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Inspection on 11/10/05 for Jansondean Nursing Home

Also see our care home review for Jansondean Nursing Home for more information

This inspection was carried out on 11th October 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home had a welcoming and friendly atmosphere, and Service Users stated that they were well looked after. One said that "the staff are always there for us" and "they answer the call bells quickly." The Manager ensures that there are sufficient care staff on duty in relation to the needs of the home. There are 2 nurses and 6 care staff on duty in the day time, when there is a full complement of Service Users. Night duties are covered with 1 nurse and 3 care staff. It is important for the home to have this level of staffing, as the layout of the home is not conducive to managing nursing care, having 4 floors and many corridors.

What has improved since the last inspection?

Requirements given at the last inspection had been met, or were in the process of being met. Some redecoration of the home had been carried out, and some new items of furniture were seen in bedrooms. Medication charts were being stored in new files, and this enabled the staff to complete the charts more easily, and to ensure safe storage of the information. A new steam cleaning machine had been purchased for cleaning carpets, and was being found to be effective in areas where carpets were relatively new.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Jansondean Nursing Home 56 Oakwood Avenue Beckenham Kent BR3 6PJ Lead Inspector Mrs Susan Hall Unannounced Inspection 11th October 2005 09.50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Jansondean Nursing Home Address 56 Oakwood Avenue Beckenham Kent BR3 6PJ 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 8650 7810 020 8325 8008 jansondean@btinternet.com Sage Care Homes Limited Mr David Walters Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 28 April 1997 Date of last inspection 10th July 2005 Brief Description of the Service: Jansondean is a large, detached, older building, situated in a pleasant residential area of Beckenham. It is near to local facilities and shops, and is close to a main road, bus routes and train stations. The Providers (Sage Care Homes), have several other Homes for the care of older people at different locations around the country. Accommodation is provided on 3 floors (ground, first and second), and a passenger lift facilitates access to all floors. A new build extension was completed at the rear of the property about 12 years ago, and this incorporates a lounge/dining room on the lower ground floor which leads out into a large garden; this is mostly laid to lawn, and has mature trees and shrubs. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place from 09.50 – 15.30. The Inspector was made welcome throughout the visit, and was able to talk freely with Service Users, relatives and staff. The Manager was on the premises, and assisted the Inspector with providing documentation and up to date information. The Lead Inspector for the home (Rosemary Blenkinsopp), had carried out an additional unannounced visit during the previous night, to check on some specific aspects of the way in which the home was running at night. She had arranged this day visit, so that a different Inspector (Susan Hall) would follow up the general progress of the home. The inspection included a tour of the home; checking documentation (e.g. preadmission assessments, care plans, medication charts, staff files); conversation with 7 Service Users and 2 relatives; and also chats with 10 members of staff as well as the Manager. The staff were seen to interact well with Service Users and with each other, and generated an atmosphere in the home that was both friendly and efficient. The Inspector talked with 2 nurses, 3 care staff, the chef, 2 domestic staff, the handyman, and the administrator. A care liaison nurse from the Primary Care Trust (Bromley PCT) was in the home during the morning, and she also gave helpful feedback. The Inspector’s overall impression was that while the layout of the home and the age of the building does not lend itself to nursing care, the staff make up for this with their commitment to the Service Users, and the generally good standards of care. What the service does well: The home had a welcoming and friendly atmosphere, and Service Users stated that they were well looked after. One said that “the staff are always there for us” and “they answer the call bells quickly.” The Manager ensures that there are sufficient care staff on duty in relation to the needs of the home. There are 2 nurses and 6 care staff on duty in the day time, when there is a full complement of Service Users. Night duties are covered with 1 nurse and 3 care staff. It is important for the home to have this level of staffing, as the layout of the home is not conducive to managing nursing care, having 4 floors and many corridors. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Care plans viewed were mostly satisfactory, but wound care was not well documented. There is a recommendation to ensure that wound care is documented in such a way as to show a clear pathway of progress for each wound. The Manager stated that there was a programme in place for replacing carpets in communal rooms and corridor areas – and these had already been ordered. There is a recommendation to ensure this is carried out as planned, as some carpets (mostly in identified corridor areas) smelt offensive and appeared stained, in spite of a regular cleaning programme. The recommendation is also to review the state of carpets in bedrooms, and arrange for replacement of these where indicated. Some items of bedroom furniture were noted to be old and in poor condition; and some items of equipment (e.g. commodes) were seen to be in a poor state of repair. There is a further recommendation to review all items of furniture and equipment, and repair or replace them as necessary. Staff files did not include a recent photograph of staff members, and there is a requirement to put these in place. One staff file was noted as not having a Criminal Record Bureau check for the employee. There is a further requirement to check that all staff files contain all required documentation, as listed in Schedule 2 of the Regulations. Staff members spoke about different training sessions which they had attended, and some specific training in non-mandatory subjects. However, the staff training matrix did not show that all staff had received training in mandatory subjects, and there is a recommendation to update this accordingly. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 7 The Home does not have a format in place for written feedback from Service Users, relatives and visitors. A recommendation is given to implement a quality assurance system which incorporates this; and a requirement is made to keep a copy of Regulation 26 visits to the home on file, or send one to the Commission. 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. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 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 Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 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): 3,4,5 There are suitable systems in place to assess Service Users prior to admission to the Home. EVIDENCE: Pre-admission assessments are usually carried out by the Manager, using a set format to ensure that all relevant data is discussed and recorded. The Inspector viewed 4 completed assessments, and these included personal and family details; medical history; medication; and details in respect of individual care and nursing needs. The format follows the basic “activities of daily living”, such as assistance needed with personal hygiene needs; pressure area care; specific nursing needs; moving and handling; communication; continence management; pain management and social and cultural needs. Consideration is given to any additional equipment needed, and to the size of the room available. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 There is a consistent care planning system in place to provide staff with the information they need to give effective care. However, this could be improved in some areas. Medication administration at the Home is satisfactory, although the clinical room is limited in size and storage space. EVIDENCE: The Inspector viewed 4 Service Users’ files in detail. Pre-admission assessments are followed up by the nursing staff, who carry out additional assessments for the Service User’s general condition, observations for temperature and blood pressure, weight on admission, and risk of falls. A dependency profile itemises their level of care needs, and specific concerns such as moving and handling needs, pressure area care and nutritional needs. Assessments for risk of pressure areas, nutritional needs and weight are carried out monthly, and these were properly signed and dated, except for 1 file where the nutritional risk assessment had not been completed. Care plans are implemented according to the findings of the assessments. Most care plans viewed were well written, with a suitable amount of detail and specific Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 11 instructions. These included topics such as personal care and hygiene needs, weight reduction, management of back pain, management of constipation, assistance with feeding and incontinence care. A specific risk assessment was seen for a Service User who is unable to use a call bell, and another for someone who has 24 hour oxygen. Daily reports are completed by the nursing staff, who check with care staff for any changes noted in the Service User’s general condition. Some of these daily records mentioned wounds such as a sacral sore, or wound on the arm or leg – but there were no care plans in place for these individual wounds to show: e.g. how the wound progressed, what dressings should be applied, how often the wound should be evaluated and the dressing changed, or when the wound healed. There is a recommendation to improve the documentation for wound care, so that a clear pathway of progress can be followed for each individual wound. The home has a number of pressure-relieving mattresses and cushions available for use as needed. Care staff have daily charts to complete to show details of personal care given (e.g. bath or shower, hair wash, nails cut etc.), and bowel care. Some of these were completed more thoroughly than others. Additional charts are used to record fluid balance and 2 hourly turns for any Service Users who are unwell. The files included detailed records for visits from doctors, and for multidisciplinary visits from other health professionals such as dietician, physiotherapist, chiropodist and dentist. Medication is stored in locked cabinets in the clinical room, except for the drugs fridge, which is stored in a nurses’ office. The clinical room is not large enough for satisfactory storage, and this should be reviewed. Medication administration is mainly via the nomad cassette system, and is only administered by registered nurses. It is dispensed from a medication trolley, which was correctly locked and attached to the wall. The trolley was in good order, and no out of date medication was found in the trolley or the cupboards, and there was no overstocking. Eye drops and insulin had been dated on opening. Medication Administration Records (MAR charts) were inspected, and had been well completed. Handwritten entries are signed and dated for accountability, and receipt of medication is entered on to the charts. The Manager stated that he had organised a new arrangement for the removal of waste medicines in accordance with new legislation, but the registration with the clinical waste providers had not yet been confirmed and implemented. This was causing a stockpiling of medicines for removal, and this needs to be addressed as a priority. The Inspector noted that Service Users felt that the arrangements for health and personal care were satisfactory. Care needs are met in privacy, and Service Users are treated with respect. Service Users were well dressed and groomed, and attention to detail was noted, such as drinks and call bells placed within reach. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 The home enables Service Users to take part in social activities, and visitors are welcomed into the Home at any time. Improved systems were in place for the provision of meals, and menus showed satisfactory variety for good nutrition. EVIDENCE: Service Users are able to stay in their rooms, or go to the lounge/diner on the lower ground floor, according to choice. One Service User said she liked to spend mornings in her room reading her newspaper. Special events are planned from time to time, especially inviting in different singers, who provide a variety of different musical enjoyment. An Art Therapist is employed on one afternoon per week, and encourages participation on an individual basis. The Inspector was aware that most Service Users were either ill or very frail, and not able to join in with many activities. Visitors are welcomed at any time, and the Inspector enjoyed talking with relatives who were visiting an elderly Service User during the morning. One Service User was being fetched by Social Services transport to go to a Day Care Centre as the Inspector arrived at the Home, and these arrangements for additional company and stimulation are made where possible. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 13 The Inspector visited the kitchen and talked with the chef, who works with the Manager to produce the menus. These are discussed at regular intervals, and take into account different food preferences, special diets, and general nutritional needs. Fresh fruit and vegetables are available every day, and the Inspector noticed that one of the fridges was well stocked with fresh produce. Fridge, freezer and meat temperatures were being recorded daily, and items of food in the fridge were covered, labelled and dated. The kitchen was basically clean and tidy, especially considering that lunch had just been served. Some areas looked as if they may be in need of refurbishment before long, but were satisfactory as viewed on the day. The chef said that he takes Service Users’ individual preferences into account. An example of this was during the previous week, when he had made a “spicy” beef stew. He had checked with Service Users and served up an additional “non-spicy” stew as well, for those who preferred this. Soft options were available, and the chef made sugar free dishes for diabetic Service Users. The lunchtime meal was well presented, and the Inspector noted that Service Users were assisted with feeding, and were not rushed with their food. A separate cook had been employed to assist with tea time meals. No record was being kept of the food eaten by individual Service Users, and the Inspector discussed the importance of this in the event of any Service User being taken ill with food-related conditions. However, the Manager stated that they were in the process of implementing a new system to incorporate these records, and this was due to start the next week. The Inspector did not issue a recommendation in view of this information. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The complaints procedure contains satisfactory information and is easily available. Satisfactory policies and procedures are in place for the prevention of adult abuse. EVIDENCE: The complaints procedure was displayed in the entrance hall, and was available in every bedroom. It contained all the required information. The Inspector viewed the complaints record, and noted that 3 complaints had been made to the Home during 2005, and one of these had been since the last inspection. The record showed clear details of the complaints, of the initial response, and of the subsequent action taken. The records showed a due consideration for the concerns raised, and appropriate action. No complaints had been made to CSCI. There were good training records in place for staff training in the prevention of adult abuse, and staff showed an understanding of the importance of this subject. New staff said that this had been included during the induction process. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 15 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, & 24-26 The layout of the building is not advantageous for nursing care. However, there had been some improvements to the décor since the last inspection, and other improvements were included on a planned maintenance programme. Bathroom, toileting and laundry facilities are adequate, and suitable equipment is available. EVIDENCE: Bedrooms are situated on 3 floors – ground, first and second, - and communal space is situated on the lower ground floor. The home has many corridors, which do not facilitate easy access for Service Users and staff. A passenger lift is available for all floors. The lounge/diner is on the lower ground floor, with a view of the rear garden through patio doors. This was suitably decorated and furnished, with comfortable armchairs and dining furniture. Toilet facilities are situated within easy reach. There is no additional quiet area for Service Users, and some preferred to remain in their own rooms. The Home has 6 bedrooms which are suitable for 2 people to share, but these are let as single rooms unless there is a specific reason where 2 Service Users Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 16 wish to share – e.g. a married couple. The Manager stated that he was discussing ideas for possible change to the building with the provider. Service Users seemed satisfied with the facilities provided in their rooms, but the Inspector noted that some furniture items were old and dilapidated, and in need of replacement. The Manager stated that there was a programme in place to gradually replace some furniture items. The Home has a number of rooms with en-suite facilities, and additional bathrooms and shower rooms. These were fitted with baths which had integral hoisting facilities, or showers with mobile shower chairs. One commode was noted as being in a poor state of repair. There is a recommendation to review the furniture in bedrooms, and all commodes, and replace or repair as necessary. Satisfactory mobile hoisting facilities were available. The Home was generally clean, and the domestic staff said that a new steam cleaner for carpets was proving to be more effective than a previous carpet cleaner. Some of the carpets looked stained and old, and there were offensive odours in 2 areas, which appeared to come from carpeting. New carpeting had already been ordered for communal and corridor areas, and the samples were impervious backed, and of high quality. There is a recommendation to continue the programme for replacing other carpets (i.e. bedroom carpets) as applicable. The home was suitably warm and well ventilated. Hot water outlets are fitted with thermostatic controls. Domestic lighting is satisfactory, and emergency lighting is fitted and appropriately tested. The laundry room is on the lower ground floor, and was in good order. There are 2 washing machines, and 1 of these has a sluicing facility. The home uses a red alginate bag system for laundering soiled items. There are 2 tumble dryers, and some space for hanging clothes. Clean items are separated into individual baskets and returned to Service Users on a daily basis. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 17 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): 27-30 There are good staffing levels in place, and staff show a committed and caring attitude towards Service Users. Recruitment procedures are generally satisfactory, but need some attention to meet all requirements. Staff training is carried out, but records need updating. EVIDENCE: The Inspector was pleased to see that there are suitable numbers of care staff employed to meet the needs of Service Users, in relation to the numbers of Service Users, and the layout of the building. There are 2 trained nurses on duty throughout the day time, so that 1 can oversee the top 2 floors, and the other can oversee the ground and lower ground floor. They have 6 care staff to work alongside them, when there is a full complement of Service Users. There were some vacant beds at this visit, and therefore only 5 care staff on duty, as this was sufficient to meet the needs. Night duties are covered with 1 nurse and 3 care staff. The Home’s Lead inspector has written a separate report in respect of the night visit made during the previous night. Several staff were employed from other countries, and 2 of these were nurses in their own country, but acting as senior care staff while waiting to carry out adaptation training for nursing. These are equivalent to NVQ 3 training, and 3 other care staff had completed NVQ 2 training. This means that out of a total of 12 care staff, 5 had training in NVQ 2 or above – which is 41.6 . The Manager stated that he had applied for the other 7 care staff to commence NVQ training, and for 1 trained nurse to carry out Assessors’ training. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 18 3 Staff files were examined in regards to recruitment procedures. Application forms included a record of previous employment, (with any gaps in employment); a health questionnaire; declaration re any criminal convictions and a record of qualifications and training. Proof of identity was included in each file, and 2 written references. Work permits and confirmation of NMC PIN numbers for trained nurses had been obtained where applicable. Staff had been issued with job descriptions and contracts. The Inspector noted that there were no up to date photographs on record for staff members, and a requirement was given for this. One staff file viewed id not contain a Criminal Record Bureau (CRB) check, and there is a further requirement to review all staff files and ensure they contain the required information listed in Schedule 2 of the Regulations. There was good evidence of staff training. Some care staff discussed recent training they had attended (e.g. adult protection awareness, moving and handling training, and infection control), and fire training was well documented. Certificates were retained on staff files. The staff training matrix did not demonstrate that all staff had received training in mandatory subjects, and there is a recommendation to update the staff training matrix to show clear evidence of this. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 19 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, 37,38 The Manager is supported well by senior staff in providing clear leadership throughout the home, and staff demonstrate a good understanding of their different roles and abilities. EVIDENCE: The Manager has many years of experience in caring for elderly Service Users, and was currently completing the Registered Managers’ Award (RMA). There were clear lines of accountability for staff to follow, including named nurses and keyworkers for each Service User. These take a lead on ensuring that documentation and details of care are carried out effectively. Staff meetings are held for nurses and for the whole staff group, although the Inspector did not view records for these at this visit. The Manager stated that daily feedback is obtained from relatives and visitors for Service Users, but there was no written programme in place for quality assurance purposes. The Inspector could see that there was a good rapport between the Manager, staff and relatives, and relatives told the Inspector that staff were always very helpful and pleasant. There is a recommendation to put Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 20 a system into place which enables Service Users and their relatives to provide written feedback if they should wish to do this. The Manager also stated that the Provider visits the home every month to check progress (Regulation 26 visits), but there was no evidence to support this. There is a requirement to supply a copy of these reports either directly to the Commission, or for a copy to be retained with the Manager for viewing at inspections. Policies and procedures were in evidence, and the Inspector read some of these in respect of medication. Other documentation was satisfactorily completed, and up to date – (except where already identified in this report). The Inspector was satisfied that mandatory training of staff in safe working practices was taking place, and this has already been referred to in standard 30. Fire records were satisfactory, and fire risk assessments had been carried out. The Inspector did not view accident records at this visit. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 21 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 2 X 2 3 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X X X 3 3 Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 13 (2) Requirement To follow up the arrangements being made with clinical waste providers, for the removal of unused medicines. To include an up to date staff photograph on each staff file. To ensure that all staff have had a current CRB check, and that all staff files include the required documentation listed in Schedule 2 of the Regulations. To supply a copy of Regulation 26 visits directly to the Commission, or to keep a copy on file for viewing at the home. Timescale for action 11/11/05 2 3 OP29 OP29 19 (1) (b) 19 30/11/05 31/12/05 4 OP33 26 (5) 11/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations To improve documentation for wound care, so that a clear pathway of progress can be followed for each individual wound. DS0000010138.V258706.R01.S.doc Version 5.0 Page 23 Jansondean Nursing Home 2 3 4 5 6 OP9 OP24 OP26 OP30 OP33 To review the storage facilities in the clinical room, adding new cupboards if appropriate. To review bedroom furniture and commodes, for repair or replacement as necessary. To continue the programme of maintenance for cleaning and replacing carpets as needed. To update the staff training matrix to show that all staff are receiving training in mandatory subjects. To implement a quality assurance system which facilitates written feedback. Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Jansondean Nursing Home DS0000010138.V258706.R01.S.doc Version 5.0 Page 25 - 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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