Inspection on 14/08/07 for Jasmine

This inspection was carried out on 14th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but 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 12/09/06

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 Sue Jordan Key Unannounced Inspection 14th August 2007 10:00 Jasmine DS0000064033.V338626.R01.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.V338626.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 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.V338626.R01.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 stoke.enquiry@caretech-uk.com 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.V338626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2006 Brief Description of the Service: Jasmine is a care home for six people with a learning disability and/or mental ill health. It is run by Delam Care, a company owned by Caretech. The property is a detached Victorian property in Hanley, adjacent to two other care homes owned by the same company. The registered manager, Tracey Baddeley is also responsible for the two adjoining homes. The Home has a small back yard area and a small front garden and shares a laundry with the two adjacent care homes. The Home has six single bedrooms, a lounge, dining room and small domestic kitchen. Some of the people using the service attend college in term time. They also have the opportunity to go on holiday at their own cost. There are two care staff member on duty during the day and the aim is to provide service users with support, encouragement, supervision and monitoring in order to enable them to live as independent a life as possible. Some of the people using the service require more support. The home monitors, supports and encourages the people using the service to access appropriate health care facilities and to maintain their own personal care. They are also involved in a range of domestic and household tasks within the home. The fees range from £333-£463.50. The people using the service have to pay for their own holidays, contribute to the use of the minibus and buy their own toiletries. The organisation has been asked to look at this area and ensure that all parties are fully aware of what is and is not included in the fees. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and three quarter hours. This was a ‘key inspection’ and the core standards were assessed. The methodologies used were: A day of preparation before the inspection, including scrutiny of the Commission for Social Care Inspection Annual Quality Assurance Assessment completed and returned by the manager. During the visit, the inspector met and spoke to four of the people living in the home and discussions were held with the assistant manager and the support worker. Observations were made of staff and service user interaction and non-personal care tasks. The medication systems were checked and a walk round the home taken. Two residents’ care records were checked. The service users financial records were also checked. A staff recruitment file was examined together with the training records. A random selection of the Health and Safety and maintenance records were examined. The last Key Inspection was in September 2006. A short random inspection took place in February 2007. Five requirements and seven recommendations have been made as a result of this inspection. What the service does well: Health needs are closely monitored and the people using the service are supported to access the appropriate health professionals. Staff receive regular supervision and team meetings are held monthly. Regular mandatory training is provided on a regular basis. Regular meetings are held with the people using the service both in groups and individual sessions. They discuss a variety of relevant topics. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 6 Care plans and risk assessments are developed for all of the people using the service, which are regularly reviewed. The people using the service are encouraged to be as independent as possible. Staff recruitment procedures are robust and protect the people using the service. Protection of Vulnerable Adults and Criminal Records Bureau checks are carried out for all prospective staff members. There have been no complaints made about the service at Jasmine. The financial arrangements for the people using the service are safe and robust. Receipts are obtained for all purchases and the staff and residents sign against each transaction. The people using the service are able to choose how they spend their day. The people using the service have access to two seven-seater people carriers and have bus passes. Each person has their own bedroom and they are encouraged to personalise them. Keys to the house and bedroom are available if people choose to have them. What has improved since the last inspection? The manager has obtained the National Vocational Qualification 4 and Registered Managers Award. The complaints procedure has been developed in pictorial format to help the people using the service better understand it. The organisation has recently introduced the Person Centred Plan approach to care planning, which should further ensure individual needs and wishes are established and addressed. The organisation has set up a service user forum, which one of the residents has joined. The manager has recently been trained to deliver courses in the Protection of Vulnerable Adults. One bedroom has been redecorated and a new carpet fitted. Staff have recently had infection control training. The number of staff with appropriate National Vocational Qualifications has increased. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 7 Caretech had developed and implemented an auditing system and two audits took place at The Cedars in 2006. However there have been none in 2007. Medication training and assessments are now in place, ensuring that staff follow procedures that safeguard the people using the service. Protocols have been developed for medication prescribed ‘as required’. This makes sure that the staff administer this medication in agreed situations. The organisation obtains proof of identity for all new staff and keeps them on file. Staffing levels throughout the day have increased, which has improved the quality of lives for the people using the service. Support is available for them to access the community more readily. What they could do better: The manager must ensure that all items not included in the cost of fees are clearly listed in the contracts and Service Users Guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. All of the staff must be trained in the Protection of Vulnerable Adults, to ensure that they all know what to do in the event of an abusive situation or allegation. The organisation needs to formalise their Quality Assurance arrangements to ensure that the views of people using the service, staff and stakeholders are gathered, the results collated and a report as to any action required available. The Statement of Purpose and Service Users Guide should be developed in formats, which can be understood by the people using the service, to ensure that they have access to the information they may need. The information within the care plans should be updated to ensure that the staff have easy access to current information, which tells them how to meet the needs of the people using the service. More information is needed as to how staff should manage behavioural problems safely and consistently. Up to date the people using the service have been very reluctant to discuss death and any after death wishes they may have. The organisation has commited to continue working in this area, to ensure that individual wishes are known and followed at this very difficult time. Work is still required to improve the environment and the management need to consider redecoration and refurbishment of the Home as outlined in this Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 8 report, to ensure that the people using the service live in more pleasant and safe surroundings. Systems should be in place to control the risk of infection and consideration given to providing paper towels in the communal bathrooms, toilets, kitchen and laundry. The office door should be fitted with a closure that is connected to the fire alarm system. This will better enable safe and free passage throughout the Home. 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. The summary of this inspection report can be made available in other formats on request. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 9 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.V338626.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the Home, the service provided and the expectations and responsibilities of all parties is available to the people using the service in a standard format. Staff have the skills and ability to care for individuals admitted into the Home. EVIDENCE: The Home’s Statement of Purpose was reviewed and amended at the beginning of 2007. The organisation has plans to develop the Statement of Purpose and Service Users Guide into more accessible formats for the people using the service. This was agreed as being useful to ensure that all of the people using the service are able to understand their rights and responsibilities. However, regular meetings are held with the people using the service where they discuss issues such as the running of the Home, trips out and activities. Two of the people using the service decline to attend these meetings, but the assistant manager makes sure that they are informed of the discussions. The Statement of Purpose lists the services included in the fees and those not covered. However, the manager needs to revisit these lists to ensure that all items are listed. For example, the people using the service pay Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 11 for their holidays and for the accommodation used by the accompanying staff. This is not listed. This information should also be included in the contracts. The manager is aware that the present contracts also need amending to reflect the fact that Caretech now owns the Home. Before people are admitted into the Home, their needs are carefully assessed and the Home receives the required information from the referring agencies to ensure that they can meet the person’s needs. The manager also undertakes an assessment and writes to the referring agency to confirm that the Home is able to meet the person’s needs. The present residents have lived at Jasmine for many years. The people using the service predominately have mental health needs and/or a learning disability. Organisational training is available in mental health awareness and new staff completed a Learning Disability Awards Framework induction. The people using the service are also supported to attend outpatients’ specialist appointments with various mental and physical health services. Two of the people using the service have diabetes and one is a vegetarian. Their dietary needs are catered for. The care plans contain comprehensive details about the individual mental health difficulties, including information for staff as to how they are to be assisted and addressed. Many of the organisational and Home’s documentation could be adapted to be more easily understood by the people using the service, including the Statement of Purpose, Service Users Guide, menus and vital procedures. This could include pictures, photographs, symbols or written in a more easy to understand manner. The organisation has recently developed a more ‘user friendly’ complaints procedure. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has systems in place that allow the people using the service the opportunity to make their views known and join in any decision-making. Information is available for staff regarding the needs of the people using the service, however it is not always kept up to date. EVIDENCE: The care records for two of the people using the service were checked. Care plans and risk assessments are in place for all aspects of the person’s life and they are regularly reviewed. It was noted that although the care plans have been reviewed the initial information is out of date and it is recommended that this be updated to ensure that the staff have access to current information about the people using the service. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 13 It is recommended that more information be available for staff as to how to manage any challenging behaviours. There is ample evidence that the Home obtains support from the appropriate professionals regarding behavioural difficulties and record any incidents, but this should be supported by management plans for staff. This will ensure a consistent approach and that behaviours are managed safely for staff and the people using the service. The organisation has just introduced Person Centred Planning. Following the completion of individual plans the people using the service will invite significant people to meet with them to discuss their ideals and wishes and formulate an action plan. The plans are at various stages in Jasmine, some are nearly ready to plan their meeting. All of the people using the service are assisted with their finances, although they are encouraged to maintain their independence as far as is possible. An inventory clearly shows what belongs to each individual person using the service. Regular meetings are held with the people using the service at which they discuss a variety of topics, including activities and holidays. Each person using the service has a monthly one to one session with a member of staff, where they can discuss any concerns or just discuss day-today issues. It was evident during this visit that people using the service are generally able to choose how to spend their day; two attend college in term time, whilst others are supported by the staff to go into the community. Most of the people living at Jasmine require support from staff and therefore there are two staff on duty during the day. The staff are trying to find new activities for one of the people using the service. Some of the people using the service help with meal preparation and tasks around the house. Limitations to this are recorded in the care plans and risk assessments. The menus are devised with the people using the service prior to the weekly shopping day. An alternative is available for the vegetarian. None of the people living at Jasmine have been involved in staff interviews, although the organisation is planning to explore this. The organisation is setting up a service user forum to which, one of the people living at Jasmine is to attend. The Person Centred Plan process will further enable the people using the service to be involved in decision making. The introduction of ‘user friendly’ documentation will assist the people using the service to make more informed choices and decisions. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisational ethos promotes independence and the right to live in a flexible environment where the residents’ choice of routines are acknowledged and respected. The people using the service are able to go out more frequently since there has been an increase in staff support during the day. EVIDENCE: Five of the six people living at Jasmine have recently been on holiday to Blackpool. They were accompanied by three members of staff. The person choosing not to go, went to visit family. All of the people using the service regularly access Hanley town centre, which is close by, although most require support from staff. As a result there are two members of staff on duty during the day. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 15 Two people go to college during term time. The Home is actively looking for alternative activities for one person, such as possible attendance at a day centre. The staff are now recording the daily activities. The people living in Jasmine are encouraged to be involved in keeping their home clean, but this varies and depends on their abilities. The organisation has the use of two 7 seater people carriers and each person has a bus pass. All people using the service are on the electoral register and have the opportunity should they so wish, to cast their votes in local and national elections. Some of the people using the service have regular contact with their family. Friendships and relationships have formed in the Home and with some of the residents in the other Homes. Each person using the service has their own bedroom if they wish to spend time alone. Keys are available to the people using the service. Staff confirmed that the budget allows them to buy good guality food. The people using the service accompany staff to any of the local supermarkets. Two people have a diabetic diet and one is a vegetarian. The organisation provides food and hygiene training. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services have access to healthcare and remedial services and staff assist them to attend appointments and visit local health care services. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. EVIDENCE: Some of the people living at Jasmine require support with their personal care and this is indicated within their care plans. There is ample recorded evidence that the health of people using the service is monitored and the appropriate medical, professional services accessed. All of the people using the service are registered with a general practitioner and are they supported in making appointments and if necessary attending those appointments. All have six monthly medication reviews. All of the people using the service are encouraged and supported to attend Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 17 dental, chiropody and optician appointments for check ups and treatments. People using the service are supported in attending outpatients specialist appointments e.g. psychiatry, psychology and mental health services, dermatology, rheumatology, physiotherapy. Some residents are in receipt of Community Care Approach reviews. Two people attend diabetic clinics. The medication systems and procedures were checked. Medication is appropriately stored and stock control is monitored. Records are kept of all medication brought into the Home or returned to the pharmacist. The administration records are well maintained and no errors or gaps were seen during this inspection. Protocols have been developed for all PRN medication and explanations as to the reason and effects of medication are available for staff. These have not however been signed by the general practitioner. The staff at Jasmine have received ‘in-house’ medication training and their continuing competency will be checked every six months. The assistant manager has undertaken the indepth ‘Safe Handling of Medicines’ course. It is hoped that all staff will receive this training. Up to date the people using the service have been very reluctant to discuss death and any after death wishes they may have. The organisation has commited to continue working in this area, to ensure that individual wishes are known and followed at this very difficult time. This was evident and seen to be recorded for one person using the service during this inspection. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been no complaints about this service and the people using the service have opportunities to express their concerns. Some staff have had training around Safeguarding Adults but others have not and more information is needed for staff as to how difficult behaviours should be managed safely. EVIDENCE: There have been no complaints made about this service to the Commission for Social Care Inspection. A new complaints procedure in pictorial format has been developed and this has been discussed at one of the meetings with the people using the service. The people using the service have opportunity to express their concerns during regular meetings or within their monthly one to one sessions with staff. The Home has recently obtained the new ‘Safe Guarding’ policies. The organisation undertakes Protection of Vulnerable Adults and Criminal Records Bureau checks on all prospective staff. The financial procedures were checked and the records and monies tallied. The people using the service and the staff member sign all transactions and receipts are obtained. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 19 Some, but not all staff have been trained in Adult Abuse and the procedures to follow in the event of an allegation or suspicion of an abusive situation. More training is being planned. The manager is trained to provide this training. Staff undertaking Learning Disability Awards Framework and National Vocational Qualification training will cover the area of adult abuse in basic detail. Some staff have attended training in the management of challenging behaviour and more training is being planned. More work is needed to ensure that management plans are in place for people experiencing behavioural difficulties. An advocate was obtained to assist one person using the service in making some difficult decisions. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable but some areas have not been decorated for many years and although there is a programme to improve the decoration, fixtures and fittings, maintenance tends to be reactive rather than proactive. The staff endeavour to keep the Home clean however this is made difficult by the dated decoration and furnishings. EVIDENCE: Jasmine is a large Victorian house, close to Hanley city centre. All of the people using the service have their own bedroom, although none have en-suite facilities. Each has a wash hand basin. The people using the service are encouraged to personalise their rooms, all of which are lockable. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 21 There is an upstairs bathroom and separate toilet and a downstairs bathroom. An additional separate toilet is situated downstairs. A small office/staff ‘sleeping in’ room is provided on the first floor. The people using the service have the use of a communal lounge, a dining room and there is a small ‘domestic’ kitchen. Jasmine shares a laundry facility with an adjacent Home belonging to the same organisation. Externally the home has a small front garden and a rear yard. The rear yard could potentially be a pleasant area for people using the service to sit in the summer. The rear yard is quite uneven and slippery in the wet weather. The Home is comfortable and domestic in style but does need redecoration and refurbishment in most areas. Some of the decoration and furnishings are very dated. One of the bedrooms has been repainted and a new carpet fitted. The dining room chairs have been reupholstered. Shelving has been provided in the cellar and additional sockets added in two bedrooms. The central heating pipes have been covered. The bathrooms and toilets are in desperate need of refurbishment and redecoration. The bath panel in the downstairs bathroom is cracked and unsafe. It could cause an injury to the people using the service. The flooring in the upstairs toilet is not impermeable and hygiene standards cannot be maintained. There is a large crack in the lounge ceiling. The kitchen needs upgrading and the fridge and freezer are not working properly. The temperatures are too variable and do not provide a constant safe environment for food storage. The manager has requested a new cooker. The staff and residents do a good job in maintaining cleanliness in the Home, although it is recommended that together with the liquid soap, paper towels are provided in the communal bathrooms, kitchen and laundry to maintain infection control. Staff have recently received infection control training. The Fire Safety Officer visited the Home in April 2006 and the organisation was required to make a number of improvements. He visited again in November and confirmed that they had been completed. The environmental health officer has not visited the Home recently. The organisation recognises the improvements needed to the environment and have developed an action plan for 2007. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service recognises the importance of effective recruitment procedures in the delivery of good quality services and for the protection of the people using the service. The increased staffing levels during the day have improved the quality of life of the people using the service. EVIDENCE: Two staff are available to the people using the service during the day, which has improved their quality of life. Most people require the support of staff to access the community and this is now more readily available. People using the service are able to stay at home with the support of a staff member if they do not wish to join others on a trip out. The Home does not use agency staff and the staff attend monthly team meetings and receive monthly supervision. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 23 Six staff are employed at the home, three of which have National Vocational Qualification 2 or above. The assistant manager is undertaking the Registered Managers Award. As an organisation, Caretech provides a range of training courses and the staff also attend some arranged by the Local Authority. The training records of the staff employed at Jasmine were checked and mandatory training is mainly up to date. The staff member on duty said that the training opportunities are very good. The organisation has introduced the Learning Disability Awards Framework award as part of the staff induction. The file of a recent member of staff was checked. The organisation obtains Protection of Vulnerable Adults checks before people work in the Home and Criminal Records Bureau checks are also undertaken. Two references are sought and the file contains all of the required elements. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 24 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. 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 organisation is improving and developing systems that monitor practice and compliance, although more work is needed in this area. The manager is qualified and has the necessary experience to run the Home. Improvements have been made to fire safety arrangements. EVIDENCE: The manager, Tracey Baddeley has recently completed the National Vocational Qualification 4/Registered Managers Award. She is the registered manager of three homes in close proximity. Jasmine is managed on a daily basis by the Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 25 assistant manager, Lindsay Salt, who has National Vocational Qualification 3 and is currently undertaking the Registered Managers Award. The fire safety officer visited Jasmine in May 2006 and made a number of requirements. These have been addressed. Caretech has developed generic risk assessments. The manager and assistant check them and add additional, specific information if needed. A random selection of the maintenance records were checked, which confirmed that fire safety, electric and gas provision are afforded the appropriate priority. The office door is still being propped open, although only staff are working in there. It is however strongly recommended that the office door be fitted with closures, which is connected to the fire alarm system. The area manager visits the Home on a monthly basis to monitor the quality of the service provided. The people using the service regularly meet as a group and in one-to-one sessions with the staff. The organisation does not use surveys or questionnaires to gather people’s views. Daily checks are made to check the cleanliness of the Home. Staff receive regular supervision and attend monthly meetings. Caretech had implemented a quality audit system and Jasmine had two audits in 2006. They were given a score, which improved at the second visit. There has not been an audit in 2007. The manager completed the Commission for Social Care Inspection Annual Quality Assurance Assessment document prior to the inspection. The organisation is planning to implement a new Quality Assurance system and an appointment has been made for the new regional Quality Assurance manager to visit Jasmine in September. A forum has been set up for the people using the services in Hanley. Jasmine sent a representative and they held their first meeting on 02/08/07. Caretech has the Investors in People award. Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 26 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 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 3 X Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 27 No 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 YA5 Regulation 5 (1b) Requirement The manager must ensure that all items not included in the cost of fees are clearly listed in the contracts and Service Users Guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. The ground floor bathroom must be refurbished to provide a more suitable and safe environment for the people using the service. Timescale for action 10/10/07 2. YA24 23(2)(d) 01/11/07 3. YA24 12 (1a) 16 (2g, h, j) 16 (2j) 12 (1a) 4. YA30 5. YA39 24 Food must be stored at safe 01/10/07 temperatures to ensure the health of the people using the service. Environmental improvements 01/11/07 must be made to ensure a high standard of hygiene and therefore safeguard the people using the service. The organisation needs to 01/11/07 formalise their Quality Assurance arrangements to ensure that the views of people using the service, staff and stakeholders are gathered, the results collated DS0000064033.V338626.R01.S.doc Version 5.2 Page 28 Jasmine and a report as to any action required available. 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 YA1 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be developed in formats, which can be understood by the people using the service, to ensure that they have access to the information they may need. Care plans should be amended when changes occur to ensure that the staff have access to current information about the people using the service. It is recommended that the protocols for ‘as required’ medication be signed by the prescriber. The manager must ensure that all staff are trained how to recognise and respond to potential abusive situations. To consider total redecoration and refurbishment of the Home to ensure that the people using the service live in more pleasant surroundings. Systems should be in place to control the risk of infection, including paper towels in the communal bathrooms, toilets, kitchen and laundry and washable flooring in the bathrooms and toilets. The office door should be fitted with a closure that is connected to the fire alarm system. 2. 3. 4. 5. 6. YA6 YA20 YA23 YA24 YA30 7. YA42 Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ 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 Jasmine DS0000064033.V338626.R01.S.doc Version 5.2 Page 30 - 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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