Inspection on 07/01/08 for Jeian

This inspection was carried out on 7th January 2008.

CSCI found this care home to be providing an Adequate service.

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 09/07/07

Jeian 10/07/06

Jeian 10/01/06

Jeian 05/09/05

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 Jeian Care Home 322 Colchester Road Ipswich Suffolk IP4 4QN Lead Inspector Tina Burns Unannounced Inspection 7th January 2008 09:45 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 Jeian DS0000047113.V357440.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. Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jeian Address Jeian Care Home 322 Colchester Road Ipswich Suffolk IP4 4QN 01473 274593 F/P 01473 274593 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) Mr Felix Emejulu Chukwuma Mr Felix Emejulu Chukwuma Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th July 2007 Brief Description of the Service: Jeian Residential Home is registered for up to thirteen older people. It is situated on the corner of several main roads in a suburb of Ipswich. It is close to Ipswich hospital, several local shops, bus routes and other amenities. The home has a communal lounge, which leads onto a conservatory dining area. In addition there is another communal room, which can be used by residents and their visitors for more privacy. There is an emergency call bell system in operation in each bedroom, toilet and bathroom. There is a small car parking area at the main entrance and a garden to the rear. Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an Unannounced Inspection of Jeian Residential Home that took place over a period of ten hours on the 7th and 8th January 2008. It was the homes second “key” inspection for the year 2007/2008 and focused on the key standards relating to Care Homes for Older People. The report has been written using accumulated evidence gathered prior to and during the inspection. The inspection process included reviewing a range of documents required under the Care Home Regulations including staff and residents records, staff rosters and a number of policies and procedures. A tour of the premises was also undertaken and interaction between staff and residents was observed. The inspector also spoke with several residents and two members of staff that were on duty on the day of inspection. The Registered Manager and Owner Mr Felix Chukwuma was present throughout the day and fully contributed to the inspection process. Information was also gathered from the homes Annual Quality Assurance Assessment (AQQA) submitted to the Commission in January 2008 and notifications made by the home since the last inspection. ‘Have Your Say’ surveys were not distributed to residents or their representatives on this occasion as survey forms had been returned to us prior to the last inspection in July 2007. However feedback has been received from health and social care professionals with an interest in the home. What the service does well: The home has a warm and friendly atmosphere and resident’s friends and relatives are welcomed and visit regularly. People living at the home were complimentary about the manager, the staff and the care they receive. Comments included “They are very good to us in here”, “They are very helpful and very friendly” and “They are all very pleasant”. Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home needs to better evidence that residents are consulted about their likes, dislikes and preferences; that they support residents to make choices and decisions and consult them about their social and leisure needs. Some areas of the home are ‘shabby’ and poorly maintained. There must be a programme of routine maintenance in place to ensure that residents live in a safe and well-maintained environment. Laundry and sluicing facilities are poor and must be improved so that the risk of infection is controlled. Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 7 There is no evidence that new care workers undertake thorough and comprehensive induction programmes. Consequently, we cannot be sure that they have the appropriate knowledge, skills or competencies to meet resident’s needs. Quality assurance systems should be developed so that the home has an effective self-assessment system in place to ensure that it is run in the best interests of residents. It was recommended that the home provides staff training around the promotion of activities, seeks guidance on how to improve meals and meal times and brings forward protection of vulnerable adults training for staff that have not yet had access to it. The manager was keen to resolve shortfalls identified during the inspection but a more pro-active approach is necessary to ensure that standards are maintained or improved. Consequently, it was further recommended that the registered manager, who is also the proprietor, consider ways of accessing professional supervision, advice and support. 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. Jeian DS0000047113.V357440.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 Jeian DS0000047113.V357440.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): 1, 3, 4 & 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect to have the information they need to make an informed choice about whether or not the home is suitable and able to meet their needs. EVIDENCE: The homes Statement of Purpose and Service User Guide was displayed in the entrance hall of the home and included all the elements required by regulation, including information about staffing and staff qualifications, private and communal facilities and space. The records of four residents were examined and included evidence of local authority assessments and pre admission assessments undertaken by the home. The home used the Roper, Logan and Teirney model of assessment that covered twelve activities of daily living: maintaining a safe environment, Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 10 breathing, eating and drinking, elimination, dressing and undressing, controlling body temperature, mobility, working and playing, expressing sexuality, sleeping and dying. There were also records of nutritional assessments; falls risk assessments and pressure sore risk assessments in place. Overall the assessments examined were adequate in terms of identifying resident’s primary needs but they did not consistently detail resident’s likes, dislikes and personal preferences. Residents spoken with were satisfied with the quality of care they received and felt that their needs were met. Comments included “They are very good to us in here”, “They are very helpful and very friendly”, “Yes, they are very good; I can’t complain about them girls”. Observations during the inspection were that residents were assisted appropriately and call bells were responded to in a timely fashion. Residents spoken with confirmed this was the case; one said; “I’ve got an alarm; I ring; they come straight away”. The homes Annual Quality Assurance Assessment (AQQA) and Service User Guide stated that introductory visits are encouraged and new service users can be admitted on a trial basis, to ensure the home is suitable for their needs. The home does not provide intermediate care. Jeian DS0000047113.V357440.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their ‘key’ needs met but they cannot be sure that their individual wishes and preferences will be taken into account. EVIDENCE: Four residents care records were examined during the inspection. Each had an assessment in place and “Key Care Plans” for areas such as Personal Hygiene, Mobility, Healthcare, and Nutrition. They had details of aims and actions for the provision of care in these areas however they were not entirely person centred and tended to focus on physical needs. Information about their preferred daily routines, how they make choices in their lives and how the home intended to support them with their individual social, leisure and religious or cultural needs was not included (see section; Daily Life and Social Activities). Findings at the last inspection, notifications received from the home and consultation with health and social care professionals have raised some concerns about whether or not the home is able to meet residents health care Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 12 needs. However since the last inspection two safeguarding adult investigations found that concerns reported about the care of two residents were unsubstantiated. Records examined during the inspection, residents spoken with and reviews undertaken by the local authority indicate that overall residents health care needs are met and individuals are supported to access health care services such as GP’s, chiropodists, district nurses and hospital outpatient services. Records evidenced that the out of hours doctor and the paramedics had been called to one resident when they were unwell. Another resident said that the manager had recently taken them to a routine hospital appointment. They said; “He took me himself, it took the best part of a morning”. At the last inspection there were concerns about monitoring nutrition and food intake. However at this inspection there was good evidence that residents weight was regularly monitored and where applicable food supplements were recorded on Medication Administration sheets. The issue about one resident that was unable to use a call bell at the last inspection had also been resolved. The call bell was now gently secured to their person so that they could reach it. They did not look distressed by the bell and the bell had not damaged the resident’s skin. There was also an appropriate risk assessment in place signed and agreed by the residents GP and next of kin. During the inspection staff were observed attending to the resident when they called out or used their call bell. Medication Administration Sheets examined during this inspection were satisfactorily completed. Staff spoken with, records seen and discussion with the manager indicated that staff responsible for administering medication had been appropriately trained. With the exception of controlled drugs the medication was stored in a locked medication trolley and medication was administered to residents directly from the trolley. The controlled drugs were stored separately in a locked metal tin in another locked cupboard as an interim measure. There was evidence that a controlled drugs cabinet had been ordered from the chemist. The manager had put a register of controlled drugs in place and two people had signed for all controlled drugs administered. At the time of inspection the manager confirmed that the only medications being selfadministered by residents were inhalers. Discussion with the manager and the resident concerned indicated that potential risks had been considered and were minimal. However, this was not documented in a risk assessment. The manager agreed to undertake a written risk assessment for the individual concerned regarding the self-administration of their inhalers as a matter of priority. Residents spoken with and observations made indicated that residents are treated with respect and their dignity is upheld. All residents have their own bedrooms and can see health care professionals or personal visitors in private if they wish. Jeian DS0000047113.V357440.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 adequate. This judgement has been made using available evidence including a visit to this service. Resident’s can expect their friends and families to be made welcome at the home, however they cannot be sure that they will be appropriately supported to make choices about their daily lives and social activities. Overall, meals are suitably nutritious but residents cannot be certain that they will find them consistently appetising. EVIDENCE: On the morning of the first day of the inspection, seven residents were observed in the main communal lounge; one was reading a newspaper, four were asleep in their armchairs and two were watching television. In the afternoon two staff were seen sitting and chatting with them, one was playing dominoes with one resident and the other was organising a game of bingo. Later three of the residents were seen using the smaller ‘quiet room’. The remaining residents spent their time in the privacy of their own rooms. Activities recorded for the month of December indicated that they were mainly organised by care staff during the afternoon and included ball games, Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 14 dominoes, old time music, music with exercise, and reading news. Since the last inspection the manager had also organised visits from the mobile library. Residents spoken with indicated that they generally amused themselves by watching television or reading. Residents spoken with and information provided in the homes Annual Quality Assurance Assessment indicated that social activities is an area in which the home could improve, most particularly by providing opportunities for outings. Residents did confirm that the home is good at celebrating occasions such as birthdays and Christmas. They also confirmed that their relatives and friends are always welcome at the home. Although the homes AQQA says that “Service Users are helped to exercise choice and control over their lives” there was no clear evidence to confirm that residents are consulted about matters such as an activity programme or menu planning, and care plans did not detail how the home intended to support individual residents with their social contacts, personal interests or leisure needs. Evidence indicated that since the last inspection the manager had recruited two cooks and care staff were no longer relied upon to prepare and cook meals. However Individuals spoken with confirmed that the food was generally pre packed or frozen rather than freshly supplied. A visit to the kitchen confirmed that it had limited space and facilities to prepare and cook thirteen meals with only a domestic cooker in place and a small work surface. However, the menu indicated that overall a varied and balanced diet was on offer. Plans seen and discussion with the manager confirmed that the home was being extended to provide more dining space and a new kitchen. Preliminary work on the extension commenced during the inspection. Observations made and residents spoken with confirmed that they could take their meals in the main lounge or the adjoining dining area/sun lounge, the ‘quiet’ room or in the privacy of their own rooms. The dining area was furnished to seat eight residents at two tables and the quiet room had the capacity to seat the remaining residents. During the inspection most service users chose to eat in one of the communal areas but some did have their meals in their rooms. Residents confirmed that they were asked to select from a choice of two options each morning, they could also request an alternative if they wished. Comments regarding the food were mixed and included “The food is pretty good generally”, “Its good food really”, “Sometimes it’s a bit bland” and “I don’t like the food”. Several residents were observed on the first day of inspection eating fish in batter, chips and vegetables for their midday meal. Most complimented it. One care worker spoken with said that the food had improved a great deal. Jeian DS0000047113.V357440.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 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their complaints listened to and taken seriously. However, staff training arrangements do not ensure that residents are appropriately protected from abuse. EVIDENCE: The home had a copy of their complaints procedure displayed in the entrance of the home and available to residents and visitors. It detailed all information required about how to make a complaint and who to contact. Discussion with the manager and information provided in the homes AQQA indicated that there had been no complaints made since the last inspection. At the time of inspection there had been no complaints received by the Commission since our previous visit to the home. Residents spoken with during the inspection confirmed that they felt able to raise any concerns or complain directly to the manager. Comments made indicated that the manager routinely checks with all the residents individually whether they are happy or have any problems or issues. Comments included; “He always comes in to see if I am happy”, “He is a very nice man he is; he is very, very kind man I must say” and “he’s friendly, very friendly”. The homes ‘AQQA’ confirmed that the home works within the framework of the Suffolk Inter Agency Safeguarding Adults procedures. The home has made no Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 16 safeguarding adult referrals since the last inspection although there have been two concerns about resident’s health care that have been dealt with by the local authority safeguarding team (see section on Health and Personal Care). The ‘AQQA’ confirms that there is also a ‘whistle blowing’ policy in place so that staff are able to raise any concerns. Records seen and staff spoken with indicate that established staff members have undertaken safeguarding adults training but recently appointed staff have not. It was not clear whether adult protection procedures are discussed during staff induction. The homes training plan indicated that abuse awareness training for all staff is programmed for September 2008. Jeian DS0000047113.V357440.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, 20 & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Overall the home is warm and comfortable but residents cannot be certain that communal space and facilities will meet their needs. EVIDENCE: A tour of the communal areas was undertaken during the inspection and three residents were visited in their individual rooms. Since the last inspection the bedroom that had been converted into a communal area for residents had been improved. The bedroom furniture had been removed and replaced with comfortable seating and dining furniture and the hand basin had been removed. A new carpet had also been laid. Different residents were observed using the room at different times during both days of the inspection and positive comments were made about the extra space. In addition, and contrary to findings at the last visit, there was no chain on the fire escape door and it was easily opened. The inspector was concerned about the potential hazard of Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 18 a low television shelf in the room that had sharp corners but it was removed during the inspection. A second conservatory accessed through the office was clearly being used as a staff sleeping in room and was not routinely used by residents. The main lounge continued to be the central communal area where most residents congregated. The room was pleasant overall but not large enough to comfortably accommodate everyone and at busy times it felt ‘cramped’. This was not helped by the fact that the lounge is in fact also a passageway from one side of the home to another. At the time of inspection the home was warm and areas seen were clean and free from unpleasant odours. Some of the décor and fixtures and fittings were out dated and “shabby”. For example, MDF radiator covers had not been painted and were unsightly and what had once been a front door was being used as an internal toilet door. This was in contrast to the four new bedrooms with en-suites that were completed in 2007. Discussion with the manager indicated that they did not have a maintenance programme in place. Records examined and staff spoken with indicated that infection control training had taken place in October 2008. The Laundry room provided adequate washing and drying facilities but there was no sink or hand basin and the floor and wall finishes were not impermeable or easily cleaned. The manager advised that the adjacent toilet and shower room that was previously used as a staff toilet was now used as a sluice area. Incontinence pads were also disposed of in this area using yellow hazardous waste bags. There was a small hand basin in this room but facilities to clean bedpans were inadequate. It was also identified that a ‘fold up’ sink provided in an upstairs communal WC was unsuitable and likely to discourage hand washing. Discussion with the manager, plans seen and observations made during the inspection confirmed that the process of building a second extension had begun. The manager advised that as well as three additional en-suite bedrooms the building works would increase the communal lounge and dining areas and provide a new kitchen and office. The manager also indicated that he would look at how the sluice and laundry facilities could be improved as part of the extension plans. Records seen, staff spoken with and observations made confirmed that care workers were no longer responsible for the cleaning. The two members of staff employed as cooks were also employed as domestics during the afternoon when kitchen duties were quiet. A copy of the last health and safety inspection undertaken in May 2007 by a local authority Health and Safety Officer said “No health and safety issues – all satisfactory”. A fire inspection undertaken in July 2007 had identified deficiencies and made two recommendations. The first was to provide fire routine notices at each call point and this had been done. The second was to Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 19 provide three additional fire extinguishers of specific types. At the time of the inspection one had been provided; the other two were ordered at the time. A tour of the garden was not undertaken on this visit but a view from the rear conservatory confirmed that building works taking place on neighbouring grounds had been appropriately fenced off. Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by sufficient numbers of staff and protected by the homes recruitment procedures. However, they cannot be sure that all staff will be suitably trained or competent to meet their needs. EVIDENCE: Previous inspections have identified concerns around staffing numbers, roles and responsibilities but on this occasion discussion with staff and residents, records examined and observations made indicated that the home is adequately staffed and care workers are no longer relied upon to prepare and cook meals or clean the home. Residents spoken with confirmed that they felt that their needs were met by kind, caring, and competent staff. Comments were all positive and included; “They are good staff; they are very helpful and very friendly”, “They are very good to us here”, “I’m well looked after” and “They are very, very good”. Information provided in the homes ‘AQQA’ and records examined indicated that over fifty percent of care staff employed by the home had achieved or were working towards NVQ level two or above. Training that had taken place since the last inspection included infection control and dementia awareness. Records also indicated that with the exception of recently employed staff, care workers had been provided with training in moving and handling, food hygiene, Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 21 administration of medicines, first aid, fire safety and protection of vulnerable adults. Records examined and staff spoken with indicated that care workers induction programmes were based on the Skills For Care Common Induction Standards, however there was not a satisfactory or accredited assessment system in place to evidence that they had achieved a minimum standard of knowledge, skills or competencies. Moving and handling training was outstanding for at least two staff employed since the last inspection although there was evidence to confirm that all outstanding moving and handling training was planned for later in the month. At this inspection the manager produced a staff training plan for the year 2008. It evidenced that a budget of three thousand pounds has been allocated to provide a range of staff training over the next twelve months. Four staff personnel files were seen. They included photographs, application forms, written references, verification of identity, statement of health and evidence of Criminal Record Bureau (CRB) Disclosures. One member of staff was working before their CRB check was returned but a satisfactory POVA first check had been undertaken. The manager advised that they were not working unsupervised. Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 22 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 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall residents can expect their health, safety and welfare to be promoted and protected. EVIDENCE: The manager confirmed that the home did not manage resident’s money; Residents retained responsibility for their own finances with support from family or representatives where appropriate. On the day of inspection hot water temperatures were tested at four outlets. One was at a satisfactory temperature of 43.8 degrees centigrade and the other three were found to reach temperatures as high as 64 degrees to 68 degrees centigrade. This was immediately reported to the manager. The Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 23 manager very promptly tested temperatures at all outlets and informed staff and residents of the risk. He also called a contractor out who confirmed that there were faults with the individual thermostats. The manager arranged for the contractor to attend to the fault and put interim safety measures in place that included a staff alert in the daily ‘log’ book and warning signs at each outlet. Records examined indicated that generally the manager tested the water temperatures every two weeks and they were usually on or around 43 degrees centigrade. Health and safety records seen and found to be satisfactory included an electrical appliance test certificate, a Fire Fighting Equipment certificate of maintenance, a Fire Alarm Service Certificate, and a Fire Service Log book. The ‘AQQA’ also confirmed that other equipment appropriately serviced or tested within the last year included the stair and shaft lift, the emergency call system and the heating system. Records held relating to Food hygiene included temperature records for the refrigerator, the freezer and cooked meat. The cook on duty had completed a basic food hygiene awareness course but discussion with the manager regarding food hygiene legislation, food hygiene training and HACCP’s (Hazard Analysis and Critical Control Points) indicated that further training for staff working in the kitchen would be beneficial. The manager agreed to consult the environmental health office for advice about training in this area. The manager submitted their second Annual Quality Assurance Assessment (AQQA) to the Commission in January 2008 as required and on time. Overall the information provided was more detailed than the first and identified a number of improvements that have been made since the last inspection. However, it did not consistently provide enough information to show what they do well or evidence that they have thorough and reliable systems in place to assess their strengths and identify the areas that need to be improved. The proprietor, Mr Felix Chukwuma is also the homes Registered Manager. He is a registered nurse and has completed the Registered Managers Award. There were no concerns raised about the management of the home by staff or residents during the inspection. Mr Chukwuma was helpful and co-operative and addressed some of the issues raised by the inspector at the time of inspection however there are still shortfalls in standards. It was not clear whether or not he ensured that his own training and development needs were met. There was no access to the Internet from the premises for up to date guidance and information. Jeian DS0000047113.V357440.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP19 Regulation 23 Requirement A programme of routine maintenance and renewal must be produced and implemented to ensure that residents live in a safe and well-maintained environment. Adequate systems must be in place to manage the sluicing and cleaning of commodes and hand washing facilities so that the risk of infection is controlled. There must be a comprehensive induction process in place to ensure that new care workers have the appropriate knowledge, skills and competencies to meet resident’s needs. Timescale for action 18/02/08 2. OP26 23(2)(k) 13(3) 07/02/08 3. OP30 18(1)(a) 25/02/08 Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations Residents care plans should be developed to include details of their preferred daily routines: their likes, dislikes and preferences and details of their social and leisure needs. Staff should undergo appropriate training to help them promote stimulation, promote choice and offer a wider range of leisure opportunities. The manager should refer to the report “The highlight of the day” for guidance on how to improve meals and meal times. The Protection of Vulnerable Adults Training planned for September 2008 should be brought forward for staff that have not yet attended training in that area. The manager should consider how to access appropriate professional supervision, advice or support. Quality Assurance systems should be developed so that the home self monitors its performance more effectively. 2. 3. 4. 5. 6. OP12 OP15 OP18 OP31 OP33 Jeian DS0000047113.V357440.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Jeian DS0000047113.V357440.R01.S.doc Version 5.2 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. 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