Inspection on 23/04/07 for Jean Garwood House

This inspection was carried out on 23rd April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jean Garwood House 08/05/06

Jean Garwood House 17/01/06

Jean Garwood House 27/09/04

Jean Garwood House 16/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Jean Garwood House 25 Bramley Hill South Croydon Surrey CR2 6LZ Lead Inspector Barry Khabbazi Key Unannounced Inspection 23rd April 2007 8:30am Jean Garwood House DS0000025802.V336583.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 Jean Garwood House DS0000025802.V336583.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. Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jean Garwood House Address 25 Bramley Hill South Croydon Surrey CR2 6LZ 020 8681 7338 020 8604 8904 jgh@garwoodfoundation.org.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) Garwood Foundation Ms Jacqueline Nannette Jenner Care Home 14 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Room number 11 is to be used for 1 respite bed. Date of last inspection 8th May 2006 Brief Description of the Service: Jean Garwood House is sited in a residential street close to the centre of Croydon on Bramley Hill. The house is fully registered as a residential care home for adults with physical disabilities and learning disabilities. Some residents visit their families at weekends and so the numbers in residence can vary at certain times. The ground floor of Jean Garwood House provides 11 single residents rooms. The shared rooms in the home consist of a lounge and dining room. Corridors in the home are wide and long and easily accessed by wheelchairs. Bathrooms are located either end of the long corridor, as are the toilets. All ground floor bedrooms exit onto a patio area that surrounds the house. The first floor has been converted into a semi-independent living unit for three people and has now been registered as such. The fees range from £623/week. Jean Garwood House DS0000025802.V336583.R01.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 started early in the day to allow the residents to be met, before they went to their day centres. The manager and deputy manager was interviewed, and records, policies, care plans, and the building were also examined. The home was found to be generally well run with a noticeable improvement in assessment documentation for new service users, and a increased level staff induction training. One Standard has been exceeded, ‘Staff qualifications’. All previous requirements have been met with a few needing a little further adjustment, which has been addressed with new recommendations. Although staff recruitment documentation and supervision are in place for most staff, there were a few minor shortfalls in this area which have been addressed with new requirements. Some service users talked about recent activities and outings they had attended. One said he liked the food and the home and a new service user said he also liked it at the home. Only positive comments were received from the service users at this inspection. Where communication was limited by the service user’s disability, those service users appeared relaxed and contented. Staff were seen to be supportive and responsive to service users’ needs. As usual there was a positive relaxed and jovial atmosphere at the home with residents and staff sharing humour together. The home was observed to be particularly clean and hygienic at this unannounced visit. No areas of serious concern were identified at this inspection. What the service does well: The residents have raised the good quality of outings. Residents have also raised the good food, good access in the home, and that they were happy at this home. The home has been one of the first to achieve funding agreements for holidays. In addition these are realistic holiday funding figures. This will ensure that the residents receive all the paid holidays they are entitled to. Shared communal spaces exceed the National Minimum Standard. Care plans are reviewed monthly which exceeds the six monthly reviews required under the Standards. The Standards require homes of this type to have 50 of staff trained to NVQ level 2. At this home 10 out of 12 staff have the NVQ 2 which represents well over the 50 required. The deputy is well trained and has the qualification that is usually required for managers, the registered managers award, NVQ 4. Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although staff recruitment documentation was fully in place for most staff, one staff member had two personal references instead of the one personal and one official work reference required. Although staff supervision was in place for most staff, one staff member had only one session in her first six months of employment. Care plans should continue to be translated into more accessible formats for the residents so that the residents can understand them. The contract should contain the elements of the care plan to be met outside the home through other resources. This will clarify which needs are the responsibility of the home to meet and which needs are to be met by other agencies. Although previous progress has been made, the home should continue to translate policies relevant to the residents into more accessible formats. This will assist relevant policies at the home being known by the residents, for example the fire policy and procedures and access to files policy. Jean Garwood House DS0000025802.V336583.R01.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. The summary of this inspection report can be made available in other formats on request. Jean Garwood House DS0000025802.V336583.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 Jean Garwood House DS0000025802.V336583.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): Standards 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement Of Purpose contains all the information required as set out in Standard 1. This will assist relatives and placing authorities in having a fuller understanding of what the home provides. The service users guide contains all the information required including the residents’ views of the home. This is important so that new residents are clear about how other residents feel about living in this home. Prospective service users’ needs are assessed before they start at the home to ensure that all needs are known. Each service user has an individual contract with the home so that expectations are clarified. EVIDENCE: Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 10 Standards 3 and 4 were not re- assessed on this occasion but were met at previous inspections. See previous reports for information on those Standards. All remaining Standards in this section were assessed and are recorded below: The home has a Statement Of Purpose and a Service User Guide. These are clear and well laid out and both cover all the elements required under standard 1, including the residents’ own views of the home. The last inspection report recorded that a new service user had been admitted without the placing authority’s care management assessment and a copy of the placing authority’s care plan. In addition the home’s own new service user assessment documentation did not cover all the elements of Standard 2, for example cultural needs. The following two requirements were then set to address this shortfall under Standard 2: 1, Service users must not be admitted to the home until receipt of the summary of the Care Management assessment and a copy of the Care Plan. 2, The home’s own new placement assessment documentation must cover all the elements of Standard 2.3. At this inspection the newest service user had all the required documentation, in addition the home’s own assessment doiocumentation had been updated to include the information required under Standard 2. Both these requirements are currently met. The residents all have contracts as required under Standard 5. However, there is a minor shortfall in these and the last inspection report contained the following recommendation to address this under Standard 5: Contracts should contain the elements of the care plan to be met outside the home through other resources. For example transport or daycentre activity. Although this is occurring for new residents it has not yet occurred for existing residents. This recommendation therefore remains in force. This is a very minor shortfall under one of the 5 Standards of this group of Standards. As all other Standards in this section are currently fully met, the overall judgement will be recorded as good on this occasion. Jean Garwood House DS0000025802.V336583.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): Standards 6, 7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care contain originally assessed needs and are updated regularly. This will help staff know all a resident’s needs and how to meet them. Service users are supported to make decisions about their lives and these areas are recorded. Risk assessments contain all the information required. Including this information could reduce unnecessary restrictions of liberty for the Service users. EVIDENCE: Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 12 The service users each have a care plan generated from the comprehensive assessment completed by the care manager. All of a service user’s needs, how they are to be met and by whom, are recorded in their care plan. Care plans sampled did cover all the areas required under Standard 6. The continuing practice of producing monthly key-worker reports means that care plans are reviewed monthly. This exceeds the six monthly reviews required under the Standards. The last inspection report contained the following recommendation under Standard 6: Care plans should be translated into more accessible formats for the residents. This had started but needs to conclude. This recommendation will remain in force until such time. Choices are only limited through involving the service user and relatives where appropriate. This is always through a risk assessment process and recorded in the service user’s file. Service users participate in the day to day running of the home and contribute to the development and review of policies and services through regular meetings, individual discussions with their key workers, regular house meetings. Risk assessments were updated during the last inspection to now include other options and training that has been explored before implementing any restriction of liberty for the protection of the resident. These risk assessments now contain all the elements required under Standard 9. Jean Garwood House DS0000025802.V336583.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): Standard, 12, 13, 14, 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 have the opportunity to be part of the local community and are able to take part in appropriate activities and holidays. This promotes inclusion and quality of life. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Residents’ rights are respected and responsibilities recognises. The food provided is sufficient in quantity, and it is sufficiently nutritious which is important to ensure good health. EVIDENCE: Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 14 The home mainly supports residents to find and keep jobs, continue their education and training {including literacy and numeracy}, and take part in other activities, through the sister day centre next door. As all the residents attend this day centre. As its work is used to evidence the home meeting a number of Standards. A copy of the day centre’s activities timetable has therefore been sent in to the Commission to evidence the above. A number of service users now attend college to study cookery. The local community is well used by the residents and access is assisted by the home having its own transport. The local shops, bowling, bingo halls, college, swimming pools, cinema and clubs are accessed and some residents access the local community independently. Staff are available to support service users while accessing the community and this is now occurring in the evenings as well as the weekends. Activities provided within the home include individual interaction, puzzles, games, music, books, art and crafts and support with individual hobbies. The staff job descriptions have now been amended to reflect their responsibilities with regards to supporting activities. Residents spoke of enjoying recent outings and that the outings were now occurring more frequently Although holidays have previously occurred, funding for this has recently been secured from placing authorities to the value of £700 per resident. The home has been one of the first to achieve funding agreements for holidays. In addition these are realistic holiday funding figures. During the last announced inspection, family members were observed to be welcomed to the home. There are no restrictions about when family or friends can visit. Many of the service users go home at weekends and some visit friends or have friends visit them. Service users have the opportunity to make friends that do not necessarily have their disability, through community use. Staff have information and health training to support them in making appropriate and informed decisions where they wish to develop close relationships, and they would ensure that this was mutually welcomed. Evidence was provided to confirm that where this is not welcomed or appropriate, staff do take appropriate action to protect the service user. It is the home’s core philosophy to promote independence and individual choice, and the daily routines and house rules generally promote this. Mealtimes in the evening and morning have been frequently observed and are always presented in a clean and congenial setting. Meals were unrushed and residents can take as much time to eat, as they want. Meals are regular and menus appeared nutritiously balanced. The residents design the menu themselves and are able to take meals at flexible times and are also able to choose alternatives. This was also confirmed by a resident at this inspection. Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 15 Residents are actively encouraged to be involved in the preparation of meals. Snacks and drinks are available at all times. Nutritional monitoring and dietician support occur where required. A pictorial menu has been developed. The last inspection recorded that records of food eaten by residents covered breakfast and the evening meal but did not cover lunch time. The main cooked meal of the day is the lunch provided by the home’s daycentre. Records of food eaten did not appear sufficiently nutritious as the main meal of there day was excluded from these records. The service users commented positively about the food quality and did confirm that they received the main meal of the day at the day centre. The following recommendation was therefore set: The practice of recording what a service user ate for breakfast and the evening meal should be expanded to cover lunch. This information is now recorded and the recommendation is met. Jean Garwood House DS0000025802.V336583.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, and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical health needs are met well by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health. EVIDENCE: Timings for support with care are flexible. Consistency and continuity is achieved through designated key workers. The residents have access to relevant professional support to maximise independence, including physiotherapists, occupational therapists and speech therapists. Residents are supported to attend regular health checks, outpatient appointments and other medical appointments as required. The continence advisor has visited, and access to chiropody, dentists and audiologists was Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 17 demonstrated. Evidence was seen of regular monitoring of residents’ health including regular weighing and action in an event of significant loss or gain. Medication records were examined and were in order. Residents are encouraged to administer their own medication where possible, and they have a lockable space in their rooms to facilitate this. Medication is only provided through the G.P and prescriptions are sought for homely remedies to ensure secure record keeping and ensure against combining medication in a haphazard way. Medication is stored securely in a lockable cabinet fixed to the wall and individual blister packs are used. Medication profiles were present with a list of possible side effects. Training in administration of medication for staff includes identifying adverse reactions to medication. The home has now obtained and recorded the service users’ consent to medication. Jean Garwood House DS0000025802.V336583.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): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. On the whole this home manages complaints well. The home’s policies and procedures relevant to this standard facilitate protecting residents from abuse. EVIDENCE: On this occasion no areas of concern were raised by the residents. There had been no official complaints since the last inspection. The home has a complaints procedure that meets all the elements of this Standard including a minimum response time of less than 28 days, details of the Commission and this is now also available in more accessible formats. The more accessible formats include a bold, high contrast large print version, a simplified language version, a ’Makaton’ symbol version and a pictorial and symbol version and a photograph version that requires a photo of the inspector for the home. The home does have a copy of the adult protection procedures and staff have now received training in this area. The Restraint Policy has been developed to cover all the areas required. This also includes recording mechanisms. The home has a Whistle Blowing Policy, a Gifts Policy and the Wills Policy does preclude staff from being involved in the making of, or benefiting from residents’ wills. Jean Garwood House DS0000025802.V336583.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): Standards 24, 27, 28, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building, rooms and furniture generally meet the residents’ needs and provide a comfortable and safe environment which promotes independence. Shared spaces are in excess of the minimum standard giving more communal space for residents. The home is hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: The home’s premises were accessible and in keeping with the local community. At the time of the inspection the premises were decorated in an appropriate style and reasonably maintained. The grounds were observed to be well kept and accessible. There was suitable lighting and ventilation. The premises were wheelchair accessible and there is a lift to the first floor. Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 20 A conservatory has been built with the service users’ choices in this evidenced. The outdoor space is accessible from many areas of the building, including all of the ground floor rooms. These areas had level or sloped access. There is a lounge at 17.05 sq.m, which is domestic in design and contains a television, video player, music playing equipment, armchairs and couches. There is a dining area at 28.67sq.m. and a conservatory at 11.36sq.m. Half of the kitchen is adapted for services users’ own use. There is also a quite area to the rear of the building. Staff facilities included sleeping-in facilities and a place to store personal belongings. Evidence provided to confirm standard exceeded: This standard that refers to communal shared space sizes is exceeded in actual available communal space. Communal required is 4.1sq.m/service user. The actual space is 5.2sq.m/service user and there is additional kitchen space adapted for the service users. Toilets and bathrooms were inspected. They afforded reasonable access to wheelchair users, and offered privacy. The tracking hoist serving the bath in one bathroom has been extended to also reach the toilet in that room. All water outlets were individually thermostatically controlled and tested regularly. Thermometers were also available for double-checking water temperature when running a bath. Hoists were present and also aids for independent transfer to baths and toilets. The toilets were functioning, regularly cleaned and had clean and working sinks and supplies of towels and soap. The home has 3 baths. The building is always particularly clean and tidy. The home gives the impression of a clean and hygienic home. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and easily cleanable walls. Washing machines have appropriate programmes over 65 degrees to control risk of infection. The laundry room was positioned so that laundry does not need to be carried through the kitchen. Jean Garwood House DS0000025802.V336583.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): Standards 32, 34, 35, and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are appropriately qualified to or above NVQ level 2, and the 50 of qualified staff required under this standard has been exceeded. This raises the quality of staff, their knowledge and their practices. The home’s recruitment procedures usually protect the residents through vigorous staff vetting. However, more diligence is needed to ensure that work references are not given on a personal basis by friends, and are actually official work references. Staff receive induction and foundation training to ensure that they are appropriately inducted. Staff are generally well supervised but more diligence is needed to ensure that all staff receive the minimum number of supervision sessions required. Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 22 EVIDENCE: Standard 32 requires homes of this type to have 50 of staff trained to NVQ level 2 or above. At this home 10 out of 12 staff have the NVQ 2 which represents well over the 50 required. In addition some staff have higher level qualifications, for example, the deputy has a NVQ 4. This standard is therefore exceeded. This home has an equal opportunities recruitment policy. Criminal Record Bureau checks were available in staff files examined and these were of the required level and specific to the post. Staff do not start working with vulnerable adults until these have been acquired and assessed as satisfactory. External volunteers are not currently used at this home. The staff files sampled contained interview notes, statements of terms and conditions, identification checks, copies of a passport and birth certificate or home office documentation, two written references and staff photographs. All staff have copies of the ‘General Social Care Council’ {GSCC} standards and code of conduct. Staff recruitment documentation was fully in place for all but one staff member. This staff member had two personal references instead of the one personal and one official work reference required. More diligence is needed to ensure that work references are not given on a personal basis by friends, and are actually official work references. The following requirement is now set to address this under Standard 34: One of the two references required for staff must be an official work reference. The last inspection report contained the following requirement under Standard 35: All staff recruited since April 2002 must undertake six month foundation training to Sector Skills Council workforce training targets and both this training and the induction training must be evidenced. At this inspection it was ascertained that Induction training is now followed by foundation training and records of these are kept. This requirement is therefore currently fully met. Staff supervision was in place for all but one member of staff. This staff member had only one session in her first six months of employment. The following requirement is now set to address this: Supervision sessions for all staff must occur at a rate of at least 6 sessions per year. To put this in context, other supervision records either met the required frequency of exceeded it. Jean Garwood House DS0000025802.V336583.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): Standards 37, 39, 40 and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a generally well run home and the manager has the required qualification. In addition, the deputy also has the qualification that is required for managers. The home’s quality assurance system involves the residents and relatives, and provides feedback to them, to allow them to be fully involved in improvements and measure improvements in the home for themselves. Service users’ rights and interests are generally promoted by the home’s policies and procedures. The home promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk. Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 24 EVIDENCE: The new registered manager has the NVQ4 required under Standard 37, and also well exceeds the years of experience in the field required. The following new good practice has been identified: The deputy also has the qualification that is required for managers. The last inspection report contained the following requirement under Standard 39. The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home should also ensure that an annual development plan is produced that is open to the service users and information in it should include information from their quality questionnaires. The home already had all of the tools needed for a quality assurance system that makes the service users central to the process. For example quality questionnaires for both service users and relatives, a complaints procedure, provider inspections, commission inspections, residents meetings and relative ‘s meetings. All that was needed was for the residents’ views about development to be included in an annual development plan where appropriate and for an annual meeting to be held for residents and relatives to monitor improvements in quality via the implementation of the annual development plan. Good progress had been made with regards to the home implementing a quality assurance system. There is now an annual development plan available which also includes issues raised from service user surveys. Once fed back to the service users this will tie together the quality assurance system together, into one that makes the service users central to the process. The requirement set is now therefore met. A new recommendation will be set here, to reflect the remaining good practice element that is planed to be implemented. The home should continue with its plans to feed back the developments in the new annual development plan, to the service users at the next residents meeting. The last inspection report contained the following recommendation under Standard 40: The home should continue to translate policies relevant to the residents into more accessible formats. This has since happened with new pictorial staffing rotas, menus, fire evacuation procedures, photo complaints procedure, but needs to continue for activities, and some policies that are relevant to the service users, for Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 25 example, access to files policies. The recommendation therefore remains, but it is recognised that this work will need to be ongoing once the main areas are addressed and the recommendation met. All of the health and safety policies and procedures relevant to this Standard were seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. All of the procedures and testing of systems required in Standard 42 were also present. These included for example, fire fighting equipment testing, Portable Appliance Testing, gas testing, and Bacterial analysis and testing of the water supply. Although still just in date, the home is reminded that the boiler will need a test certificate imminently. Jean Garwood House DS0000025802.V336583.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 x 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 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 4 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 2 35 3 36 2 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 x 3 x 3 2 x 3 x Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 27 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. 2. Standard YA34 YA36 Regulation 17 18(2) Requirement One of the two references required for staff must be an official work reference. Supervision sessions for all staff must occur at a rate of at least 6 sessions per year. Timescale for action 01/06/07 01/07/07 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. 4. Refer to Standard YA5 YA6 YA40 YA39 Good Practice Recommendations The contract should contain the elements of the care plan to be met outside the home through other resources. Care plans should be translated into more accessible formats for the residents. The home should continue to translate policies relevant to the residents into more accessible formats. The home should continue with its plans to feed back the developments in the new annual development plan, to the service users at the next residents meeting. Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Jean Garwood House DS0000025802.V336583.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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