Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 13/06/08 for Jansondean Nursing Home

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

This inspection was carried out on 13th June 2008.

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

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

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

During the inspection al staff were helpful and courteous. The administrator was able to evidence well organised files particularly those relating to health and safety service certificates and staff personnel files. There was evidence that recruitment checks were undertaken prior to employment to ensure staff are safe to work in the home. The staff team and the Manager in the home have been in post for some considerable amount of time, which ensures that residents receive consistent care from staff that are fully conversant with their needs and the workings of the home. The staff we met had a working knowledge of dealing with adult protection issues and more importantly the reporting of such matters.

What has improved since the last inspection?

It was evident that money had been invested in the building with the new extension completed and ongoing upgrading of individual bedroom areas. New furniture has been purchased along with curtains and soft furnishings providing great improvements in the communal and individual bedroom areas. The kitchen has been relocated and some new equipment has been installed. The kitchen is now located adjacent to the dining area hence food can be served more directly to residents and prevents delays particularly as the lift in this home is slow.

What the care home could do better:

The practice of leaving medications on resident`s tables without supervision is unsafe and all medications must be managed safely. Those eye drops which are opened and in use, must be used within the time frame for expiry which is usually 28 days. The practice of giving out all of the medications, then signing all of the charts at once, must cease and all medications must be signed for immediately after it has been taken by the resident. All of the fire equipment, which is in located within the nursing home, must be kept fully functioning. More specifically the fire /smoke detector in the lower ground floor kitchen must not be covered to prevent it from going off. This matter has been referred to the relevant Fire Officer at Bromley fire station for his attention. Immediate requirements were left regarding the two issues identified above. Since the last key inspection the staffing skill mix has been reviewed and the qualified nurse on duty reduced from two to one. On both of the site visit the qualified nurse was working a long day, almost fourteen hours. There was no other nurse to relieve the individual during break hence effectively they were on duty with out a break. Staff who work long days and become fatigued can make mistakes which could impact on resident`s welfare.

CARE HOMES FOR OLDER PEOPLE Jansondean Nursing Home 56 Oakwood Avenue Beckenham Kent BR3 6PJ Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 13th and 15 th June 2008 09:10 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.V365363.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. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 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.V365363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 32 13th September 2007 Date of last inspection 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 4 floors (lower ground, ground, first and second), and a passenger lift facilitates access to all floors. A new build extension was completed at the end of 2007, and this has extended the lounge/dining room on the lower ground floor, which leads out into a large garden. Disabled access has bee provided into the garden although currently this is unusable due to building materials and uneven surfaces. The home is currently underway extensive refurbishment of individual bedrooms to incorporate en suite facilities. Fees range between £645.00 for a superior single and £625 for a standard single. The Local Authority fees range between £558.00 to £634. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 1 star. This means the people who use this service experience adequate. Two site visits were undertaken, the second as a result of immediate requirements left during the first site visit. Prior to the inspection the Manager had completed the AQAA and forwarded this to the CSCI. Four comment cards were provided and returned during the inspection. During the visit the inspector met with two relatives, several residents and observed staff interaction and engagement with residents. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans staff personnel files as well as health and safety records. Feedback was provided to the person in charge at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the service does well: During the inspection al staff were helpful and courteous. The administrator was able to evidence well organised files particularly those relating to health and safety service certificates and staff personnel files. There was evidence that recruitment checks were undertaken prior to employment to ensure staff are safe to work in the home. The staff team and the Manager in the home have been in post for some considerable amount of time, which ensures that residents receive consistent care from staff that are fully conversant with their needs and the workings of the home. The staff we met had a working knowledge of dealing with adult protection issues and more importantly the reporting of such matters. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 7 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. Jansondean Nursing Home DS0000010138.V365363.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 Jansondean Nursing Home DS0000010138.V365363.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): People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The pre-admissions procedures provide residents with some of the information they require prior to any decision regarding placement being made, to establish whether the service is right for them. Staff have a pre admission assessment to establish that they can meet individual residents’ needs and on which to base an initial care plan. EVIDENCE: On the first site visit there were 23 residents on site. Of those residents one was suffering MRSA and two others had pressure sores. A selection of residents file were selected for case tracking which included viewing of the assessment records as well as care plans and supporting documentation. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 10 Those files inspected had an assessment conducted by the home prior to admission. In those seen, it was the registered manager who had conducted the assessment. He was out assessing a resident for possible admission during the first site visit. In the first file, there was information obtained from Bromley hospital which included a number of multi disciplinary team members reports. This would have provided good information about the resident’s needs and abilities. In addition there was an enquiry form and a property checklist completed on admission. On the “activities of daily living “assessment the resident was said to have a pressure sores to their heels and sacrum although there was little else stated regarding the grade or other wise. There was however a community discharge letter which provided information on the pressure sore. In the event that residents are admitted with pressure sores or are susceptible to developing them, as indicated by a high waterlow score, then pressure relieving equipment should be provided on admission to prevent further deterioration of skin integtity. The second assessment information indicated this person had short term memory loss. Again the assessment prior to admission had been conducted by the Manager although the assessment on admission was incomplete with many areas blank it was also without a date or signature. The inspector was unable to view contracts either those provided by the funding authority or those issued to private residents. Details of trial visits or visits made to the home by families of prospective residents was not available. There was little evidence relating to what other information had been provided to the family pre admission. Jansondean Nursing Home DS0000010138.V365363.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are not fully reflective of specific individuals’ needs and without such information inconsistencies in care can occur and staff lack sufficient guidance to undertake the care. The administration of medications, and that alongside the poor recording, introduce risks and could cause residents harm. EVIDENCE: Those care plans included in the case tracking evidenced the following information. Care plans were a mix of standard typed formats and hand written. The care plans mainly focused on physical health issues and little on other areas of need. The care plan for “ visual impairment “ was limited mainly referring to instilling eye drops and nothing on how the resident could be enabled to manage with limited vision. The care plan covering diabetes focused on issues around dietary intake and little on other complications such as Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 12 glaucoma and foot care. Staff signatures were recorded although not that of the resident or their advocate. Without signatures in place it is impossible to establish what input the resident or their advocate had into their care plan. Risk assessments were in place for bedrail usage, manual handling – this needs to specify the hoist to be used and size of sling, and a nutritional assessment. There was high risk identified for nutrition and skin integrity these areas need to be closely monitored. Supporting daily events records provided limed information with entries such as “had a good day” and “quiet night “. The sheet headed “resident profile “was virtually blank. The multidisciplinary sheet indicated the date of the visit and a brief summary of the purpose. In the second care plan these were all in the standard format, and included four areas of need. This care plan provided little information in respect of the resident’s identified needs including those outlined in the assessment information including Parkinson’s disease, short term memory loss etc. It was also indicted that the resident had a limited appetite and the nutritional risk assessment was not dated. A third care plan contained items as found in those two previously referred to. In the event that standard care plans are used then these must be fully reflective to include the resident’s specific needs as these will differ from person to person. In light of current residents needs the hoist provision must be adequate and different types of hoists may be useful to assist residents’ independence such as a standing hoists. The qualified nurse addressed the medications and this was very time consuming taking a great deal of her time. This allowed her little time to over see other aspects of care supervise staff or undertake anything else including record keeping. The medication records were inspected and the practice observed. The medication charts themselves were reasonably well completed with residents photograph and allergies recorded except for two checked. More specifically the information for the administration of “as required “medication was comprehensive. On sampling the medication charts and the dosette boxes it was observed that all of the medications had been administered yet in some of the charts the Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 13 medications were not signed either for the previous day or the day of inspection. It was only those medication charts relating to the Upper floor which were signed for on Thursday, although not Friday. Of all of those sampled nil were signed for Friday. This was put to the RGN in respect of the practice and she admitted that yesterday it had been an oversight and that she intended to sign the charts at the end of the medication round. It was evident that on occasions, all medication charts are signed after all of the medications are administered. This is not safe or acceptable practice. Those medications received into the home has been entered except for two charts. The inspector observed medications left in a pot in front of a resident who was sleeping placed there by a care staff member who proceeded to leave the room and hence the medications left unsupervised. This was observed for some ten minutes before the inspector sought the assistance of the RGN on duty. The shortage of qualified staff was cited as a reason for the medication issues. The inspector checked those eye drops in use. It was evident that they had been dated on opening although the four week of 28 day time frame for use was exceeded this was pointed out to the RGN who later that day removed the and replaced them with new eye drops. An immediate requirement was left regarding medication issues. Please see requirement 2. Jansondean Nursing Home DS0000010138.V365363.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are activities provided although more engagement by staff outside of these organised events would benefit residents. Some choices are provided which means residents are enabled to input into their day. This promotes resident’s independence and enhances individuals’ well being. EVIDENCE: On the day of the first site visit residents were in the process of being assisted to get up. Residents spend the majority of the morning usually in their bedrooms and late morning are brought to the lounge for lunch. Some residents did remain in their own bedroom in their chairs. During the second site visit he inspector arrived early -07:40 and the home was extremely peaceful with most residents resting in their beds. Visiting is flexile and the inspector met with 2 visitors during the first site visit. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 15 A resident and her sister met with the inspector as did one gentleman and his wife. Favourable comments regarding their stay and care at Jansondean were related to the inspector. Food was said to be very good and in fact one resident had gained so much weight she was on a diet as requested by her GP. She was however concerned that the W/C was not working and indicated this had been the case for two years. This needs to be addressed. All of those bedrooms seen had either TV’s or radios in them which residents had playing. The lunch was observed on the first site visit, and the breakfast on the second. The lunch was fish and chips which were nicely presented. The menu is a four week cycle offering two choices. The evening meal is mainly soup and sandwiches with a hot meal midday. During the afternoon an external entertainer was in the home singing and dancing olde tyme music hall favourites. The residents were participating as was one member of staff. It seemed that residents enjoyed this and one lady participated throughout. During the second sit visit a Sunday morning, residents were in the main still in bed with staff assisting some to get up. Sometime later the breakfast trolley was brought to the floors and residents had breakfast in their bedrooms. The home was peaceful and relaxed. Staff performed their tasks in a pleasant yet unhurried manner. Please see recommendation 1. Jansondean Nursing Home DS0000010138.V365363.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 and 18.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints information is provided to residents, relatives and visitors, which provides opportunities to raise issues. Staff demonstrated a working knowledge of adult abuse procedures, which affords protection to residents. An open ethos prevails within the home which allows concerns to be raised without fear of reprisal. EVIDENCE: The complaints information is available and on display in each of the bedrooms. The type face on this could be enlarged to aid those with visual impairment. All complaint information is retained in a file with notes and investigation records retained although this is not in the form of an actual complaint log. A complaints log would give a quick reference to what complaints had been received and identify if there were any emerging themes and indicate if the complainant was satisfied with the outcome. The last complaint received by the home was October 2007 which was investigated through the home in conjunction with London Borough of Bromley. One concern had been referred to the Provider two weeks prior to the inspection and it had been responded to. Staff who met the inspector were aware of the need to report any suspected or actual abuse and usually stated the CSCI. Staff should be made aware of the Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 17 guidance in relation to reporting adult protection matters through the Local Authority. In respect of the term whistle blowing this staff had a variable standard of knowledge of this subject, with two care staff who were not at all clear of what it meant. This needs to be actioned with further training on the subject. Staff confirmed that some training had taken place in respect of abuse and protection. It is recommended that this be revisited to ensure staff are fully aware of the external organisations to refer abuse to and they are fully conversant with the term whistle blowing. Please see recommendation 2. Jansondean Nursing Home DS0000010138.V365363.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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the environment provide residents with a better home to live in. The limited bathing and toilet facilities would have a negative impact on residents care needs and may inhibit choice. EVIDENCE: The front of the building has been made very attractive with hanging baskets in full bloom. Within the home fresh flowers were noticeable and gave a homelike feel. The home is undergoing major refurbishment. The lower ground floor communal space, had been completed December 07 and now provides residents with much improved sitting areas. In addition there was evidence of new carpets to the hall and ground floor corridors. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 19 The home was clean and tidy although some odour was present in the hall area on arrival the first day this was resolved later that morning. The residents in their bedrooms in the main had access to their call bell leads and fluids in reach. In a couple of bedrooms the lead had to run across the bedroom floor to be in the residents reach. This should be monitored to ensure it does not pose a risk to residents, visitors or staff. Many of the bedrooms had improved and had personal items in them. New furniture curtains and other items gave them a homely feel. Bedroom 2 is very dark and was referred to in the previous inspection report. This room should be used for residents who do not spend long periods of time in their bedroom. The current resident was seen to be in bed during the two site visits and seemed to be bed bound. This room is unsuitable for such a resident and should be reviewed. In one bedroom a portable radiator was approximately two feet from the resident and this could pos a risk. The sluice room door was open during the first site visit. This poses a potential risk to residents. There were some bathrooms and toilets which were out of use including that one adjacent to the staff office. One resident also remarked that her toilet was not working. The staff advised the inspector that currently there was one shower and one bathroom in working order. In a facility where there are four floors and a small slow lift it would make it difficult and time consuming to transport residents to other floors to address bathing/showering. This needs toe addressed. In light of the current staffing levels, the Manager needs to review the situation in respect of opening the front door by perhaps an intercom system, as delays can occur when staff have to travel between floors to answer the door. Equipment such as hoists specialist beds and walking aids were available. However, staff stated that a standing hoist would benefit residents and as referred to in the last section under health and safety, some hoists require replacement. Please see requirement 3 Jansondean Nursing Home DS0000010138.V365363.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided in adequate numbers although with the lay out of this building and dependency of residents, the skill mix and number of staff should be reviewed. The provision of one qualified nurse per shift allows little staff supervision or input into residents care. Robust recruitment procedures ensure that staff working in the home are subject to appropriate checks which affords protection to residents. EVIDENCE: At the time of the site visits there was one Registered General Nurse and five care assistants on duty. Support staff by way of domestics, cooks and an administrator were also on duty. The handyman was working as a cleaner on the first site visit due to staff shortages. The home employs male and female staff so that gender care issues can be addressed. The staffing levels have been reviewed in light of resident’s numbers and possible long term bed reduction. Whilst there are probably enough staff to meet the residents needs, the skill mix, namely one qualified nurse on duty Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 21 places a lot of pressure on that person. On the day of the first site visit Manager was out for the day assessing residents and therefore the qualified nurse was left to field calls, deal with any arising issues as well as co ordinate the inspection. The reduction in nurses was commented upon by two people one resident and one relative, with regret expressed at losing these staff members. It was also related in comment cards and in particular the areas of concern were organisation of breaks, resident dependency and practice issues, in particular the use of the hoist which requires two people, and in a lay out such as Jansondean delays can occur. One comment which was repeatedly referred to in comment cards was the good staff team working which prevailed. Comments received from relatives included “The nurses are extremely kind and helpful and they never make excuses not to do things “. The inspector was advised that interviews for care staff had taken place earlier that week. In light of the current staffing levels the Manager needs to review the situation in respect of opening the front door by perhaps an intercom system as delays can occur when staff have to travel between floors to answer the door. The staff personnel files were sampled. They contained application forms, self declaration medical assessments, identity checks, references and offer letters. The offer letters set out the hours of work salary etc. In some files the original Criminal Records Beaureaux CRB checks were retained. These are confidential documents and should, once checked be disposed of. The only information retained should be the date the CRB was received, the number and an indication if it was satisfactory, with the signature of the person confirming it recorded. In another file there was evidence of all of the afore stated as well as the POVA first check. Other information included an investigatory meeting, NMC information – this needs to include details of how the PIN number was checked and by whom. Immigration information and work permits were also on file. It is recommended that CRB’s are renewed every three years. The administrator was unable to locate an up to date training matrix which was requested to be sent to the CSCI. At the point of writing this report it had not been received. Staff with whom the inspector met demonstrated a good knowledge on those topics selected for inspection including infection control and MRSA. Dementia was also asked about although staff had a variable knowledge on this subject. Please see requirement 4. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 22 Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 23 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, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a trained nurse with experience in care of the elderly. Health and safety procedures are in place to ensure the home is safely maintained for residents. Quality assurance measures are limited and do not fully allow feedback from all parties involved in the home to further input into the service. EVIDENCE: The Manager has been in post for three years and is an experienced qualified nurse. He has completed the CSCI process to be registered. Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 24 A selection of health and safety certificates were provided to evidence servicing of the hoists lift gas and electrical appliances. The hoist certificate did indicate that two hoists were over five years old and should be replaced. Certificates for fire equipment including the extinguishers and fire panel were current. The administrator was unable to locate the records relating to weekly fire alarm testing, fire drills and other tests made to ensure that fire precautions are adequate. Confirmation that these had all been conducted was requested to be sent to the CSCI. The kitchen was inspected prior to lunch. The smoke/heat detector was obstructed with a cardboard box and black tape. When the inspector enquired about this she was advised that it was like that because the deep fat fryer set the alarm off and it had been like that for months. This was the subject of an immediate requirement and the local fire brigade have been contacted for a site visit. The resident’s money was checked. The receipts for expenditure where retained in an envelope and the money although there was no transaction sheet. There was a general sheet for expenditure. All items are invoiced to relatives /next of kin. A record of all transactions, of all monies held for residents, should be retained with evidence of expenditure of money supported by receipts, with staff and where possible relatives or residents signatures. In relation to quality assurance measures the administrator was unable to locate much evidence in relation to these. There were minutes of staff meeting held September 07 with one planned 24/6/08. A relatives survey had been conducted the end of 2007 although the inspector was unable to see the results of this. Regulation 26 reports were also not available. The inspector requested details of quality assurance to be forwarded to the CSCI. Please see requirements 5 and 6. Jansondean Nursing Home DS0000010138.V365363.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 X X 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 X x 2 Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement The Registered Manager must ensure that full and comprehensive assessment information is provided to the residents and their families prior to admission and that contracts outlining the service are issued. The Registered Manager must ensure that care plans are fully reflective of needs, completed with dates and staff signatures and where possible residents signatures to confirm the care plan. There had been some progress on this requirement although not fully addressed. Previous time frame for action 31/10/06. This was partially met The Registered Manager must ensure that all parts of the building, facilities and equipment are maintained in a safe working and hazard free condition. This must include toilets bathrooms and hoists. DS0000010138.V365363.R01.S.doc Timescale for action 31/07/08 2. OP7 15 31/10/08 3. OP19 23 31/07/08 Jansondean Nursing Home Version 5.2 Page 27 4. OP27 18 The Registered Manager must ensure that the skill mix and numbers of staff are sufficient to meet resident’s needs and to address all areas of their work. 31/07/08 5 OP33 6 OP35 35 17 Quality assurance measures 31/10/08 must include the views of all stakeholders. A record of all transactions of all 31/07/08 monies held for residents, must be retained to record income and expenditure of money supported by receipts, with staff and where possible relatives or residents signatures. 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 OP12 Good Practice Recommendations The Registered Manager should review the activities available to residents in line with their needs and preferences and include 1:1 sessions. A complaints log should be devised to provide a brief overview of complaints received. 2 OP16 Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. Extracts may not be used or reproduced without the express permission of CSCI Jansondean Nursing Home DS0000010138.V365363.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!