Inspection on 05/09/05 for Jeian

This inspection was carried out on 5th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Jeian 07/01/08

Jeian 09/07/07

Jeian 10/07/06

Jeian 10/01/06

Jeian 29/11/04

Jeian 14/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Jeian 322 Colchester Road Ipswich Suffolk IP4 4QN Lead Inspector Mary Jeffries Announced 5 September 2005 th 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 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. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Jeian Address 322 Colchester Road, Ipswich Suffolk IP4 4QN 01473 274593 01473 274593 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Felix Emejulu Chukwuma Post vacant Care Home 10 Category(ies) of Old Age (OP) 10 registration, with number of places Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29/11/04 Brief Description of the Service: Jeian residential home is a care home registered for up to ten older persons, situated on the corner of several main roads in a suburb of Ipswich. There are several local shops, bus routes and other amenities a short walking distance away, as well as Ipswich Hospital, which is located just across the road. All bedrooms are fully furnished single bedrooms. The main lounge area leads off the main corridor and is adjacent to a sitting room situated in the veranda. There is an emergency call bell system in operation in each bedroom, toilet and bathroom. The home is currently owned by Mr Felix Chukwuma who took ownership of the home at the end of October 2003. The registered manager’s position was vacant at the time of inspection with Mr Chukwuma providing the management support. The owner advised that they have recently sought planning permission for a four room extension and shaft lift. An application had not yet been received by the CSCI. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on one day in September 2005, between 10 and 5 pm. It lasted for seven hours. The home’s owner facilitated the inspection, and two other care staff assisted. The inspector met all service users, spoke with a group of five service users, and also individually with a service user who was confined to their room. Three service users were tracked. There was one vacancy at the time of the inspection, nine service users in residence. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments need further development. This includes some environmental risk assessments, for example of hot water outlets and for fire, and also of some care practices. Service users all have a risk assessment that covers a range of risks however the individual elements are not well developed, for example for pressure areas. A number of areas relating to staffing need to be addressed. Formal staff supervision is not in place for the majority of carers, this is a long standing shortfall that must be addressed. Staff recruitment procedures must Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 6 safeguard service users. Training needs must be analysed and a training plan drawn up. Medication system needs to be reviewed. 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. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5 Service users are able to make an informed choice about this home, and the home takes appropriate steps to ensure they can meet service users’ needs. EVIDENCE: A revised Statement of Purpose dated April 2005 was provided. This had been updated as had been previously required, and there fore met the regulation. The inspector examined paperwork relating to service users recently admitted to the home. In all cases there were records of pre-admission assessments that had been undertaken by senior staff at the home. Hospital discharge assessments and assessments written by social workers had also been obtained. Pre-admission assessments, care plans and risk assessments were all in place and reviewed regularly and accurately described the care provided to each service user. All service users spoken with were complimentary about the care they received and the staff who provided the care. These service users felt their needs were being met appropriately. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 9 One service user explained that their social worker had brought them to the home to have a look before they were admitted, and they liked it because their were not too many people there. Another said that they couldn’t remember coming, but a service user who had been at the home before them said that they could remember their friend bringing them to have a look at the home, as they could recall on other visiting before admission. The Statement of Purpose states that prospective residents will be encouraged to visit. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8,9,10 Service users can expect to be treated well by staff and to have their individuality, their privacy and dignity respected. Some procedures do not afford protect service users as fully as they might, and need reviewing or developing. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 11 EVIDENCE: The care plans and care records were in place and kept up to date appropriately in a locked filing cabinet in the office. The home used the 12 activities of daily living, designed by Roper, Logan and Tierney as the basic template of needs assessment. Other specific personal information required by regulation was present. The care plans had goals, and were reviewed monthly. Files contained a schedule of review dates, and it was found that one date that had not yet occurred had been initialled. A carer confirmed that reviews did occur, and described the process by which the senior carers reviewed plans. Full records of service users’ healthcare appointments were present in the care records. A chiropodist had visited the home during the week prior to the inspection. Training had been arranged for staff in nail care for later in the month. One service user was full of praise for the acting manager, who they thought was responsible for getting them to be ambulant after a period when they had not been walking. Risk assessments had been completed around the risks of falling and included actions taken to minimise this ongoing risk. Nutritional assessments and risk assessments in relation to the susceptibility of service users developing pressure ulcers were in place for two service users who spend all or some of their time in their beds during the day, they were quite basic, but were being reviewed regularly. One service user, who spends most of their time in bed, did not have a special mattress, and the manager advised that the service user had chosen to have their own mattress. The risk assessment did not indicate whether this was considered suitable. (The service user did not have any pressure areas.) One service user had bedsides in place, these had been risk assessed but had not been signed for by the service users GP. An example of good practice was noted in the case of one service user who was mainly restricted to bed had a risk assessment on vulnerability to abuse, which had identified that not having the alarm bell in reach would constitute a form of abuse for this service users, and prescribed action to ensure it was always accessible. The report of a pharmacy inspection undertaken by the chemist in January 2005 was seen. No errors had been found at that time. The medicine cupboard had been moved from the proximity of a heat source, and thus medicines stored within it were kept at a suitable temperature. Service users photographs were kept with the Medical Administration records (MAR sheets). Several MAR sheets had been printed with medicines which were no longer Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 12 prescribed by the pharmacist, and also with duplicate entries for the same medication. They advised that they had discussed this matter with the pharmacist but had been unable to achieve consitently correct MAR sheets. The acting manager had in all cases, crossed the duplicates or errors out and added an explanatory note. Bottles of medicine and creams were seen to have been dated upon opening. The home had a Boots dosset blister pack system. The carer giving the medication prepared it in the office next to the medication cupboard. They popped open all the relevant tablets for all the service users into the individual pots (which had service users names on them) and then took these in to the dining room and other rooms on a wooden tray and gave them to service users. This amounts to secondary preparation of medicines, and is considered to be unsafe practice. All service users rooms were seen. There was no evidence of continence aids inappropriately stored. Service users confirmed that their provacy was respected, and that even if their door was open, staff would still usually knock before entering. Two carers spoken with and observed demeonstarted a good understanding of service user’s needs. During the inspection, a service user fell over, and a gentleman who was attending the home to provide musical entertainment assisted a carer in picking up the service user. This was found to have taken place whilst the carer was fetching a hoist, and an incident report was subsequently completed. The carer understood clearly that service users must not be manually lifted. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13,14, 15 Service users were satisfied with daily life and with food at the time of the inspection, although a recent staffing shortage had led to some dissatisfactions with levels of care and with food. Service users can expect to be treated as and respected as individuals at the home: daily living patterns varied to suit the individual service users needs. EVIDENCE: All service users spoken with stated that the staff were “very nice” or made similar compliments. Other comments included “I’m very satisfied” and “I wouldn’t change anything”. Service users also confirmed that they were able to get up and go to bed whenever they wished to. All interactions observed between staff and service users were appropriate, professional and friendly. Service users confirmed that visitors were welcome at the home at all reasonable times and this accorded with the statement observed in the statement of purpose. Service users described a range of activities available to them within the home. These mostly took place during the afternoon and included card games, board games, bingo musical sessions. An entertainer providing old time music was visiting the home on the day of the inspection. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 14 One service user said “They are all very good to us, everything we want, we can go out in a wheelchair if we want, if there are three carers here, one will take you shopping” . This was confirmed by another service user, who said that they would also pop out and get you something if 3 were on shift. Service users confirmed that twice a week they had the option of a cooked breakfast. Breakfast is available from 8.30. One service user said that they usually came down last in the morning, at about 9.15, and there was never any difficultly having breakfast at that time. One service user responding to the pre inspection questionnaire, and one relative commented that the home did not have a cook, and one stated that the food was of a poor standard. The home’s cook was on maternity leave, and the acting manager confirmed that for a period of time, carers had undertaken cooking duties whilst on shift. The cook on the day of the inspection advised that they had taken on this duty two weeks ago, and now was the only cook. They were employed in addition to the carers on duty, although this worker was also a carer. Service users spoken to confirm that they had enjoyed their lunch on the day of the inspection, when they had a choice between a casserole or pork chop. They said that on Friday’s they generally had fish and chips, and enjoyed this. One service user said that the meals were quite good, good, but that the joint of meat at the weekend was generally tough which meant they could not eat it. Service users spoke of enjoying the food at tea-time, when a trolley came round with all sorts of sandwiches and cakes. They said that they got more or less what they asked for, and lately had had buns rather than cakes. Another said that they liked this because they could choose exactly how much they wanted, and they didn’t feel over-faced by the meal. Another said they liked it because they could have another sandwich if they felt like it. One service user said that they had to go the hospital several times a week routinely, and the home would fit in with them regarding meals. Two of the seven service users resident at the time of the inspection were spending most or all of their time in their rooms. One of these confirmed that staff took time to go into their room, through out the day, and spend time talking with them. They had their door ajar, with a door guard self-closing device in place, and confirmed that they liked their room, and the position of it, close to the front door, where they could see what was going on. The other person chose to use their room because of hearing difficulties, but was seen spending time in the communal areas of the home during the day. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 An appropriate complaints policy is in place and accessible to service users, however service users can be confident that the home would try to put matters right if they are aware of a problem without a complaint having to be made. The practices around the most recent recruitments did not fully protect service users. EVIDENCE: The home’s complaints policy was displayed on the wall. The complaints policy was examined and was satisfactory and in line with regulation. Plenty of copies were made available at the home, as were complaints forms. The acting manager stated that no formal complaints had been received at the home since the last inspection. It was not possible to verify this as the home did not have a complaints log. Complaints were discussed with the group of service users. One commented that if there is anything it is dealt with, and gave the example of water having been too cold in the mornings, being put right within 2 days. They said that they did not have to complain about this. Evidence detailed under standard 29 demonstrates that the home’s employment practices did fully protect service users. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21,23, 24 25, 26 A comfortable, clean, homely environment is provided for service users. Service users will be afforded a higher degree of protection if the risk assessments around hot outlets are developed, particularly in respect of the downstairs assisted bathroom, and also in respect of the fire risk assessment. EVIDENCE: The main lounge area leads off the main corridor and is adjacent to a veranda which is used as the dining area for a small number of users. Other users can have their meals in the lounge or in their individual bedrooms. Furniture in the communal areas is domestic in character, there are comfortable chairs and upright chairs, all of good quality. The home had a very large widescreen television in the main lounge. The home provided 4.8 square metres of communal space per service user at the time of inspection. This figure was reached on the basis of information previously submitted to the National Care Standards Commission (the previous regulatory authority). No measurements were taken during this inspection. Communal space included a main lounge, a Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 17 conservatory and a back lounge with a sofa bed – this room being also used for one sleep in staff member. The grounds of the home are tidy and safe, attractive and accessible to the service users, two were sitting outside in the afternoon, choosing to do this rather than to join in the musical activity that was taking place. All toilets are accessible and clearly marked both upstairs and downstairs. Each toilet downstairs is close to the communal areas and dining room. Sluicing facilities are separate from the service users toilet and bathroom facilities. There is a washbasin in each bedroom. The door to the downstairs lavatory outside bedrooms 9 and 10 had been replaced with one that did not contain frosted glass. Assisted lavatories were also located close to communal areas downstairs. The home had two operational assisted bathrooms, one located upstairs, which contained an assisted lavatory, and another downstairs – a suitable hoist having been provided since the previous inspection. This downstairs bathroom however, still had an uncovered radiator, and there was no thermostatic valve on the bath to control the water temperature. The upstairs bath had been fitted with a thermostatic mixing valve that ensured hot water flowed at close to 43°C. A book of temperature records was seen to be maintained, for other hot water outlets, and the recorded temperatures were consistently high. The hot water at one service user’s wash hand basin was measured at close to 49°C. A general risk assessment had been undertaken for the wash hand basins that were not fitted with these valves, however this was very basic. It did not include full consideration of the individual service users. For example, on some it noted that the service user was washed by carers, and so deduced that the sink did not present a risk. These service users were however capable of washing their hands and may reasonably choose to do so alone. Consideration must therefore be given to other factors such as skin condition. One service user said that they found the rooms a bit cool in the evening for their strip wash, but another said they did not find the rooms cool and that they always opened the windows. In addition to the hoists in the bathrooms, a new hoist had been recently purchased. Wheelchairs were seen to be appropriately stored. All rooms are individually and naturally ventilated with windows. There is emergency lighting throughout the home. Service users bedrooms are equipped with a single bed, wardrobe, chest of drawers, bedside cabinet, easy chair, mirror and washbasin. The inspector was advised that service users are encouraged to bring their own personal possessions into the home, and this was evident in the service users rooms. Emergency call bells were found to be in operation in each room and bathroom. The staircase to the first floor has a stair lift, which has a lap belt, although this does not negotiate the first two stairs of the flight, which are at Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 18 an angle. Radiators through out the home were covered, with the exception of the radiator in the downstairs bathroom. The home was clean on the day of inspection. No unpleasant odour was detected. Suitable laundry facilities were in place. All bathrooms were seen to have liquid soap, paper towels and bins. A number of carpets were seen to have been replaced or cleaned through out the home, and all were acceptable. The washing machine had a sluice cycle. A number of notices concerning care matters, including hand-washing techniques and a notice about different types of infectious diseases were pinned up on the walls in the hall of the home. This detracted from the otherwise homely feel of the building. Fire exits were seen to go through two service users rooms, one o n the ground floor, one on the first floor which led to a metal escape. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staffing was at an acceptable level at the time of the inspection, but should not fall lower than two carers and a domestic assistant during the day time. Although Criminal Record Bureau checks are not in place, the home’s practices around the most recently recruited staff had fallen short of the legal requirements, which put service users at unnecessary risk. EVIDENCE: The proprietor’s actual hours worked were marked on the staffing roster as is required by Regulation. Staffing rosters and discussion with service users confirmed that staffing levels were appropriate at the home with two carers available at all times of the working day to attend to care tasks. One staff member and a sleep-in staff member were available at night. The carers are also responsible for all of the domestic work in the home, but ancillary staff were available each day to attend to the kitchen duties. The proprietor was managing the home at the time of inspection and was supernumerary to these staff. Three of four pre-inspection questionnaires returned by service users relatives or visitors stated that there were not enough staff at times. This was discussed with the owner, and the inspector was advised that for a period up until two weeks ago, there had been no cook. Carers on duty had been required therefore to cook lunch during this period. A person had subsequently been recruited to the cooks post. This was shown on the rota as additional staffing, and the cook confirmed this. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 20 One service user required two person to assist them move, and on one occasion had been worried by the time it took to assist to their toileting needs. The files of two recently recruited members of staff were inspected. Both had the required information on file, including 2 references, proof of identity and Criminal Record Bureau checks. These staff had both been recruited prior to the receipt of the CRB checks, and reference numbers for PoVA first checks, however there was no evidence of the PoVA first checks having been done and confirmed prior to the staff being employed. The PoVA first had subsequently come through for one of these. Three out of 10 care staff held National Vocational Qualification (NVQ) Level 2 or above. Another was part way through NVQ 3, and another due to start NVQ 2the following day. A recently recruited member of staff had completed an induction. A manual handling training event had recently taken place which 6 staff attended. Evidence of individual training certificates was seen on staff files, however there was no training needs analysis or written plan available. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36,37,38 The ethos of the home reflects the kindness towards service users, consideration of their needs, and knowledge of them as individual people demonstrated by the acting manager. Managerial responses to inspection requirements and to the expressed wishes of service users have been demonstrated to be very positive, but a more proactive approach to managing the home, in looking for and anticipating problems and in having contingency plans, and in analysing and planning training would benefit the smooth running of the home. The lack of formal supervision for care staff must be addressed. EVIDENCE: There has been no Registered Manager since October 2003. The proprietor had been managing the home on an interim basis since the summer of 2004. They provided evidence of having completed two units of the registered manager’s Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 22 award, and advised of their intention to take on the position of Registered Manager. Staff meetings were held, the minutes of the last one which took place two months prior to the inspection were available. The acting manager advised that service users meetings were not held, as their being a reasonable small number of service users, they were able to speak with them individually. Service users and/or their families handled all financial matters, with the exception of a small amount of cash which the home kept on behalf of a small number of service users. A service user confirmed that if a member of staff popped out and got them something they received a receipt. A spot check was undertaken on two service users monies held. They were kept in individual locked boxes, include a book evidencing transaction, supported by two signatures. The record did not keep a running total of funds available, but the amounts held tallied with the records once these were calculated. A current, up to date certificate demonstrating appropriate Employers Liability Insurance for the business was on display in the hallway of the home. Other types of insurance cover, for example buildings and contents were not assessed at this inspection. The accident book was appropriately maintained, but was an old style format and does not comply with the Data Protection Act. A carer spoke with advised that they had not received supervision during the last five months. The manager advised that they had only commenced supervision with two staff, the two deputy managers. Fridge and freezer records had been maintained and were seen to show temperatures within the acceptable limits. The CoSHH cupboard was seen to be locked on two occasions during the day when it was checked. No hazardous substances were found elsewhere in the home. No product data sheets were available. Service users confirmed that the home had regular fire drills, and these were recorded in the fire log book. The homes fire risk assessment was inspected. It noted potential hazards, but did not consider the presence of these throughout the home, or include steps taken to minimise risks. For example, the home did have a separate policy on electrical equipment, but the fire assessment did not include any specific measures such as turning off TV’s at night. Also, a hall cupboard underneath stairs, which was not locked, contained fabric and paper items, but had not been considered on the fire risk assessment. Service users are allowed to bring in their own chair of bed, and the manager advised that these are always checked to ensure they meet modern fire safety standards, but this was not included in the fire risk assessment. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 23 Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 2 x x 3 1 2 2 Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 25 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. 2. Standard 9 18, 29 Regulation 13(2) 19(1) Requirement Medicine administration procedures must be reveiwed. Staff must not be recruited prior to the receipt of a satisfactory Criminal Records Bureau check, and must not be, under any circumstances, recruited prior to confirmation that a satisfactory PoVA check being received. Risk assessments on the possibility of pressure areas developing, including all actions agreed or considered to reduce risk should be developed. Risk assessments on all sinks need developing, and appropriate remedial action taken. A risk assessment and appropriate remedial action must be in place for the radiator in the downstairs assisted bathroom. A risk assessment and appropriate remedial action must be in place for the hot water at the downstairs assisted bathroom. The homes owner must write to confirm that they intend to be the Registered Manager. Timescale for action Immediate Immediate and ongoing 3. 8 13(4) 30/09/05 4. 25, 38 23(1)(a) 15/10/05 5. 25,38 23(1)(a) 30/09/05 6. 25,38 23(1)(a) 30/09/05 7. 31 Care Standards Act 2000 Section 11 30/09/05 Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 26 8. 36 18(2) 9. 37 10. 11. 12. 13. 38 38 17(2) Schedule 4(6)(f) & 18(2) 13(4) 13(4) All staff must receive ongoing regular formal supervision. This requirement has been made at a number of previous inspections. The accident book must be repalced with one that conforms to Data protection legislation. CoSHH product data sheets must be available in the home for all hazzardoius substances in use. The fire risk assessment must be reveiwed and developed. 31/10/05 30/09/05 15/10/05 30/09/05 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. 5. 6. 7. 8. 9. Refer to Standard 7 7 7 15 16 19 25 30 35 Good Practice Recommendations Service users GPs must be asked to sign risk assessments for bed sides. Risk assessments for pressure areas should be developed. Review shecules should not have dates initialed until a review has taken place Service users should be consulted about their satisfaction with the weekly roast. A complaints log should be set up. Notices regarding care practoices should be moved from the hall/corridor walls to a more suitable location. Service users should be consulted about the temperature of their bedrooms , with a view to ensuring service users are warm enough in the winter. A training analysis and plan should be drawn up. A running total should be maintained in records of service users monies. Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 5th Floor, St Vincent House Cutler Street Ipswich IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jeian I54-I04 S47113 Jeian V234008 050905 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!