Inspection on 12/09/06 for Jasmine

This inspection was carried out on 12th September 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jasmine 08/10/09

Jasmine 14/08/07

Jasmine 03/01/06

Jasmine 29/06/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Jasmine 125 Regent Road Hanley Stoke on Trent Staffordshire ST1 3BL Lead Inspector Key Unannounced Inspection 12 September 2006 9:00 Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 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 Jasmine DS0000064033.V311684.R02.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 Adults 18-65. 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. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jasmine Address 125 Regent Road Hanley Stoke on Trent Staffordshire ST1 3BL 01782 208590 01782 269187 chris@delamcare.co.uk 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) Delam Care Ltd Miss Tracy Anne Baddeley Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: Jasmine is a six bedded unit providing long term care services to residents with a learning disability who may also have mental ill health. The emphasis of the care is on providing support, supervision and monitoring. The residents assist with a range of household tasks associated with running a home including keeping their bedroom tidy, food preparation and shopping. The home is one of six homes in the neighbourhood owned by the same company, Delamcare, that provides services to the same category of users. Delam Care is owned by Care Tech. The homes have close links with each other. The care manager of Jasmine also has responsibility for two other neighbouring six bedded homes. The homes premises are in a Victorian detached house that provides single bedded accommodation on the ground and first floor. The home has no off road parking and has a small front garden area, a side garden and a small rear yard. The homes staffing level allows one staff member on duty throughout the day and two for periods during the day. One staff member sleeps at the home overnight. Residents have the opportunity to attend college several sessions a week and there are some activities organised. The residents have the opportunity to go on holiday and they fund this themselves. The current fees are between £325 -£425. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a two day period and lasted approximately hours. All the residents were present at the home during the first day of the inspection. The inspection focussed on the residents’ experiences of living at the home and discussions took place with five of residents. A discussion was held with the staff member on duty. The inspection included examining a sample of residents’ support plans, looking at the procedures and practices for safeguarding residents’ finances and administering medication. The inspection also included looking at a sample of the residents’ accommodation and looking at all the communal areas. The recruitment procedures were inspected as well as the training provided to the staff. The home’s arrangements for assessing the quality of the service to residents were also looked at. Health and safety practices were also considered. A pre inspection survey took place. Replies were received from all of the residents who had been assisted in their completion by a staff member and from one relative. An additional visit took place in March 2006 to follow up on previous requirements. This confirmed that the home had met all the requirements. What the service does well: The resident said they liked living at the home. Comments by residents included: ‘ I like living here’, ‘I like the staff’, I love my bedroom’ and ‘I enjoy the holidays’. Residents’ personal care and health care needs were met. Residents reported that they received general and psychiatric health care screening and treatment and were supported to attend the GP, dentist and the optician. Residents with diabetes were supported to attend the diabetic clinic. The home responded to residents’ sensory needs ensuring that health assessments were completed and that specialist equipment was provided. The residents said that staff provided any support and assistance they needed with their personal care and stated that they could have baths and showers when they wished. Staff supported residents with hair washing and all confirmed that they had their haircut and styled. Nail care was attended to and those that required attended the chiropodist. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 6 Residents took part in aspects of running the home. Residents said that they had weekly menu meetings, a few went with staff to do the weekly shop and all helped to keep their bedroom clean. Residents also helped to lay the table, wash up and help make the meals. The home’s routines were quite flexible. Residents said they could get up and go to bed when they wanted and could choose to sit in the lounge or in their bedrooms. One resident who chose to spend time in her bedroom stated ‘ I love being in my bedroom and that’s ok here’. Residents were happy with the accommodation. There was a comfortable lounge and a separate dining room. Residents liked their bedroom and they had made them their own with photographs, ornaments and personal items. All bedrooms had locks fitted. What has improved since the last inspection? What they could do better: The home was meeting most of the standards however there were areas that needed to be addressed. The home was required to ensure that there was always sufficient staff on duty to meet the full needs of the residents. The home also was required to increase the opportunities for activities both in and out of the home to provide residents with a varied and fulfilling lifestyle. The home’s recruitment and selection needed to ensure that staff’s identity was checked. The home needed to provide appropriate training in medication for all staff that administer medication and to provide all staff with training in infection control, adult protection and working with people, with challenging behaviour. A number of recommendations were also made that would improve the service to the residents. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 7 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. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure ensures that an assessment takes place identifying the needs of the residents. Residents are provided with contracts that show their rights and responsibilities. EVIDENCE: The home had a Statement of Purpose and a service user guide that described the service provided. Residents confirmed that they had been given a copy of the service user guide. Examination of residents’ files showed that residents had been provided with a contract and that had been signed by the residents. Discussions with residents confirmed that they were aware of their rights and responsibilities. There have been no admissions to the home for over a year. However examination of the most recently admitted resident’s care documentation confirmed that an assessment of prospective residents was taking place both by the home and by the local authority. The assessment covered the areas of health and personal care, accommodation, education and occupational needs and spiritual needs. The assessment formed the basis of the support plan. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The support planning process identified the residents’ needs and included them in the review process although these would be improved through using person centred planning. Residents were encouraged to make decisions over their daily lives and had the opportunity to participate in a number of activities relating to the running of the home although there was scope for further development in this area. EVIDENCE: A sample of resident support plans were examined and these showed that the home had identified the needs of the residents and the actions needed to meet the needs. Support plans covered residents’ health and personal care needs, their educational and domestic needs as well as any spiritual needs. Plans also covered any needs relating to budgeting their finances. Records seen showed that each element of the plan was being evaluated on a regular basis. A discussion with a resident confirmed that information was accurate and that meetings were held with their key worker to review the information. There was evidence in files that behavioural plans had been put in place to deal with any potential aggression. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 11 Currently they were some issues relating to the level of support required for two residents and although the home had requested local authority reassessments the outcome was still awaited. The home had plans to put support plans in a more user-friendly format and using person centred principles. Sampling of support plans showed that a range of individual risk assessments had been developed and these were up to date and had been reviewed. There was a need for some development to identify the assessment process that had taken place to identify the level of risk in for example the use of kettles in bedrooms. Residents confirmed both in the pre inspection survey and through conversations during the inspection that their views were sought through having regular resident meetings. They reported that they discussed menus, activities and any problems or concerns they had. All residents stated that they took part in activities relating to the running of the home including meal preparation such as laying and clearing the table, washing up, making drinks, and keeping the home clean and tidy. Some residents said they went with staff to do the weekly food shopping and several said they went to the local shop to buy bread and milk. Residents said that they discussed where they went on holiday. There was scope for further participation in such areas as staff recruitment. The home encouraged residents to make decisions over their life. Residents said that they decided when they got up and went to bed and whether they spent time in their bedrooms or in the communal areas. Those that were able went out either independently or with another resident shopping or visiting friends when they wished. Residents decided whether to take part in any activities or to go on any day trips. The support plans identified the support residents needed to manage their finances. The company was the appointee for five of the residents. Residents confirmed that staff had discussed with them methods to manage money including plans to save money for holidays and activities. One resident confirmed that they had requested to have all of their personal allowance every week and this had occurred although the staff were monitoring how this was working. The home looked after the money of the other residents and kept appropriate records of expenditure. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided opportunities for residents to go on holiday and to take part in some day trips but needed to provide more opportunities for residents to regularly engage in activities in the home and in the community to provide them with a more varied and interesting lifestyle. The home had relaxed routines enabling residents to make choices over their daily lifestyle. The meals within the home were varied but the home is recommended to ensure that residents were aware there was always an alternative and that a sweet was available at lunchtime. EVIDENCE: At the time of the inspection no residents were undertaking any educational activities as they were waiting to see the college could offer what courses. The home does have a good history of supporting residents to attend college courses. Several of the residents were keen to go to college and were hoping that they would be able to start attending soon. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 13 The home had supported one resident to be assessed for a work placement but unfortunately this had not led to employment. The residents accessed a number of community resources including health services and leisure resources. The residents regularly accessed Hanley shopping centre, local shops and occasionally went to the theatre and out for meals. Residents had recently obtained bus passes making it easier to go to shopping. The residents had access to a people carrier for which they pay £18 a month. The residents said that they had been on trips during the summer and they had enjoyed these with comments made such as ‘I like the holidays, day trips and parties’. They had been to Llandudno, a safari park and to Manchester United football ground. Additionally the home had organised a disco and one resident had been to a pop concert and the home had organised a BBQ. The residents did state that they sometimes took part in activities in the home such as baking and sewing. Several of the residents said that they really enjoyed baking and wished to do it more often. Within the daily records there were few activities recorded and the records made showed that the last activity in the home took place over a month ago. The residents had been on holiday to Blackpool. The residents pay for this themselves. The residents said they had gone with the two adjoining care homes and had really enjoyed it. The residents were supported to develop friendships within the home and with residents in adjoining home. Several residents said that they visited their friends on a regular basis. One resident was observed going to visit friends in the house next door during the inspection and stated that they went nearly every day. Another resident said that she enjoyed visiting residents in the Poplars, the care home next door. Two residents said that they had recently become engaged and to celebrate had gone out for a meal. Residents said that they visited family members or family visited them at the home and one resident said that a relative visited every week. The relative that responded to the pre inspection survey felt welcomed when visiting the home and was kept informed of important issues. Residents spoken to stated that the home’s routines were quite relaxed. Comments included ‘we get up when we want and get our own breakfast’, ‘I visit friends when I want’ and ‘ I love to spend a lot of time in my bedroom and that’s ok’. Bedrooms were lockable and those that wished kept them locked. Residents said that they were involved in planning the menus. The main meal was held in the early evening and on the day of the inspection the menu stated that it was steak with potatoes and vegetables followed by chocolate sponge. Residents generally said that they liked the meals and that there was always fruit available although they would sometimes have preferred a wider range of fruit including for example melon. This was raised with the staff member on duty. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 14 A resident that had a vegetarian diet said that there was always a vegetarian meal available. A concern was raised by one resident who felt that the evening meal did not always meet their health needs and would have preferred an alternative. It was also noted that there was no sweet identified at lunchtime. These issues were raised with the staff member on duty. The residents confirmed that the home monitored their weight through regular weighing. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was meeting the health and personal care needs of the residents. Medication needs were being met although the home needed to ensure that all staff received appropriate medication training. EVIDENCE: Examination of support plans showed that residents’ health and personal care needs were identified and that plans were in place to meet the needs. Residents stated that the staff helped them to have their personal care needs met. Most of the residents did not require practical care but needed prompting and monitoring. A resident spoken to said that she did not need support to bath and shower but staff helped her to wash her hair. The residents said that they could have a bath or a shower whenever they wanted. Observation showed that residents’ hair was clean and tidy and that residents were receiving nail care. A resident spoken said she went to the chiropodist and the records confirmed that residents had regular chiropody appointments. Residents choose their own clothes and either went shopping independently or with staff support. Residents said they all had a key worker and were able to identify who this was. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 16 Residents were receiving support to have their health care needs met. The residents reported in the pre inspection questionnaire that they all went to the doctor. The home supported residents to attend the dentist although one spoken to said that he did not wish to go although staff had tried to persuade him. Records conformed that residents accessed a range of specialist health care services including from the psychiatric services and the learning disability services. A resident with a sensory impairments stated that she regularly attended for visual and audiologist appointments and was due to receive specialist visual aids to help with watching the television. She also had a watch with a large clear face. She also confirmed that the home had regular supplies of batteries for hearing aids. Examination of records and a discussion with the staff member on duty confirmed that the staff were alert to changes in residents general and mental health and recent healthcare needs of two residents were being addressed through the involvement of specialist healthcare staff. The home had a medication procedure in place and the staff member on duty confirmed that she had been shown how to do medication by a senior staff member and had been observed by senior staff prior to administering medication. Staff training records showed that most staff had completed appropriate medication training. The medication was kept securely, locked in a cupboard in the office. Examination of three residents’ medication showed that medication was being administered as prescribed. There were no gaps in medication administration records. No residents self medicated. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a complaints procedure in place and residents were confident that any issues they raised would be addressed. The home had a procedure in place for the protection of the residents but residents would have greater protection if all staff had received training in this area. EVIDENCE: The complaints procedure was seen in the hallway but this was not in a user friendly format. Discussions with residents and comments made on the pre inspection survey confirmed that they felt able to raise issues with the staff and that the staff listened to them and that any concerns they raised would be addressed. Comments made included ‘the manager is brilliant. She listens to our problems’ and ‘ If I have a problem I go to the manager and she sorts it’. Residents and records confirmed that regular resident meetings were held and issues of concern were raised there. A relative confirmed that they were aware of the complaints procedure. The home involved advocates to support residents when necessary. No complaints had been received by CSCI since the last inspection. The residents stated that they felt safe at the home. The home had a protection of adult procedure and the company offered staff training in signs and symptoms of abuse. Examination of the records and discussions showed that some staff had not yet received this training. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided residents with suitable accommodation having bedrooms that provided privacy and communal areas that were comfortable and domestic in style. The home provided residents with a clean and hygienic environment. EVIDENCE: The home was adequately furnished and decorated in a domestic style. The home had a plan for maintenance and upgrading and since the last inspection some areas had been decorated. All bedrooms were for single occupancy and had washbasin. They provided suitable accommodation. All bedrooms provided residents with privacy having locks and several residents decided to use these. Bedrooms provided adequate furniture providing seating and storage. One bedroom was not carpeted although did have adequate flooring. Carpeting would make the room more homely. Bedrooms were well personalised with residents having a range of belongings including furniture, ornaments, and photos. Comments from residents included ‘I like my bedroom’ and ‘It’s warm at night, cosy and the bed’s comfy’. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 19 The home had suitable communal rooms. There was a lounge that was homely and provided residents with a pleasant place to sit. The home had a separate dining room and a domestic style kitchen. Externally there was a rear yard with provision for seating and a garden area at the side. The home had adequate toilet and bathing facilities. These were all lockable. Upstairs there was a separate toilet and very deep bath that was not suitable for some residents. However downstairs there was a separate toilet and bath with shower over. The latter would benefit from being decorated and upgraded. The home was clean and tidy throughout. The home had cleaning schedules in place. The home had procedures in place for the control of infections and staff had received some training as part of their induction although additional training should be provided. The home had a small laundry that was shared with the adjoining care homes. This was adequate to meet the laundry needs of the home. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents were positive about staff and staff were aware of residents’ needs the home needed to ensure adequate staff were on duty at all times to meet the full needs of the residents. The home provided staff with training to meet residents’ needs but there was cope for increased relevant training and there was an increase in the number of qualified staff. The home’s recruitment and selection procedures were safeguarding the residents by seeking pre employment check but would be increased by ensuring that staff’s identifies were confirmed and applications properly completed. All staff receive support to do their work. EVIDENCE: The home identified in its pre inspection questionnaire that it had a staffing level of 150 hours a week. This level would enable two staff to be in duty for most part of the day and one staff sleeping in at the home. This level of staffing would be suitable to meet the full needs of the residents. However an examination of the rosters showed that this level of staffing had not been consistently provided at the home for the previous two weeks although rosters for the following two weeks did show increased staffing levels. On the day of the inspection there was one staff member on duty that was not sufficient to meet the full needs of the residents. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 21 A low level of staffing was enabling residents’ basic needs to be met but was not able to support them to have a full and varied lifestyle. This issue was subsequently raised with a senior manager and the home confirmed that it would provide the necessary staffing to meet the full needs of the residents. The home also confirmed that it was aware of the issue and had referred two residents for a reassessment some time ago due to an increase in their level of needs. The staff member on duty had been working at the home for approximately a year and was aware of the residents’ needs. She had undertaken induction training and Learning Disability Framework training and was due to do the NVQ level 2 qualification. She had received training in mental health awareness. She was observed to be approachable and had a positive attitude towards the residents. Residents made positive comments about staff feeling them to be quite supportive. Comments included ‘I like the staff’, and one resident when talking about her key worker said ‘She’s nice. She takes me shopping and once we did baking’. The home maintained a training matrix to identify training that staff needed and had completed. All staff had received induction training and of the three main staff members one had obtained NVQ level 2. Whilst staff were receiving training staff should receive training in working with people who display challenging behaviour. The home operated the company’s recruitment and selection procedures. Sampling of personnel files confirmed that the home obtained two references and a POVA and Criminal Records Bureau check. All prospective staff completed a health check. Records examined did not contain confirmation of staff’s identifies and one did not have properly completed application form. The home provided staff with support to undertaker their role. Individual supervision was being provided and the home had staff meetings. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a home that is suitably managed. The home’s health and safety procedures are safeguarding the residents. The home monitors and reviews the service but there is scope for this to be further developed and to include a plan to improve the service. EVIDENCE: The Care Manager had the necessary knowledge, experience and qualifications to effectively manage the home. She also undertook periodic training to ensure she kept up to date with current practices. The home has some quality assurance systems in place to review and monitor the service. This included resident meetings, resident questionnaires and monitoring of support plans. There were also procedures in place to monitor the environment including the cleanliness of the home. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 23 There was scope for the systems to be further developed to include the views of significant others and to develop a business plan. The home did confirm that this was planned to occur. The home had health and safety procedures in place. The home had undertaken the necessary servicing. The home had a current gas safety certificate and electrical installation check. The fire safety checks were completed including regular testing of the fire alarm and emergency lighting. The home had an evacuation plan and the fire risk assessment was being updated. Fire drills were undertaken regularly. The home was undertaking checks on water temperatures and the temperature of fridges and freezers was being completed. The home was maintaining a record of accidents. The staff had undertaken most of the required health and safety training including fire safety, food hygiene and first aid. All staff had undertaken basic infection control as part of induction but there was a need for more comprehensive training. The home had a procedure for the safe storage and handling of COSHH products. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 25 Yes 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 YA14 Regulation Requirement Timescale for action 21/10/06 16(2)(m)&(n) To increase the level of social and leisure activities both within and out the home. 13(2) & 18(1)(c) 18(1) 19 Schedule 2 18(1)(c) To ensure that all staff receive appropriate training in medication To ensure that there is always sufficient staff on duty To ensure that the identity of staff are confirmed. To provide staff with training in infection control, working with people with difficult behaviour and adult protection. 2. 3. 4. 5. YA20 01/11/06 13/09/06 21/10/06 01/01/07 YA33 YA34 YA35 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 YA6 Good Practice Recommendations To develop plans in line with the principles of person centred planning. Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 26 2. 3. 4. 5. 6. 7. 8. 9. YA22 YA8 YA9 YA39 YA17 YA17 YA24 YA24 To develop procedures in user friendly formats e.g. complaints procedure. To develop increased opportunities for residents’ participation in the running of the home for example in staff recruitment. To develop the risk assessments to show the assessment process taken to identify the level of risk in for example the use of kettles To further develop the quality assurance system. To ensure that residents are aware of alternatives available and that a sweet is available at lunchtime. To consider providing a wider range of fruit. To have a carpet in the identified bedroom To decorate/upgrade the downstairs bathroom Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Jasmine DS0000064033.V311684.R02.S.doc Version 5.2 Page 28 - 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. 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