CARE HOMES FOR OLDER PEOPLE
Jane Campbell House Waverley Road St. Albans Hertfordshire AL3 5ST Lead Inspector
Alison Jessop Unannounced Inspection 1st February 2006 10:00 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 Jane Campbell House DS0000019438.V281610.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. Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Jane Campbell House Address Waverley Road St. Albans Hertfordshire AL3 5ST 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) 01727 858 130 01727 799 964 www.quantumcare.co.uk Quantum Care Limited Amanda Neville-Patterson Care Home 54 Category(ies) of Dementia - over 65 years of age (54), Old age, registration, with number not falling within any other category (54), of places Physical disability over 65 years of age (54) Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: Jane Campbell House is a care home providing personal care and accommodation for 54 older people. It is one of a number of homes operated by Quantum Care Ltd. The home offers single room accommodation on each of three floors; there is a passenger lift. Just over 50 of the rooms are below 10 square metres and are limited in layout because of built in wardrobe units. The bathrooms and toilets are appropriately situated throughout the home and fitted with appropriate aids. The home has well-maintained and accessible gardens. Jane Campbell House is set in its own grounds on a fairly steep road, in a quiet residential area of St Albans, to the north of the city and close to the City Hospital. A small parade of local shops is close by the foot of the hill. The bus stop for the local bus service to the City Centre is just outside the home Jane Campbell House DS0000019438.V281610.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 place over half a day by one Regulation Inspector. Feedback was gained from service users, staff and visitors and time was spent scrutinising care plans and other records. What the service does well: What has improved since the last inspection?
A lot of work has been done to improve Care Plans; these contain comprehensive information and are very person centred. Procedures relating to medication have improved. A lot of training has been carried out with staff, which is continuous. Staff appeared to very clear about the procedures and regular, thorough auditing by managers appears to be very effective. The communal areas of the lower ground floor have been refurbished. The décor, new carpets and soft furnishings offer a pleasant environment to service users. Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 & 6 A comprehensive needs assessment along with information from other professionals ensures that the service is appropriate to their assessed needs. EVIDENCE: The duty manager stated that she had carried out a needs assessment that morning. Managers assess prospective service users in their current environment prior to moving into the home. They and their family/representative are invited to visit the home prior to making a decision to move. The Service User Guide and other information about the home is then given to them which they take away, this offers information after they have left the home and may assist them to make a decision. Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 A lot of work has been done to improve care plans and risk assessments. The care plans had been reviewed and are now very person centred. EVIDENCE: Fluid charts observed have been completed for intake however output had not been regularly monitored. Where this had it appeared that staff were completing this as a matter of routine procedure but were not acting on the results. Procedures relating to medication have much improved. Staff are now recording PRN administration correctly. Team managers carry out daily audits at the end of the day so that any gaps or anomaly can be rectified. Staff spoken to also appear to be acting more responsibly about this and were clear about the correct procedures. Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 10 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): None of these standards were inspected on this occasion. EVIDENCE: Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 11 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): None of these standards were inspected on this occasion. EVIDENCE: Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 12 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 & 26 The malodour detected by the inspector and a visitor on the 1st floor may have been due to the open sluice door and waste disposal unit without a lid. This not only creates an unpleasant environment to everyone in the home, it is also a risk to health and safety and the spread of infection. EVIDENCE: The lower ground floor, which has undergone decorative improvements looks clean and bright. The colour schemes offer a colourful but relaxing environment and the soft furnishings offer a more homely feel, which service users complemented. The second tumble dryer in the home has not been replaced; therefore laundry staff find it difficult to get clothes laundered within time limitations. This requirement has been carried forward from the previous inspection report. The kitchenette on the fist floor has not been replaced, this requirement has been carried forward from the previous inspection report.
Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 13 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): 28 & 29 An ongoing programme of recruitment ensures that the home is suitably staffed. EVIDENCE: Records relating to the recruitment of staff were satisfactory. References and POVA first checks had been received and checked prior to staff starting work in the home. Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 14 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): 35 Service users money is stored securely and access is only available to delegated managers. This safe guards service users from financial abuse. EVIDENCE: Procedures relating to service user finances appeared to be satisfactory. Comprehensive records are maintained and a secondary system is available for when managers are off duty, which continues to safe guard service users. Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 15 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 16 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 OP8 Regulation 12(1)(a) Requirement Monitoring of food and fluid intake and output must be documented and any concerns must be acted upon and fully documented. The broken tumble drier in the laundry must be repaired and/or replaced. An action plan must be submitted to CSCI. Carried forward from previous inspection. The work surface and broken units in the ground floor kitchenette must be replaced. Carried forward from previous inspection. Clinical waste units must have lids to prevent the spread of infection and ensure the environment is free from offensive odours. Carried forward from previous inspection. Timescale for action 14/02/06 3. OP19 23 (2)(c) 31/03/06 4. OP19 23(2)(b) 05/04/06 5. OP26 13(3) 28/02/06 Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 17 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 Jane Campbell House DS0000019438.V281610.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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