Inspection on 31/01/07 for Jasmine House

This inspection was carried out on 31st January 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jasmine House 28/02/08

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

CARE HOME ADULTS 18-65 Jasmine House 48 Radnor Road Handsworth Birmingham West Midlands B20 3SR Lead Inspector Brenda O’Neill Key Unannounced Inspection 31st January 2007 09:25 Jasmine House DS0000068337.V328136.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 House DS0000068337.V328136.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 House DS0000068337.V328136.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jasmine House Address 48 Radnor Road Handsworth Birmingham West Midlands B20 3SR 0121 551 4326 0121 551 4326 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) Mrs Maudlyn Smiley Mrs Maudlyn Smiley Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can care for five named service users over 65 years of age which is outside the category of registration (5 MD (E)). The home must ensure that the changing care needs of the older service users can be met, these care needs remain under regular review. Date of last inspection Brief Description of the Service: Jasmine House offers a residential service to 8 adults who are users of mental health services. Some residents also have additional needs relating to medical conditions that restrict mobility and the home is currently able to meet these additional needs. The home is situated in a popular, residential area, and the home is not distinguishable from other houses in the road. The home benefits from being close to a range of services including a GP, shops, chemist and public transport. The property has three storeys. On the ground floor there are two en-suite bedrooms and a single bedroom, a formal lounge, lounge/diner, kitchen, combined toilet/shower, and conservatory. The laundry is housed externally in an outhouse/garage. The first floor has 4 bedrooms; 1 single, 2 en-suite singles and 1 en-suite double there is also a communal bathroom and a small manager’s office. The second floor is used for staff accommodation. At the rear of the property is a well-maintained garden. To the front of the building is off road parking and a ramp with handrail, by which you obtain access to the home. The homes range of charges is currently £326.44 to £418.00 per week. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Jasmine House was formerly known as Ashleigh House. Due to some issues being raised that are being investigated by a body external to the Commission the home was re-registered under the new name with the former manager as the owner/manager. One inspector carried out this key inspection over one day in January 2007. During the course of the inspection a tour of the premises was undertaken, two resident and two staff files were sampled as well as other care and health and safety records. The inspector spoke with the manager, two members of staff and four of the six residents. The pre inspection questionnaire had not been returned to the Commission prior to the inspection but the manager gave it to the inspector during the inspection. This was partially completed and included additional information about the home. There had been no complaints logged at the home since it was registered and none had been lodged with the CSCI. What the service does well: The manager had undertaken a full reassessment of the residents’ needs. The files sampled included an assessment of daily living needs. These assessments had been used to inform the care plans. There were some good details included in the care plans of the preferred daily routines of the residents, what their dietary requirements were, how they kept in contact with their families and any health care needs. Residents were enabled and encouraged to make decisions about their lives on an ongoing basis. Residents were involved in meaningful daytime activities and were part of the local community. Contact with families and friends was supported and encouraged. There was a very detailed food diary being kept at the home. It was obvious from this that residents had an extremely varied diet that met their cultural and the majority of their medical dietary needs. All the residents spoken with were very satisfied with the food served to them. Residents’ personal and health care needs were met with the input of the appropriate health care professionals. The medication system was well managed and ensured residents received their medication as prescribed. There were adequate numbers of appropriately trained staff on duty to meet the needs of the residents. Staff spoken with had a good knowledge of the Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 6 residents needs and there were good relationships between them. Residents spoken with were very positive about the staff team and they were very comfortable in their presence. The recruitment procedures at the home were robust and safeguarded the residents. The home was safe, comfortable and well maintained. Residents said they were comfortable at the home and quite satisfied with their bedrooms. The manager of the home had a lot of experience of caring for people with mental health needs and the running of a residential home. She was appropriately qualified for the post of registered manager. Relationships between the manager residents and staff were very good and the inspector was left with no doubt that the home was run in the best interests of the residents. What has improved since the last inspection? What they could do better: Care plans needed to detail all the identified needs of the residents and how these were to be met by staff. There needed to be evidence that either residents or their representatives had been involved in drawing up the care plans. The manager needed to ensure there were risk assessments in place for any identified risks in relation to the residents. These needed to include details of how staff are to minimise the risks to ensure the residents were safe guarded. Where residents were to follow specific diets for medical reasons details of these needed to be included in the individual care plans or on separate management plans to ensure staff were aware of these. The manager needed to ensure that the adult protection procedures complied with the multi agency guidelines so that staff had all the correct information. Staff needed to undertake induction training as specified by Skills for Care and within the given time scales to ensure they were equipped with all the necessary skills and knowledge to fulfil their roles. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 7 The home must have in place a quality monitoring system based on seeking the views of the residents with a view to continuous improvement. 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 House DS0000068337.V328136.R01.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 House DS0000068337.V328136.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was some information available for prospective residents to help them make a decision as to whether the home was suitable for them. Residents ongoing needs had been assessed to ensure the home could continue to care for them. EVIDENCE: The home had a statement of purpose and service user guide which included the majority of the required information. Both documents needed some minor additions, for example, residents’ views of the service, to ensure they complied with the Care Homes Regulations. All the residents living at the home at the time of the inspection had been resident when the home was known as Ashleigh House. The majority of the residents had been resident at the home for a considerable amount of time and their pre admission assessments had been undertaken at that time. The manager had undertaken a full reassessment of the residents’ needs. The files sampled included an assessment of daily living needs. The assessments included details of the residents’ needs in relation to daily routines and interests, personal care, social aspects, their mental health and also detailed Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 10 their likes, dislikes and preferences. These assessments had been used to inform the care plans. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 11 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 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were encouraged and enabled to make decisions about their lives on an ongoing basis. Care plans and risk assessments needed to be further developed to ensure staff knew how to meet all identified needs and minimise any risks residents may be exposed to. EVIDENCE: The files sampled included care plans that had been drawn up after the assessment of daily living needs had been completed. There were some good details included in the care plans of the preferred daily routines of the residents, what their dietary requirements were, how they kept in contact with their families and any health care needs. Not all the identified needs in the assessments had been brought forward to the care plans, for example, one referred to the resident needing assistance when showering but there were no details of this in the care plan. Other needs identified on the care plans did not detail how staff were to assist, for example, needs assistance with the kettle, staff to assist to exercise within the home but the type of assistance was not Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 12 detailed. There was no evidence seen to suggest the residents had been involved in drawing up their care plans. There were some risk assessments evident on the residents’ files. These included risk assessments for falls, mental health relapse and what may cause any aggressive behaviour. These were generally well detailed and informed staff of how the risks were to be minimised. Other risks had been identified on the assessments and care plans but there was no evidence of any risk assessments being undertaken for these. For example, one resident was known to have falls but there was no manual handling risk assessment detailing how they were to be got up, one resident had diabetes and although there was some guidance for staff about the condition there was no specific risk assessment stating how staff would know if blood sugars were high or low and what they were to do about it. Residents also needed to have risk assessments in place for the use of kitchen equipment where they were exposed to risks when using them. Residents made decisions about their lives on an ongoing basis. There was ample evidence of this in the daily records which showed that residents chose what they did on an ongoing basis and this was very different for each individual. Residents were observed to spend time in their rooms if they wished, go out when they wished, spend time in the communal areas of the home and be able to eat what and when they chose. Four of the residents continued to managed their own financial affairs. The manager assisted the other two but as much responsibility as possible was given to the resident and they decided how much money they wanted and what they would spend it on. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in meaningful daytime activities and are part of the local community. Contact with families and friends is supported and encouraged. Residents were receiving a very varied diet which met their individual and cultural needs. EVIDENCE: All the residents went out of the home at some point during the inspection. Some to structured day placements, one to a doctor’s appointment and another to visit a relative. Residents spoken with were happy with their lifestyles and did not appear to get bored. They were free to come and go from the home as they pleased wherever they were able. One of the resident spoke to the inspector and said they were going to see their brother, he walked there, and had a game of dominoes or cards. Another resident spoke of how much she enjoyed going to the day centre. Daily records evidenced that Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 14 residents went out into the local community on an ongoing basis for health care appointments, going out for a meal, using the local pub and shopping. The daily recordings detailed that when at home residents took part in helping around the house, for example, drying the dishes, cleaning their rooms and ironing. There were also some in house activities, for example, progressive mobility and bingo. Residents also had access to televisions and music systems in the home as well as their own in their bedrooms where this was their choice. Residents’ files detailed how they kept in contact with their families and daily records showed that contact was maintained. There was evidence of families visiting the home, residents going out to visit their families and contact being maintained by telephone. Residents’ rights and responsibilities were recognised by staff. There were good interactions between staff and residents and appeared to be based upon a mutual regard and respect. All bedroom doors were fitted with appropriate locks and residents had their own keys so that they could secure their possessions when they were out of the home. Residents took responsibility for cleaning their own bedrooms wherever possible and assisted in dusting, laying the tables and ironing their own clothes. There was a very detailed food diary being kept at the home. It was obvious from this that residents had an extremely varied diet that met their medical and cultural dietary needs. Breakfasts were a wide variety of cereals, toast and some residents also had an egg. The main meals varied considerably depending on the residents’ individual needs in relation to any medical issues or cultural needs. All the residents spoken with were very satisfied with the food served to them. Jasmine House DS0000068337.V328136.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs were met with the input of the appropriate health care professionals. The medication system was well managed and ensured residents received their medication as prescribed. EVIDENCE: At the time of the inspection one resident needed minimal assistance with personal care, the others only required prompting. As stated previously the type of assistance required by the one resident needed to be included in their care plan. Daily records evidenced that residents’ health care needs were generally met by attending the local doctors surgeries, hospital appointments, and regular checks on blood pressures and sugar levels etc. There was also evidence that where necessary residents received specialist in put, for example, physiotherapy and attending a falls clinic. Two of the residents had specific requirements in relation to their diet due to health concerns. The manager was trying to contact the dietician for one to help with menu planning. Another was being monitored by the nurses at the local doctors surgery in relation to their Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 16 progress with weight loss and cholesterol level. The manager needed to ensure there was specific guidance in place for staff to follow in relation to the required diets. Also as previously mentioned there needed to be a risk assessment in place for the resident with diabetes. Where necessary additional equipment and aids were being obtained for the residents, for example, after assessment one resident had been provided with an aid to help them pick things up and to heighten a chair. The home was administering the majority of the medication via a 28 day monitored dosage system. The mental health team supplied one resident’s medication and this was delivered two weekly to the home. There was very little medication kept in the home in individual containers. The manager stated that all staff who were administering medication had received training. All the medication was acknowledged when it came into the home and any balances of medication held from one month to the next were carried forward. All medication that was audited was correct. The inspector was informed there was no controlled medication being administered in the home but she had purchased a controlled drug register in case this was needed in the future. There was also a safe on site for storing any controlled medication that might have to be administered in the future. One of the residents was partially self medicating and this was overseen appropriately. There were some homely remedies being kept in the home and records for these were sampled. All balances were correct. All the homely remedies were recorded on one sheet with a running balance shown. It was strongly recommended that a separate sheet was kept for each item. The medication was being stored in a locked dresser. It was strongly recommended that a specific drugs trolley be obtained. Since the manager had also become the owner of the home there had been vast improvement in the medication system ensuring it was safe and that residents received their medication at the appropriate times. Jasmine House DS0000068337.V328136.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ were listened to and acted on. The training staff received and the systems in place in the home ensured the protection of the residents. EVIDENCE: There were no recorded complaints at the home and CSCI has not received any complaints. Residents had all received a copy of the complaints procedure for the home. It was evident from the daily records and resident meeting minutes that residents were listened to and their views were acted on. Residents spoken with at the home were all very happy with the service they were receiving. There were adult protection procedures on site. The copy of the multi agency guidelines was out of date and the manager needed to obtain the most recent addition. It was also noted that the home’s procedures talked about investigating adult protection issues. This is not to be done by the home without prior consultation with Social care and Health and although the manager was aware of this it needed to be clarified in the procedures. The majority of staff had undertaken training in adult protection issues. The manager was assisting two of the residents to manage their finances. The systems in place ensured the residents were safeguarded. One resident had money brought to the home by a relative and signed to acknowledge this had been received by the home. The resident then had the cash amounts she Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 18 requested and signed to say she had received this. The other resident was drawing his own money from the post office and then giving the cash and receipt to the manager for safekeeping. Both were signing for each transaction. The resident then had the cash as when they wanted and again signed to say they received it. The cash balances being held in the home were correct. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 19 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, 25, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, homely, clean and hygienic home that meets their current needs. EVIDENCE: There had been no changes to the layout of the home since the new owner took over. It was safe, comfortable and well maintained. The bedrooms varied in size, some being quite large, and five had en-suite facilities. The bedrooms appeared to meet the needs of the residents and were comfortable and personalised to individual needs. Residents said they were comfortable at the home and quite satisfied with their bedrooms. There was a communal bathroom on the first floor that was not adapted for disabled or assisted bathing. And there was a small walk-in shower room on the ground floor. The suitability of bathing arrangements must be kept under constant review with particular reference to ageing residents and any Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 20 consequent mobility restrictions. There were some toiletries in the shower room but one of the residents told the inspector who they belonged to and that the individual insisted on keeping them in there. There was adequate communal space in the home for the residents consisting of a conservatory (the designated smoking area), lounge and connecting dining area. There was a small pond in the conservatory with a fence around. All these areas were adequately decorated. The furnishings were domestic in style and all rooms were quite homely. The home provides a ramped access into the home and also into the rear garden. Facilities are suited to the needs of the resident group at this point in time. However, as the residents became frailer the home may not be able to meet their needs without significant structural alterations. The majority of the residents were mobile and could manage the stairs. One resident used a Zimmer frame in the home and a wheelchair outside. Corridors in the home are wide enough to allow use of walking aides downstairs. There was an emergency call system available in the bedrooms so staff and residents could summon help in an emergency. At the time of the inspection the home was clean and hygienic. The kitchen was well organised and had a pantry leading off. All foods being stored in the fridges and freezers were dated. The fridge and freezer temperatures were being recorded to ensure they working efficiently. The laundry was not inspected on this occasion. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 21 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, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of inspection residents were cared for by adequate numbers of competent staff. The home operated a robust recruitment procedure that safe guarded the residents. EVIDENCE: There were two staff on duty at the start of the inspection. The manager arrived a little later. The rotas indicated that two care staff being on duty was the minimum staffing levels. The manager indicated during discussion that if necessary additional staff would be on duty to facilitate activities. The staff undertook a multi-tasking role in the home including caring, cooking and cleaning. Staff spoken with had a good knowledge of the residents needs and there were good relationships between them. Residents spoken with were very positive about the staff team and they were very comfortable in their presence. The home had one staff vacancy which the manager was in the process of recruiting to. Staff training records indicated that they undertook all the mandatory training as well as other topics. Training covered included fire safety, first aid, adult Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 22 protection, medication, risk assessment, diabetes and infection control. Further training had also been planned in food hygiene and incontinence. It was recommended that the manager developed a training matrix for the home detailing what training staff had undertaken and to enable her to identify when staff were due for any updates. The induction training for one of the new employees had only one day signed off. This was discussed with the manager. She had purchased some booklets for staff to complete which included all the necessary induction standards however these had not been started. Over 50 of the staff had NVQ level 2. The recruitment records for two staff were sampled. These included all the required documentation included, application forms, two written references and CRB checks. The manager was also keeping records of the interviews undertaken. A formal staff supervision system had been set up and records of the sessions were being kept. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff were well managed. The home needed to have a quality monitoring system in place based on seeking the views of the residents with a view to continuous improvement. EVIDENCE: The manager of the home was also the owner. She had a lot of experience of caring for people with mental health needs and the running of a residential home. She was appropriately qualified for the post of registered manager. Relationships between the manager residents and staff were very good and the inspector was left with no doubt that the home was run in the best interests of the residents. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 24 Quality assurance was discussed with the manager. She had started work on setting up a quality assurance system and was setting up the paper work for this. The system will involve auditing the service against the National Minimum Standards. There was some evidence seen on the residents files that they were consulted about the service in the form of questionnaires. There were also occasional residents’ meetings which were documented. When the meetings did take place they were being chaired by one of the residents. A resident who wanted to apologise for their behaviour first thing in the morning had called the most current meeting. The manager was looking at ways of involving the residents more in the general day-to-day running of the home. Staff meetings were also taking place. Topics being discussed included such things as quality assurance and policies and procedures. The manager stated that it was difficult to get all staff together so to ensure they were all getting the same information all staff read and signed the staff meeting minutes. Health and safety in the home were well managed. Staff received training in safe working practices. There was evidence on site that equipment was being regularly serviced. All the in house checks on the fire system were up to date and regular fire drills were being carried out. Accident and incident recording were seen to be appropriate and the manager was notifying the Commission as required of any incidents in the home. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 3 X 4 X 5 X 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 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4(1)(c) Schedule 1 5(1) Requirement The registered person must ensure that all information required by regulation is included in the homes Statement of Purpose and Service User Guide. The registered person must ensure that residents’ care plans detail all the identified needs and how these are to be met by staff. Timescale for action 01/04/07 2. YA6 15(1) 01/04/07 3. YA9 YA19 13(4)(b) 4. YA19 12(1)(a) Residents or their representatives must be involved in drawing up the plan. The manager must ensure there 01/04/07 are risk assessments in place for any identified risks in relation to the residents. These must include details of how staff are to minimise the risks. Where residents are to follow 01/04/07 specific diets for medical reasons details of these must be included in the individual care plans or on separate management plans. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 27 5. YA23 13(6) The manager must ensure that the adult protection procedures comply with the multi agency guidelines. 01/04/07 6. YA35 7. YA39 The manager must obtain an updated copy of the multi agency guidelines for adult protection. 18(1)(a) The manager must ensure staff 01/05/07 undertake induction training as specified by Skills for Care and within the given time scales. 24(1)(a)(b) The home must have in place a 01/05/07 quality monitoring system based on seeking the views of the residents with a view to continuous improvement. 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 YA20 YA20 YA35 Good Practice Recommendations It is strongly recommended that a separate recording sheet is kept for each homely remedy kept in the home. It is strongly recommended that a specific drugs trolley be obtained for the storage of medication. It is recommended that a training matrix is developed for the staff team that identifies when any updates are required. Jasmine House DS0000068337.V328136.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham 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. 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