Inspection on 08/10/07 for James Terry Court

This inspection was carried out on 8th October 2007.

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

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

Other inspections for this house

James Terry Court 03/01/07

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 10:15 8th October 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.V350644.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.V350644.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.V350644.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 3rd January 2007 Brief Description of the Service: James Terry Court is a Royal Masonic Benevolent Institute (RMBI) owned residential/nursing home that provides support for up to 58 generally older 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 homes physical environment in the past year, although we are aware that the RMBI are currently seeking planning permission from the Local Council to rebuild the home by 2009. The present building is 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 bus route and within walking distance of a main line train station with good links to central London. 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 people who use the service have their own single occupancy bedrooms, although two double rooms are also available for cohabitating couples. 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 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 use the service have all been provided with copies of the homes Statement of Purpose, Guide, and their terms and conditions of occupancy. Fees charged range from £450 per week for residential, to £735 for nursing. James Terry Court DS0000019030.V350644.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 the Commission for Social Care Inspection (CSCI) has judged the service as having significantly more strengths than areas of weakness. Key standards were generally met and no issues relating to the health and safety of the people using the service or poor management were identified during the inspection. This unannounced site visit was carried out on a Monday between 10.15am and 4.15pm. During the course of this six hour inspection we spoke at length to a number of different people, including eight people who use the service, two visiting relatives, both the registered and deputy managers, a senior nurse, two support workers, and the head chef. We also looked at records and documents, including three people’s care plans and the home’s User Guide. No surveys were received from anyone living at the service or their representatives, although the home did complete an Annual Quality Assurance Assessment (AQAA) telling us what the service provided, how it ensures good outcomes for the people using it, and any future developments being planned. Finally, two people who use the service who were unable to provide much verbal feedback due to their cognitive impairments were observed for forty-five minutes before lunch relaxing in a communal area. This methodology was used to give us a better understanding of the quality of life experienced by people who are unable to effectively communicate their views. This helps us male better judgments about the quality of care for people with dementia. What the service does well: People living at the home feel well cared for. Typical comments from people who use the service were very positive and included “the home has been my saviour – full marks”, “all round very good”, and “they do very well here, especially the food”. We saw that staff relate well with the people that live there and the atmosphere is relaxed and pleasant. Individuals spoken to said that staff was friendly and polite. Comments included “very kind and caring”, “approachable and polite” and “they do listen to you”. We saw the home continues to experience relatively low rates of staff turnover, which ensures people who use the service remain familiar with the people who provide their care. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 6 Healthcare needs are also well met, especially the prevention and management of pressure sores. Staff demonstrated a good understanding of this important area of practice and it was clear from comments made that advice is always sought from the relevant health care professionals as and when required. People living at the home generally enjoy the food provided to them and there are always at least three choices on offer at mealtimes. The home is very good at enabling families to remain fully involved in their loved ones life’s and has made suitable arrangements for relatives and or friends to join their loved ones for meals and stay over night if they wish. What has improved since the last inspection? What they could do better: All the positive comments made above notwithstanding there are some areas of weakness that still need improving: All the people using the service must be provided with an up to date and detailed Statement of Purpose and Guide that contains all the information required by the Care Homes Regulations (2001). This will ensure people have good information regarding the quality of the care provided by the home. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 7 Medication is generally well managed but there is room for improvement. ‘Unwanted’ medication waiting to be returned to the dispensing pharmacist by the home must be securely stored ensuring it is only accessible to authorised nurses and care workers. Chemicals and other substances hazardous to health (COSHH) must be kept secure at all times and must never be left in unlocked cupboards. This is vital to ensure (so far as reasonably practical) people who use the service are not placed at unnecessary risk of harm. The homes Statement of Purpose and Guide should include the views of people using the service, as well as their representatives. This will ensure they have all the information they need to know about the home and what support they can expect to receive during their stay. People who use the service should be assisted (as far as practical) to participate in more community-based social, leisure, and recreational activities of their choosing. Palliative care and person centred care planning training should be provided for all staff who work at the home. 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. The summary of this inspection report can be made available in other formats on request. James Terry Court DS0000019030.V350644.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.V350644.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service generally have good information about the home in order to make an informed decision about whether the service is right for them. However, the homes Statement of Purpose will need to be improved further to ensure it includes all the information about facilities and services offered, and is accessible to all. People’s needs are fully assessed prior to admission so the individual, their representatives, and the home can be sure the placement is appropriate. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 10 EVIDENCE: We saw that the homes Statement of purpose and guide were available which tells people about most of the facilities and services the home has to offer. The documents clearly set out the objectives and philosophy of the service and what the people who use the service can expect in terms of the quality of the accommodation, qualifications of staff, and how to make a complaint if they are dissatisfied with any aspect of their care. However, despite these document last being up dated in September 2006 it was disappointing to note they still do not contain all the information required by the Care Homes Regulations (2001). Furthermore, these documents are currently only available in normal type and we have recommended that it be made available in other formats such as large print, pictures, and audiotape. The manager told us she was fully aware of the aforementioned shortfalls and confirmed in the homes AQAA that “the way prospective residents are provided with information about the home e.g. visual displays and video could be improved.” The manager also confirmed that the homes Statement did not contain any of the views of the people currently living at James Terry Court, which had recently been ascertained as part of the providers newly introduced quality assurance review. One person who used the service told us they had been given a copy of the homes Guide before they had moved, which they kept in their bedroom. The relatives of a service user met during this site visit told us they had been copies of the homes Guide before their loved one had moved in and had found the information it contain very useful. Assessments had been completed for three people who had recently come to live there. These recorded some good information about these individuals personal, social and health care needs, as well as capturing more detailed information about these persons background and their likes and dislikes. This enables staff to plan their care better and tailor the service provided much more to the individual. We agree with the manager written comments that the questionnaire the staff asks residents and families to complete regarding their first impressions on entering the home is something the service does well. One relative met told us they were able to visit the home and were given full, clear, accurate, and up to date information about James Terry Court before deciding whether or not the place was right for their loved one. The manager confirmed that is was customary for all prospective service users to be asked about their religious beliefs and clearly understood the importance of ascertaining this type of information prior to admission. James Terry Court DS0000019030.V350644.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main care plans reflect what is important to the individual, there capabilities and what support they need to achieve their personal aspirations. Sufficiently robust arrangements are in place to ensure the people who live at the home receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are always recognised and met. The homes policies and procedures for handling medication are in the main sufficiently robust to minimise the risk of service users being harmed, although the homes new arrangements for the safe storage of ‘unwanted’ medication will need to be improved to make them more robust. People who live at the home are treated with respect and their right to privacy is upheld. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 12 EVIDENCE: We looked at the care plans for three people. Each care plan sets out how their needs are to be met and this document is reviewed on a monthly basis. As stated in the homes AQAA we can confirm care plans also contain a lot of individualised information that enables staff to deliver person centred care. We also saw some good detail recorded about peoples health and physical care needs and what support they would receive in order for it to be met. Care staff make sure that good quality and specific person centred information is recorded for everyone who lives there. The health needs of individuals are met well. We saw that people can see a GP who regularly visits the home. Records seen showed that individuals could see other healthcare professionals such as a dentist, optician, and chiropodist when they need to. The manager told us none of the people using the service pay for chiropody treatment because it is funded by donations made by the charity -The friends of the RMBI. All four care plans sampled contained up to date and detailed manual handling assessments and regular weight charts. Two care staff spoken at length demonstrated an excellent understanding of a number of different peoples unique personal and health care needs. While a visiting relative commented “people are always kept clean and are well dressed”. During a tour of the premises it was positively noted that a number of new low-rise beds had been purchased by the home. The manager told us fifteen had been ordered as they had proven so successfully in reducing the number of injuries people who use the service received as a result of falling out of bed. Staff continue to appropriately maintain details about all the accidents and incidents that occur in the home involving the people who use the service. The vast majority pertain to falls. The manager confirmed the RMBI’s health, and safety department continues to analyse this data on a regular basis in order to develop appropriate risk management strategies. Risk assessments are completed well for areas such as pressure areas, which included an up to date Waterlow scores. It was positively noted that the home immediately sought the advice a tissue viability nurse as soon as pressure sore was recently identified, established risk management strategies, and purchased a pressure sore relieving mattress. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 13 Information contained in care plans showed that based on an assessment of risk people who are willing and capable of administering their own medication are encouraged to do so. Staff appropriately maintained medication records for all those people using the service irrespective of whether or not they look after their own medication or staff administer it on their behalf. MAR sheets examined for the four people being case tracked showed there was a supply of every medicine listed on their medication profile and that these are being given as prescribed. Furthermore, all the people using the service prescribed controlled drugs their MAR sheets matched what was recorded in the Controlled Drugs register, which contained the signatures of two suitably qualified members of staff each time a CD was handled in the home. It was positively noted the home has a system for rendering all Controlled Drugs ‘unusable’ as soon as they become ‘unwanted’. The manager told us the home has recently introduced a new box for storing ‘unwanted’ medication (not Controlled Drugs) before it is returned to the dispensing pharmacist. We are concerned the box, which is kept in a designated meds room that is usually locked when not in use, still leaves large quantities of medication accessible to ‘unauthorized’ care workers and visitors. The home must ensure extra security is provided if they are going to stockpile such large quantities of ‘unwanted’ medicines in the future. The member of staff responsible for administering medication at the time of this site visit demonstrated a good understanding of the new arrangements for disposing of ‘unwanted’ medication in the home. During a tour of the premises staff were observed knocking on people who use the service bedroom doors and asking the occupants permission to enter before doing so. Several people whose the service and relatives met during the site visit confirm this was custom and practice in the home. All staff on duty was observed interacting with the people using the service in a polite and respectful manner. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes as recorded in peoples care plans. The manager told us that none of her current staff team have received any palliative care training and we recommended the providers consider making this available for staff. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A good range of activities within the home mean the people who use the service have sufficient opportunity to participate in stimulating activities of their choice, although the number of community-based events/trips on offer could be improved. Dietary needs and preferences are in the main well catered providing daily variation and interest for the people who use the service. EVIDENCE: The home employs a full time activities coordinator and there is a good range of activities on offer to people living there. It was evident from well maintain records of all the activities people whop live at the home engage in each day that there is a wide variety if in-house entertainment available. Activities include gentle exercise, visiting entertainers, monthly church services, and film shows. Trips are also arranged outside of the home, although the manager acknowledged in the homes AQAA that they could do with “more drivers, to James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 15 allow residents to have more frequent trips, and to make the most of the local community”. Comments made by a number of people living at the home and a visiting relative, included “there’s always something going on in the home, but not enough day trips”, “I would like to get out to the coast more” and “I think we need more people to drive the bus”. One person spoke very positively about a recent trip to London, which they had obviously enjoyed very much, and they were clearly very keen to get out more. Two relatives spoken with told us they were both extremely satisfied with the overall standard of care their loved ones received at the home. One relative was particularly impressed with the way staff actively encouraged them to continue playing an active role in their loved ones life, which included joining his wife for meals and staying over night in the guest bedroom at ‘special’ times of the year (e.g. Christmas, Easter ect). Most people spoken with said that they enjoyed the food offered with comments including “very good”, “lots of choice” and “the meals are the best thing about living at James Terry Court”. People spoken with told us they are always offered at least three choices at mealtimes and during lunch it was positively noted that people using the service and their guests were offered a choice of liver and bacon, vegetable risotto, and turkey salad. The head chef told us when meals need to be liquidised all the different food groups that make up a dish are kept separate to ensure it remains well presented and appetising. One person met told us they could choose to eat their meals in their rooms if they wanted to. We joined three people who used the service at their table for lunch. It was clear from the atmosphere in the dinning room at this time that mealtimes are positive social occasions where people can meet and talk to friends. Menus are displayed on each table. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people are unhappy with the care home, they or their relatives know how to complain and are confident their complaint will be looked into and action taken to put things right if necessary. People who use the service are also sure the care homes arrangements for dealing with suspected or actual abuse are sufficiently robust to protect them (so far as reasonably practicable) from harm. EVIDENCE: Comments from people who live at the home included “any problems are dealt with”. Individuals spoken to told us they felt able to speak to staff or managers about any issues they may have and knew how to make a complaint. Records are kept of any concerns or complaints received and we saw that these were well maintained. These showed that action had been taken in response to issues raised both verbally or in writing by people living there or their representatives. The complaints policy and procedure is displayed in the home and is part of the guide for the people living there. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 17 Care staff have mandatory training that teaches them how to recognise and report abuse. There is an organisational procedure for staff to follow in the event of any allegations being made. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home, which is furnished and decorated to a reasonable standard, ensures people who use the service live in a relatively safe and clean environment, although the physical layout still needs improving to make it far more homely. The people who use the service have all the specialist equipment they require to maximise their independence. EVIDENCE: People spoken to were happy with the environment. Comments from individuals included “fine”, “a very pleasant room” and “comfortable”. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 19 We saw that the home generally provides a very pleasant, comfortable, and well-maintained place for people to live. However, as identified in the homes last half or dozen or so inspection reports the size and layout of the building still does not lend itself particularly well to the concepts of ‘warmth’ and ‘homeliness’. The manager advised us that the RMBI is in the process of seeking planning permission from the Local Council to rebuild the home by 2009. It was positively noted during a tour of the premises that despite on going delays in respect of the new build a rolling programme to continue redecorating the place was still operating. Since the homes last inspection several lounges and dining rooms have been refitted with new wall coverings, curtains, and floorings. A gazebo has also been erected in the garden, which all the people spoken with said was an excellent acquisition and very popular with people who use the service and their guests during the summer. Three bedrooms were viewed with the occupant’s permission. These rooms were all personalised to the individual with many containing peoples own pictures, photographs, and ornaments. The ground floor has a very spacious communal dinning room with a conservatory attached, which provides a good view of the garden. Two relatives spoken with about the homes call bell system told us staff always respond promptly when this alarm system is activated. During a tour it was note that call bell cords were sufficiently long enough to be pulled by someone who had fallen. The manager told us the home had eight mobile hosts in operation at the time of this visit, which was sufficient to meet the physical needs of all the people currently living at James Terry Court. 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 12noon. The clothes of people using the service being kept in the laundry at the time of this site visit were being stored in individually labelled boxes in order to ensure freshly laundered items of clothing were returned to their rightful owner. The home was very clean and hygienic on the day we visited. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are generally enough staff on duty to meet the needs of people using the service and individuals are satisfied with the care they receive. There is a good staff training and development programme in place. EVIDENCE: Feedback about the way the staff carried out their duties was generally very positive. Comments included “staff are always nice and polite”, “most are kind and caring”, and “there are always enough on duty”. We saw that staff were caring and spoke to individuals in a polite and respectful manner. Care staff we spoke to had a good understanding of what person centred care is and some were completing dementia, nutrition, and infection control training at the time we visited. Most people met, including relatives and people who use the service, told us staff were ‘always’ available when needed and responded well to the call bell being activated. As previously mentioned the vast size and layout of the building sometimes makes it seem like there are not many staff around at times. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 21 Staff have access to a very good programme of training. Mandatory training is provided in a number of topics such as safeguarding adults, manual handling, food hygiene, fire safety, first aid, and Health and Safety. It is recommended more staff receive person centred care planning training. Additional workshops are provided on specialist areas as previously mentioned and there is a strong NVQ provision with staff able to study for both the Level 2 and 3 qualifications. At present over 50 of the homes support workers have either achieved or currently studying for their NVQ Level 2 or above in care in line with National Minimum training targets residential care workers. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is well run. People know that their opinions are central to how the home develops and reviews their practice because there are good quality assurance systems in place. There are generally good arrangements to make sure that the health and welfare of people using the service is protected, although arrangements for keeping COSHH products secure need to be improved. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has considerable knowledge and experience of running a care service for older people. Comments from people who use the service, their relatives, and staff were very positive about her style of leadership and included “very understanding” and “very approachable”. In the last twelve months the manager told us she had attended a number of training courses and up dated her knowledge and skills in respect of managing staff grievances and understanding the new Mental capacity Act. A formal quality management system is operated at the home to regularly look at all areas of the service. A full external audit had recently been carried out and a very detailed report published that set out their findings and recommendations. The management were looking at the results of this at the time we visited and are currently drawing up an action plan to implement them. In addition to this report senior representatives of RMBI continue to carry out monthly visits to the home. There are also monthly meetings held for people living at the home and the minutes of the last two showed staff take account of the opinion expressed by the people who use the service. Records are kept on each persons care plan of any valuables or possessions brought onto the home or held by staff for safekeeping. A copy of a fire risk assessment of the building carried out by an external organisation was made available on request. The homes fire records revealed that in line with the London Fire and Emergency Planning Authority (LFEPA) good fire safety guidance the homes fire alarm system was being tested on a weekly basis and fire drills undertaken at least once a quarter. Three fire doors tested at random during a tour of the premises all closed flush into their frames when released. Up to date Certificates of worthiness were made available on request to show that suitably qualified engineers had checked the homes portable electrical appliances; fire alarms, extinguishers, emergency lighting, mobile hoists, and platform lift in the past twelve months. COSHH products were found in an unlocked cupboard on the second floor during a tour of the premises. No staff were in the vicinity at the time and the notice pinned to the cupboard door was very clear that this space should be kept locked when it is not in use. Staff on duty immediately locked the cupboard door at the time. The manager must remind her staff team about keeping COSHH products secure at all times. James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 24 James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 25 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 2 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 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 3 3 X 3 X X 2 James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1), Schedule 1 & 5(1) Requirement All the people using the service must be provided with an up to date and detailed Statement of Purpose and Guide that contains all the information required by the Care Homes Regulations (2001). This will ensure people have good information regarding the quality of the care provided by the home. ‘Unwanted’ medication waiting to be returned to the dispensing pharmacist by the home must be securely stored. This will ensure these drugs are only accessible to authorised nurses and care workers. Chemicals and other substances hazardous to health (COSHH) must be kept securely locked away when they are not in use. This will ensure (so far as reasonably practical) the people who use the service are not harmed. Timescale for action 01/01/08 2. OP9 13(2) 01/11/07 3. OP38 13(4) (6) 08/10/07 James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 27 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 OP1 Good Practice Recommendations The homes Statement of purpose and residents Guide should be reviewed to make the formats more accessible to the people who use the service. These documents should also include the views of people using the service, as well as their representatives. This will ensure they have all the information they need to know about the home and what support they can expect to receive during their stay. Palliative care training should be provided for all staff that supports people living at the home who are approaching the end of their life or have died. People who use the service should be assisted (as far as practical) to participate in more community-based social, leisure, and recreational activities of their choice. Person centred care planning training should be provided for all staff that support people living at the home to develop individualised packages of care. 2. 3. 4. OP11 OP12 OP30 James Terry Court DS0000019030.V350644.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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