obtained in respect of these individuals by the home was examined in depth. All three files contained completed job application forms; proof of their identity; two written references; up to date Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (PoVA) checks; and where appropriate, Home Office approved work permits. It was positively noted that at least one of the written references obtained in respect of each new recruit had been supplied by the individual last employer and the manager said she had personally checked the authenticity of one by telephoning the referee. Since the homes last inspection RMBI have introduced an electronic matrix that identifies staffs training achievements and needs. The deputy manager said she found the new tool extremely and could now tell at a glance what training each member of staff had received. This tool was used to demonstrate that sufficient numbers of the current staff team had attended training in a number of core areas of practice, including: fire safety, moving and handling, basic food hygiene, first aid, vulnerable adult protection, and medication. James Terry Court DS0000019030.V311479.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, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using all the available evidence. The management team are suitably qualified and experienced to be in charge of a residential/nursing home for older people. The homes arrangements for ensuring any interested parties can access the results of any stakeholder satisfaction surveys the providers undertake need to be improved. It is essential the provider’s finders are made public to enable not only the home, but also service users; there representatives and the Commission, to accurately measure how successful or not the service has been at achieving its stated aims and objectives. Sufficiently robust fire safety arrangements are in place to ensure the health and welfare of service users, their guests, and staff are promoted and protected. James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 22 EVIDENCE: The homes registered manager, Diane Collins, has been in operational day-today control of James Terry Court for just over three years. The manager and her deputy are both registered nurses and NVQ 4 management trained. When asked about equality issues the manager said there had been a number of ‘unsavoury’ incidents in the past year when her staff team had been racially harassed by a service user and intimidated by the relative of another. The manager said no guidance was currently available to help staff deal with these situations in a safe and consistent manner. The providers will need to establish a racial harassment and unacceptable behaviours policies and procedures and ensure staff know how to put them into practice. The manager and her deputy were adamant that they had recently seen the published the results of all the stakeholder satisfaction questionnaires given out at the end of 2005. However, a copy of the published report could not be located at the time of this site visit. The manager confirmed that service users and/or their representatives are encouraged to look after service users monies. The homes fire records revealed that the fire alarm system continues to be tested on a weekly basis. The last fire drill was carried out in December 2006 and the manager said these continue to be undertaken at regular intervals. During a tour of the premises it was noted that any fire doors that were left open were not wedged preventing their automatic closure in the event of a fire. Three fire doors fitted with sound activated ‘dorguards’ were checked at random and both closed automatically into their frames when released. Since the homes last inspection two external fire doors that were ‘sticking’ have been replaced. The label on two fire extinguishers inspected at random revealed that a suitably qualified engineer had tested them both in the past twelve months in line with good fire safety guidance. James Terry Court DS0000019030.V311479.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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X 3 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 3 2 1 X 3 X X 3 James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP22 Regulation 12(1), 13(4) & 23(2)(n) Requirement Call bells must be kept accessible at all times and be fitted with suitably long cords to enable service users who fall to activate the alarm. Timescale for action 01/03/07 2. OP32 12(4)(5)& 18(1)(c) A policy that covers harassment 01/06/07 in all its forms that may occur between service users; between staff; by staff; or by service users and/or their representatives on staff, must be introduced as a matter of urgency. Staff must also be suitably trained to put the new policy into practice. The results of any quality assurance surveys undertaken by the home must be published at least once a year and be made available to any interested parties on request, including service users, their representatives and the Commission. Previous timescale for action of 1st May 2006 not met. 01/08/07 3. OP33 12(3) & 24(2) James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI James Terry Court DS0000019030.V311479.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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