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Inspection on 29/05/07 for Jeanne Jugan Residence Little Sisters Of The Poor

Also see our care home review for Jeanne Jugan Residence Little Sisters Of The Poor for more information

This inspection was carried out on 29th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The residents in this home are well cared for and their total needs are met. Comments made by residents and their relatives in the questionnaires that they completed were very positive and spoke highly of the care provided. One relative stated that the sisters constantly tell the residents that "This is your home and we want you to love living here". Residents spoken to during the visit further confirmed the excellent care and attention given to them by all the staff. One resident said, "This is a happy home where everyone is catered for with love and care, I think it is excellent".From observations and discussions, evidence was gained to confirm that equality and diversity is promoted. The residents are encouraged, within their capabilities, to be individual and their personal routines and lifestyles are respected. One person commented that their relative was able to be independent, allowed to keep their room as they liked and the home was first class. The documentation in the home is well maintained and regularly reviewed to ensure that the residents continue to be provided with an excellent service that meets their needs both individually and as a group. The staff team work well together and were seen throughout the visit to be very caring in the way in which they looked after the residents and assisted with all personal tasks in a sensitive manner. Staff spoken to said that they enjoyed working at the home and felt involved in all aspects of the care and were very supported by the management team. There was a very good atmosphere in the home and the staff, residents and visitors were very relaxed and interacted very well.

What has improved since the last inspection?

The requirements and recommendation made in the previous report had all been dealt with and there were no outstanding issues arising from these. Since the last visit a new training officer has been employed. Training was seen as a priority and staff had completed various courses including training to update their knowledge and monitor their individual abilities in order that the residents continue to be cared for by a competent and trained work force. The trainer has devised training packs to assist staff who may have difficulties in relation to studying because of any language differences. This has assisted people from other backgrounds to understand better and comply with the principals of care under which the needs of the residents are met.

What the care home could do better:

From observations and discussions during the visit evidence was gained that the management team and staff work very hard to ensure that the needs of the residents are met. There was no evidence of complacency from anyone, but there was a recognition that there was always room for improvement and the need to continually strive to ensure that each individual resident`s needs are fully met by the service and care provided in the home. The number of staff obtaining a minimum of level 2 NVQ (National Vocational Qualification) varies at times due to staff changes, however evidence was gained that the recommendation that 50% of care staff should hold this qualification would again be met in the near future.

CARE HOMES FOR OLDER PEOPLE Jeanne Jugan Residence Little Sisters Of The Poor 228 Garstang Road Fulwood Preston Lancashire PR2 9RB Lead Inspector Mrs Ruth Edgington Unannounced Inspection 29th May 2007 10:30 X10015.doc Version 1.40 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 Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jeanne Jugan Residence Little Sisters Of The Poor 228 Garstang Road Fulwood Preston Lancashire PR2 9RB 01772 717454 01772 712368 Address 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) Little Sisters of the poor Sister Deirdre Dorothy McCormack Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The registered person must employ a suitably qualified and experienced manager who is registered with Commission for Social Care Inspection The home is registered to accommodate a maximum of 43 service users in the category of OP (older people who do not fall into any other category) 8th November 2005 Date of last inspection Brief Description of the Service: Jeanne Jugan (Little Sisters of the Poor) Residential Care Home with Nursing offers care and nursing to 43 residents aged 65 years and over. Care is offered to residents based on an ethos of Christianity with management and senior staff belonging to the religious order. The home is situated in the popular area of Fulwood, Preston with local services close by. The home is on a regular bus route and the town’s railway a short distance away. The home which is a large detached Victorian property has provided care for the sick and dying since the early 1800’s and retains many of its original features and characteristics. Accommodation is provided on the ground, first and second floors and comprises of 43 single bedrooms, 27 of which have ensuite facilities, a large range of communal areas and sufficient bathing and toilet facilities around the home to meet the needs of the residents. There is a Statement of Purpose/Service User Guide, which is provided to all prospective residents and their relatives. This information informs people of the care service provided, who manages the home, who the staff are and what the resident can expect if he or she moves into the home. Information received 24/04/07, which was prior to the visit, showed that the fees ranged from £332.00 to £496.29 per week. Additional charges are made for hairdressing, toiletries newspapers chiropody and transport for holidays. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was undertaken as part of the home’s key Inspection. The visit commenced at 10.30am and took place over four and half hours. Prior to the visit the manager completed a pre-inspection questionnaire, which provided information about the people living in the home, staff and other information, which assisted in assessing how the home was meeting the National Minimum Standards. Comment cards were sent out prior to the visit to enable people to have their say about the service provided. Thirteen relatives, twentyfour residents and one visiting professional person returned completed forms. At the time of the inspection the home was accommodating forty residents of which only three were assessed as needing nursing care. As part of the visit the records of four residents were looked at in detail, staff records and a sample of other relevant records were also looked at. Discussions took place with the four residents whose records had been looked at, the deputy manager, a number of the staff responsible for specific duties relating to the running of the home, care staff and ancillary staff. A tour of the home was carried out during which general conversation with a number of staff and residents took place. From the observations made, comments received and the written documentation examined, the information has been put together to produce this report. What the service does well: The residents in this home are well cared for and their total needs are met. Comments made by residents and their relatives in the questionnaires that they completed were very positive and spoke highly of the care provided. One relative stated that the sisters constantly tell the residents that “This is your home and we want you to love living here”. Residents spoken to during the visit further confirmed the excellent care and attention given to them by all the staff. One resident said, “This is a happy home where everyone is catered for with love and care, I think it is excellent”. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 6 From observations and discussions, evidence was gained to confirm that equality and diversity is promoted. The residents are encouraged, within their capabilities, to be individual and their personal routines and lifestyles are respected. One person commented that their relative was able to be independent, allowed to keep their room as they liked and the home was first class. The documentation in the home is well maintained and regularly reviewed to ensure that the residents continue to be provided with an excellent service that meets their needs both individually and as a group. The staff team work well together and were seen throughout the visit to be very caring in the way in which they looked after the residents and assisted with all personal tasks in a sensitive manner. Staff spoken to said that they enjoyed working at the home and felt involved in all aspects of the care and were very supported by the management team. There was a very good atmosphere in the home and the staff, residents and visitors were very relaxed and interacted very well. What has improved since the last inspection? The requirements and recommendation made in the previous report had all been dealt with and there were no outstanding issues arising from these. Since the last visit a new training officer has been employed. Training was seen as a priority and staff had completed various courses including training to update their knowledge and monitor their individual abilities in order that the residents continue to be cared for by a competent and trained work force. The trainer has devised training packs to assist staff who may have difficulties in relation to studying because of any language differences. This has assisted people from other backgrounds to understand better and comply with the principals of care under which the needs of the residents are met. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 7 What they could do better: 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. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures were clear to ensure the care needs of residents are met. EVIDENCE: The records of four residents were examined in detail and were found to contain full assessment information that had been obtained prior to admission, therefore ensuring that the home could meet the residents’ individual needs. Prospective residents completed an admission application form, which provided personal information and was used as part of the assessment process. Evidence was gained that residents and their relatives had been involved in the assessment process. Comments received prior to the visit confirmed that people were made very aware of the facilities and care provided in order that they could make an Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 10 informed decision about moving into the home. One relative stated, “The communication is excellent”. Residents spoken to said that they had chosen to come to the home, they were very happy and all their needs were being met. One of the residents spoken to had difficulty in communicating effectively, however from examination of this persons records and observations made, evidence was gained that their assessed needs were being met. This home does not provide intermediate care. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Promotion of health is taken seriously, resident’s welfare is closely monitored and health needs were met. EVIDENCE: Examination of the residents records confirmed that the documentation was very comprehensive and covered all aspects of the physical, emotional, cultural, religious and social care needs of the individual resident. Risk assessments were also included especially in relation to mobility and nutrition. From this information an individual plan of care had been drawn up with the involvement of the residents and their relatives to ensure that the care needs were met. Significant events were recorded, which included visits by their doctor, hospital appointments and any other contact with health professionals. Daily entries were made of the care given and staff spoken to were able to demonstrate that they were well aware of the care needs of the residents. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 12 Evidence was seen that care plans, risk assessments and any other relevant information was reviewed monthly to ensure that the needs of each resident continued to be met. The care plans were also reviewed in depth every six months unless required more frequently, to which all interested parties are invited. Throughout the visit observations were made of the caring approach of all the staff towards the residents and the practices in the home ensured that residents were treated with respect and their right to privacy was upheld. The comments received from residents and their relatives about the care that they received were very positive. One resident said that they were “Glad to be here” and that they were well looked after. A relative commented, “In the main the staff are caring and respectful of the residents, I get the impression that this is not just a job” Another relative said that they were very impressed by the quality of care and the good standards expected of the staff. The policy of the home is that only the qualified nurses administer medication. This ensures that the residents’ health and welfare is protected by receiving their medication from a designated and trained member of staff. There is a designated medical room, which was seen to be kept in good order, with lockable facilities for the storage of medication. Examination of the records found that the correct procedures were being followed for the storage, administration and disposal of medication. Information about the health care needs of the residents was also kept on the computer system and one of the Sister’s explained that this information was very helpful when any resident needed to go into hospital or had an appointment at a health care facility. The information was also made available when residents were going away in order that their health care needs continued to be met. Evidence was seen that information produced by the Medicines and Healthcare Products Regulatory Agency (MHRA) was available. This information brings to the attention of care providers any concerns that have been identified and any action that staff needed to take to protect the health of the residents. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,& 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: Information recorded on each resident’s file identifies their social, religious, and recreational interests and also information about their life history, which all assists in identifying how their needs can be met. Comments from residents and their relatives confirmed that they are able to make decisions about how they live their lives. The records of one resident clearly showed that they did not want to join in any activities, but attended mass daily. This was confirmed through discussion with this resident who said that they were very happy with the care and attention that they received. One relative commented that although the resident was frail and confused, the staff enables them to have freedom of choice, when this is realistic. They are able to go to bed and get up when they choose. One resident stated that they were happy with the care given and that constant thought was given to ways in which the lives of the residents could be Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 14 more stimulating. Two of the residents were going to Jersey this year for a holiday and would be staying at a home run by the same order. The residents have a wide range of activities and social events that they can join in if they so wish. One resident said that they were looking forward to the bingo that afternoon and was able to say what else was going on in the home that week. There is also a large handicraft room, which was well equipped to enable residents to undertake crafts that they have an interest in. Residents who wish to attend mass each day can participate in the chapel situated in the home ensuring that they can continue with this religious observance. Comments received from the residents confirmed that they enjoyed the food that was provided. One resident commented that there was a wonderful variety of meals, which were well presented. Another said that they enjoyed a glass of wine with their meal and this was accepted practice. The cook was spoken to and was able to demonstrate her understanding of the residents needs. Special diets are provided for those residents who require these. The cook stated that residents soon let them know if they don’t like something or want to try something else. Visitors are made very welcome and one relative commented that the home had a real feel of a community, very open with different people coming and going for a variety of reasons, which was good for the residents so that there was less likelihood of isolation and feeling cut off or forgotten. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to, taken seriously and they will be protected at all times. EVIDENCE: The home has a detailed complaints procedure, which all residents and their relatives were made aware of in the information provided to them before admission to the home. Comments received prior to the visit confirmed that they would know who to speak to if they had any concerns. Located around the home is information for residents and visitors to refer to, this includes copies of a complaint form that people can use if they wish to. A record is made of any complaint made and what the outcome was. In the period since the last visit to the home, the Commission for Social Care Inspection had not received any complaints. Examination of policies and procedures found that there were detailed in relation to Safeguarding Adults. This included a copy of ‘No Secrets’ and information in relation to advocacy projects in Lancashire. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 16 Documentation was available for reporting of any suspicion of abuse. Evidence was seen that staff undertake training in relation to elderly abuse and also bullying and harassment. On the last visit it was recommended that the manager attended a training course to update her knowledge in relation to issues relating to abuse. One of the Sister’s confirmed that this had taken place. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a comfortable, homely and safe environment. EVIDENCE: The home is a very large adapted building that uses the space available to the best advantage for the residents. The entrance hall in the home is very welcoming and there is someone in attendance during the day to assist visitors where necessary. A tour of the home was undertaken and it was found to be well maintained, clean and fresh smelling. Comments made in the questionnaires received before the visit were in the main very positive. One resident had commented that the temperature of the home was high and there was a lack of ventilation due to the windows not open enough. As the comments were made anonymously it was not possible to discuss these with the person concerned, however a tour of the home did not support these Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 18 concerns at that time and the residents spoken to said that they were very happy with the home. The home has a variety of communal spaces, which encourages independence and freedom to associate with persons of their choice or have somewhere to go to be quiet other than their bedroom. All bedrooms were very individualised and additional equipment had been provided to ensure that the resident individual needs were met. The grounds of the home provided a safe, attractive and well-maintained environment in which residents can easily access and enjoy. During the visit residents were seen walking in the garden. Staff record in the maintenance book any day to day repairs that are needed and this is checked each day by the maintenance person to make sure that the residents are protected and live in a safe and comfortable environment. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28.29 &30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and training provided for staff ensure that the residents are protected and cared for by staff who are competent and qualified to undertake their role. EVIDENCE: Three staff files were looked at in detail and were found to contain all the information required by regulation before new staff members commence working in the home, confirming that the recruitment procedures had been followed in order to protect the residents. All appropriate checks had been undertaken, which included clearance through the Criminal Records Bureau (CRB) and Pova (Protection Of Vulnerable adults). Satisfactory references had been obtained and in the case of applicants coming from abroad, proof of entry clearance and permission to work in this country had been obtained. Evidence was also seen of the pin numbers of the qualified staff to ensure that their registration with the Nursing and Midwifery Council (NMC) remains current. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 20 Though examination of the files and discussions with staff, confirmation was gained that they had undergone a formal recruitment and induction process. This ensures that residents are protected and enables new staff to gain the basic understanding of the needs of the residents and how these should be met. Training is regarded by the management team as essential in ensuring that the needs of the residents are met by a competent staff group. Since the last visit a new training officer has been employed and she was in the process of ensuring that each member of staff had their the training needs met. The trainer has devised training packs to assist staff who may have difficulties in relation to studying due to language differences. Evidence was seen of the training undertaken and training to be carried out in the future. On the day of the visit a number of staff were undertaking an examination in Food and Hygiene. The home currently has thirty-six care staff. Fifteen have achieved level 2 NVQ (National Vocational Qualification), two staff have achieved level 3 NVQ and five staff and undertaking training. It was recognised that achieving the required level of 50 of care staff with this qualification can be a continual process that is affected by staff changes, however the training officer confirmed that new staff had indicated their wish to undertake NVQ training, which was reassuring and would ensure that the staff team continued to be competent in meeting the needs of the residents. Examination of the staff rotas and the number of staff on duty at the time indicated that there were sufficient staff available to meet the needs of the residents accommodated. At the time of the visit there were only three residents assessed as nursing and the nursing levels in the home were sufficient to meet their needs. Staff spoken to said that they were very happy in their job and felt that they had a good staff team who worked well together to ensure the individual and collective needs of the residents were met. One staff member said that they had worked in a number of homes and this was the best. Comments made by the residents and their relatives were very positive. One relative said that this was an excellent service with a wealth of experience from the staff. They also said that their relative had not had an accident since coming into the home due to the care and the attention from the staff. During the visit the atmosphere throughout the home was friendly and relaxed. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed for the benefit of the residents. EVIDENCE: The registered manager is a qualified nurse and also holds a recognised management qualification. On the day of the visit the manager was attending a meeting in London, however her deputy was very competent and able to produce all the information required and answer any questions raised. The home operates within a structure that delegates responsibility to individual members of staff. This includes personnel, training, maintenance and the Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 22 kitchen. In addition on both the first and second floor there is a Unit Manager who oversees the care provided and the staff working on that unit. Good systems are in place to ensure that resident’s rights are safeguarded and enable the views of the staff, residents and relatives to be gained as part of the monitoring of quality. These include regular residents meetings, which are held every month and questionnaires completed by residents and their relatives on an annual basis. A summery of the findings from the last questionnaires completed was seen and it was suggested that this was included in the information made available to the residents and their relatives to provide an overview of the service and confirmation that the needs of the residents continue to be met appropriately. Evidence was seen that there was suitable accounting and financial procedures in place to safe guard the residents. These are handled by the financial administrator who was spoken to during the visit. Staff spoken to had a clear understanding of their role and what is expected of them during their shift. One staff member spoken to said that they felt very supported and enjoyed their designated role. Residents’ records were very comprehensive, well written and up to date. From examination of records and the information in the pre-inspection questionnaire, it was evidenced that the home was complying with issues relating to health and safety. Regular checks were being carried out to systems within the home and equipment was being serviced. There were no concerns raised during the visit that related to health and safety. Evidence was seen that confirmed that the home is visited by the Provincial Manager 3-4 times per year. The report following her visit in October 2006 was available and was found to be very comprehensive. Monthly visits are also undertaken by representatives of the order, who are designated with responsibility in relation to care and in relation to health and safety issues. A copy of their report was seen. Daily discussions take place with residents and staff during identifying any concerns, suggestions or comments that may affect the well being of all involved. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP28 Good Practice Recommendations The process of encouraging staff to undertake NVQ training should continue in order that a minimum of 50 of care staff achieve level 2 to ensure that residents are cared for by a competent and qualified staff group. Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Jeanne Jugan Residence Little Sisters Of The Poor DS0000006052.V334382.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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