Inspection on 08/06/05 for Jasmin Court Nursing Home

This inspection was carried out on 8th June 2005.

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

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

Other inspections for this house

Jasmin Court Nursing Home 25/06/07

Jasmin Court Nursing Home 27/06/06

Jasmin Court Nursing Home 06/03/06

Jasmin Court Nursing Home 26/01/05

Jasmin Court Nursing Home 25/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE JASMIN COURT 40 Roe Lane Pitsmoor Sheffield S3 9AG Lead Inspector Marina Warwicker Unannounced 08 June 2005 : 08.30 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 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. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Jasmin Court Address 40 Roe Lane Pitsmoor Sheffield South Yorkshire S3 9AG 0114 278 1595 0114 278 7257 sagecare@hotmail.com Sage Care Homes (Management) Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Phillipa Williamson Care home with nursing 50 Category(ies) of Old Age 50 registration, with number of places JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three of the beds are registered for old age (OP) OR physical disability (PD) for people aged 50 and over. Date of last inspection 26 January 2005 Brief Description of the Service: Jasmin court nursing home is a purpose built home situated within the community in the residential area of Pitsmoor, Sheffield, which offers such amenities as local shops, public houses schools and a church. The area has easy access to the city centre by public transport and car. Jasmin court nursing Home was first registered in January 1992. The home provides personal and nursing care to 50 older people. The home also works alongside the Sheffield teaching hospitals and provides 20 step down i.e. rehabilitaion beds which are included in the 50 beds registered. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Tuesday 16th August 2005 between 8.30am and 5pm. The inspector spoke to several service users, some relatives and the staff. Breakfast and lunch were observed and a tour of the premise also took place. Some comments were received from the relatives by post. The inspector was given an opportunity to observe the meeting of the health professional in relation to the residents who were receiving rehabilitation. What the service does well: What has improved since the last inspection? What they could do better: The staffing levels need to be increased to reflect the service users’ needs. There must be formal arrangements to cover staff sickness. The staff supervision and training need to be improved. The shortage of hoists and the lack of storage space need to be addressed by the proprietor. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 6 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. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 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 standard(s) 1,2,3,4 and 5. Standard 6 not applicable. The home provides the prospective residents and their families with sufficient information to make an informed choice. Before moving into the home service users take part in a professional needs assessment by the placing authorities and are assured by the home that the identified needs will be met. Each resident is provided with a statement of terms and conditions once decided by the resident with the help of the care manager and / or the relatives to take up permanent residency at the home. The majority of the service users take up permanent residency after using the step down (rehabilitation) facilities. However the staff at the home encourage trial visits to other homes in the same category so that the service users and relatives are able to decide on the suitability of Jasmin court. EVIDENCE: Three relatives, four residents and staff said that there was information available to check what type of care was offered at the home. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 9 Three care plans were checked. There were needs assessments by the placing authorities in the files for the respective residents. There were also copies of the home’s individual assessments of the residents prior to admission. This indicated how the identified needs were to be met. The service users and the relatives said that they were confident that the home was suitable when they made the choice. The staff said that often the hospital assignment came to an end, most service users decided to take up permanent placement at Jasmin court. However to give them a balanced view, the staff at the home and the care managers from the hospitals encouraged trial visits to other suitable homes before taking up permanent position. Three service users were randomly selected and their contracts were checked. All three had contracts drawn by the home and the service users had signed them. However, these contracts had not been signed by the management of the home to ensure that they were legally binding documents. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 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 standard(s) 7, 8, 9, 10 and 11. All residents have care plans. In order to meet individual needs the care plans are completed fully at the earliest possible opportunity by staff. The staff ensure that the health and social care professionals from the hospitals and from the community are involved when necessary to provide a seamless service. The qualified nurses managed the medication. The residents are treated with respect most of the time and the staff value their right to privacy. Therefore the residents are able to live in a comfortable and happy environment. Most relatives are consulted about funeral arrangements when the staff feel it appropriate, so that the residents’ last wishes are respected. EVIDENCE: Three care plans were checked in detail. There were risk assessments on falls, movement & handling and tissue viability. The action plans based on the outcome of the assessments were noted in the files. However, one service user had lost weight and there was no documentation to demonstrate that a JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 11 nutritional assessment had taken place or the reason for the weight loss. The monthly weight record was incomplete. The deputy manager was informed of this. The staff said that none of the permanent residents in the home had the capacity to self-medicate. Therefore the nurses administered the medication. However there was no documentation to support this on the care plans. The deputy manager said that all service users’ medication was annually reviewed by the GP. On the day of inspection the GP visited the home to review some service users. On each floor of the home, there was a registered nurse who was in charge of staff and service users. She was responsible for 25 service users therefore the health care support workers worked as the frontline staff. During conversation with the support workers on duty it was evident that they had very little knowledge on the condition of the service users. The inspector advised the deputy manager that the health care workers need to be trained in the different conditions of the service users and the use of medication and any side effects so that they could inform the nurse in charge of the floor of any changes observed. The inspector ascertained during staff interviews that most of the care staff did not read the care plans and/or get involved in the planning and the changes made to the individual’s care plans. They felt this was the duty of the qualified nurse. Care staff said that when they return from days off they asked their colleagues about the changes to service users’ care but they were not in the habit of referring to the care plan. Care plans checked had documentation on residents’ last wishes. There had not been any formal training on palliative care, pain management or bereavement counselling. The staff confirmed this. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. The service users have the opportunity to exercise their choice in relation to routines of the day, personal and social relationships, religious observance, choice of food, frequency of meals and meal times. There is very little provision for leisure and social activities which can cause boredom among service users. Although not all residents may wish to participate in social and recreational activities there was no arrangements for those who are able to take part. Activities stimulate the residents and give them some self worth and independence. Visitors are encouraged and residents are able to maintain contact with family, friends and members of the local community. Thus the residents are able to maintain outside contacts. Meals served at the home are of a good quality and the residents are offered a choice. The residents are able to have snacks and drinks in between meals if they so wish. EVIDENCE: The service users and relatives said that the home was very flexible when it comes to service users getting up in the morning and going to bed. The service users said that the staff helped them keep in touch with family and friends. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 13 There had been several activities co-ordinators appointed over the last two years and they had not been suitable. The deputy manager said that a new activities co-ordinator is expected to start next Monday. The residents and the relatives said that the permanent service users did not have any activities and often felt left out when they saw clients from the step down beds getting attention from the NHS staff. Most service users were sitting around in the lounges looking bored. The relatives said that they were made welcome by the staff. The residents and the relatives commented on the choice of food and how good it was. One resident said that if out of five service users, three said the food here is lovely then I should assume that food is very good. She/he said that the home cannot please everybody.’ The staff were seen helping residents with feeding. The cook took pride in the food she/he prepared and helped to serve at lunchtime. Several service users appreciated this. During the inspection of the kitchen the inspector found two fridges needing replacement since the temperature records maintained by staff were too high. For several months these temperature records have been 9oC instead of being around 5οC. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 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 standard(s) 16,17 and 18. The relatives and the residents are given the opportunity to raise any concerns and complain to staff or the manager. This is to enable residents to voice their opinion of the service and also for the staff to review and make improvements to areas of concern. The residents are enabled by the staff to exercise their legal rights and for those who lack capacity, an advocate service is offered. Such arrangements help residents to receive independent advice and help. The home has a complaints policy. Staff need to be familiar with the timescales and be aware that records of all complaints are kept by the manager. There is a lack of awareness of the homes’ policies and procedures among staff. It is acknowledged that staff will not be able to know all of the home’s policies and procedures. But they are expected to know where to find the policies and procedures and be familiar with some of the frequently used policies and procedures.. The management gives opportunity for staff to attend courses on adult protection and allegation of abuse. This is to protect service users and staff. By training staff they become conversant and therefore able to take appropriate action in such circumstances. EVIDENCE: The home had a complaints policy, which the staff were aware of. But some relatives said that they were unaware of this. The relatives and residents said that when they have concerns they felt comfortable taking the issues up with the staff or the sister in charge of the floor. They said that they had been happy with the outcome. However, one service user raised some concerns JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 15 about the night staff attitude with the inspector and said that she/he had mentioned this to the sister in charge on days and had not been informed of the outcome. The deputy manager was informed of this and it was brought to the inspector attention that a staff was being investigated. The CSCI was not informed of this. The inspector noted a service user with extensive bruising to her/his face and neck. On further inquiry it was established that it was from a fall from a chair and the service users did not sustained any fractures and staff were not involved; however, due to the nature of the bruising the CSCI should have been informed of the incident and the action in place to prevent this happening in the future. Staff told the inspector that when anyone complains, depending on the issue if appropriate they take immediate action to resolve it and then inform the person in charge. The deputy manager said that the manager had records of all the complaints, but this was not accessible on the day of inspection. The staff were not familiar with Adult Protection policies and the procedures to follow if there were to be an allegation of abuse. The care staff said that they would tell the manager. Although this is true in the day-to-day management the staff must be aware of the procedures and expected action to be taken by the management. Not all the staff had attended training in the above areas. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 16 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 standard(s) 19,20,21,22,23,24,25 and 26. The layout and the location of Jasmin court is suitable for it’s stated purpose. The home is clean and some residents’ rooms are personalised. Due to the lack of storage space some parts of the home are untidy causing risk to service users and staff. Domestics are employed to carry out housekeeping duties. The rooms are naturally ventilated with windows conforming to recognised safety standards. However, some restrainers were disabled which is unsafe for the service users. The home has adequate numbers of toilets and bathrooms. But due to lack of storage these rooms are used as storerooms. There is a maintenance programme in order to keep the home in good repair. There are pleasant outdoor areas, which can be used by the residents and relatives during good weather. The residents use the lounges on the ground floor during day and night. The laundry is sited away from the kitchen and food preparation areas, thus preventing infected and soiled clothing from being carried through these areas. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 17 EVIDENCE: During the environment check the inspector found out that some of the staff and some of the service users had disabled several first and second floor window restrainers leaving the windows wide open. It was accepted that on the day of inspection it was very warm and the windows were left wide open to get some air circulation, however the rooms did not have locks on the doors to prevent other service users entering the room thus causing risk of service users falling through the windows. The deputy manager was informed of this. The corridors, the staffroom, the staff station on each floor and the bathrooms were untidy and cluttered; since these areas are used as storage space for equipment and continence pads. The service users who were ambulant and the staff were at risk of falling over the equipment stored in corridors. This arrangement also interfered with the fire evacuation procedure. The care staff and the deputy manager were informed and immediate action was taken to alleviate the risk however the home does not have adequate storage facilities. It was noted that the dependency levels of service users had risen and as a result more service users were in need of moving and handling with the aid of hoists. The home did not have an adequate number of hoists. Therefore staff were unable to attend to service users immediately and they were having to wait a considerable amount of time. The service users raised concerns regarding the lack of hoists. There were three areas for the service users and families to use as communal lounges. The large lounge continues to look too big and the service users seem lost in it. Further discussions took place with the deputy manager so that this area could be made cosier. On the day of inspection those service users who would have benefited from sitting out in the garden were not able to do so due to the lack of staff on duty to supervise them. The service users and the relatives said that this situation was quite normal and that it was not a unique circumstance. The individual accommodation was adequate and some service users had their own possessions in their rooms. However if relatives wanted to visit service users in their bedroom there was no provision for them to find chairs to sit on. On arrival the inspector noted that the bins containing clinical and domestic waste were full and overflowing. The bins used in the communal areas were full and did not have lids. The housekeeper was informed of this. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The staffing rotas are formulated on most occasions with the correct staff numbers and skill mix of qualified nurses and health care support workers so that the service users are able to receive appropriate care. The home does not use agency staff since the management perceive this causes more problems. There was documentation showing staff training and thorough recruitment practices. Thus promoting a safe environment for service users. EVIDENCE: On the day of the inspection the staff complement was inadequate and the deputy manager informed the inspector that three staff were off sick and that he/she had contacted the off duty staff and he/she was expecting staff to turn up to fill the gap. On referring to the staff rota inspector noted that there had been several occasions where staff numbers were below the minimum staffing levels. Service users and relatives voiced their concern about the lack of staff and that some staff were not adequately trained and supported. The service users said that staff were overworked and unable to support the new recruits. One set of relatives said that often it seemed as though a lot of staff were around during the day and this was due to the numbers of NHS staff working with the step down service users. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 19 Four recruitment files were checked and most information was available including satisfactory CRB. However, the home must address the following areas: The evidence of face to face interviews, explanation for any gaps in employment and two written references must be sought. Although there was documentary evidence of staff training staff had received, some staff said that they had not had training on topics such as fire safety, health and safety, dealing with abuse of service users and protection of vulnerable adults. The inspector informed the deputy manager of the comments and suggested that staff have regular training and update sessions to remind them of the subject matter so that the staff could be familiar with them. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,36,37 and 38. The service users control their own monies except where they state that they do not wish to do so or they lack capacity. There are safeguards in place to protect the interests of the service users. The home has adopted policies and procedures to induct new staff, offer training and supervise them so that the service users receive a high quality of care from trained staff. The records required by the Care Homes Regulation for the protection of service users and the running of the business are maintained by Jasmin court. The management on the whole takes responsibility for the health, safety and welfare of the service users and staff at Jasmin court care home. EVIDENCE: Three service users finances were checked. The families of these service users handled the finance and the service users had some of their pocket money JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 21 managed by the home. This was appropriately recorded and the service users said that they could have access to the money when they wanted. Four staff training files were checks and four staff were interviewed it was evident that the staff did not receive appropriate supervision at regular (i.e. six times in twelve months) intervals. Generally the record keeping was satisfactory however, comments have been made in other sections regarding particular records. The inspector ascertained during the day that not all accidents, injuries and incidents had been reported to the CSCI. For example the inspector noted that a service user had sustained severe bruising to face and upper body and a staff had been suspended from duty pending investigation. This was not reported to the CSCI. The inspector noted on arrival that all bins containing clinical waste and domestic waste were full to overflowing. Most of the safety checks and service of equipment were up to date. The five yearly electrical insulation check was last completed on 6/05/1999 and this is overdue. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 2 3 2 2 3 2 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 2 x x x x 3 2 2 2 JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 18 Regulation 18 Requirement All staff must be receive training on protection of vulnerable adults and reporting abuse. The manager must ensure that all staff are competent in following the relevent policies and procedures. Previous timescale 31/03/05 The bathroom must be used for its stated purpose and not as a store room. Previous timescale 31/03/05 The home must provide appropriate storage for the aids, adaptations and continance pads. This is an ongoing requirement and the last timescale 31/03/05 The service users must be consulted and assessed on their wishes and ability to hold a key to their bedroom. The assessment with the outcome must be included in the care plans of each individual resident. This is an ongoing requirement and the last timescale 31/03/05 All staff must receive training and updates. For example: Fire safety, moving and handling, health and safety, adult Timescale for action 25/10/05 2. 21 23 25/10/05 3. 22 23 25/10/05 4. 24, 37 13 25/10/05 5. 38 13, 18 25/10/05 JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 24 6. 8, 37 14 7. 9, 37 13 8. 12 14 9. 10. 11. 19 24 27 23 23 18 12. 13. 14. 29, 37 36 16, 38 12, 19 18 37, 17 protection and infection control. This is an ongoing requirement and the last timescale 31/03/05 Nutritional screening and monitoring must be undertaken on service users who gain or lose an unacceptable amount of weight. The service users must be assessed on their cabability to manage their medication. The outcome of the assessment must be documented in each care plan. The service users must be given opportunities for stimulation through leisure and social activities. All windows restrainers must be in place and they must not be disabled. There must be provision for relatives to access chairs to use in the service users bedroom. The manager must ensure that at all times competent and experienced staff are working in such numbers as appropriate to reflect the dependancy levels of the service users. There must be formal arrangements in place (bank staff) to cover shifts when staff become ill. the home must not just rely on calling in off duty staff if they were prepared to work. The gaps in the staff files must be explored and completed. All staff must receive regular supervision. The manager or the staff in charge of the home must give notice to the CSCI without delay of the occurance of any serious injury to service users, any event in which service users are adversley affected and any allegation of misconduct of staff. 25/10/05 25/10/05 25/10/05 Immediate 25/10/05 Immediatel 25/10/05 25/10/05 Immediate JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 25 15. 22 16,23 16. 17. 18. 19. 26, 38 19, 38 38 38 13,16 13 13 13 The home must provide an adequate number of hoists on each floor to meet the assessed needs of the service users. The home must increase the frequency of the collection of clinical and domestic waste. All corridors must be kept free from clutter ensuring easy access in emergencies. The two refrigerators in the kitchen must be replaced or repaired. The five yearly Electrical insulation must be completed. 25/10/05 Immediate Immediate 25/10/05 30/11/05 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. 2. 3. Refer to Standard 2 9 8 Good Practice Recommendations The terms and conditions of service users should be signed by both the service user and the management of the home. Care staff should understand the conditions of service users, the reason why they are taking medication and any side effects. The care staff should be encouraged to read and contribute to the individual service user plans. JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 26 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ 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 JASMIN COURT 20050819 SUI Jasmin Court X00015 Stage 4 S47893 V219897 J55.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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