Inspection on 09/07/07 for Jeian

This inspection was carried out on 9th July 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Jeian 07/01/08

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 Jo Govett Unannounced Inspection 9th July 2007 11:30 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 Jeian DS0000047113.V345513.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.V345513.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.V345513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2006 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. The current charges for the home were not available at the time of writing. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection of Jeian Residential Home and took place over six hours on 9th July 2007. It was a “Key” inspection, which 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. This includes information gathered at Random Inspections on 19th October 2006 and 2nd April 2007 which followed up on requirements made at the previous Key Inspection on 10th July 2006. Information from the Annual Quality Assurance Assessment (AQAA) completed by the Registered Provider (a requirement for all registered care services) is also referred to. The Registered Manager Mr Felix Chukwuma, was given an overview of the CSCI’s developing role in regulating social care services (Inspection for Better Lives). CSCI surveys were sent to a sample of people living and working at the home to complete if they wished. Surveys from five residents, eleven relative/visitors, two healthcare professionals and six staff were returned directly to the CSCI. We were able to speak with residents freely about their experience of living at the home. Comments from completed surveys and discussion with residents, staff and other interested parties have also been incorporated into this report. What the service does well: What has improved since the last inspection? Appropriate risk assessments were in place regarding the use of bedsides and an appropriate assessment had been undertaken for a resident with mild dementia. In addition the complaints procedure had been updated to reflect the fact that the National Care Standards Commission had been replaced by the Commission for Social Care Inspection, the local authority procedures for the Protection of Vulnerable Adults were in place and records required for Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 6 inspection purposes were accessible. The Statement of Purpose had been amended to reflect the accommodation of residents who have developed dementia whilst living at the home. In addition the building work to complete four additional bedrooms and en-suites had been completed to a good standard. 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. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Jeian DS0000047113.V345513.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4. (Standard 6 is not applicable to Jeian) Quality in this outcome area is adequate. Residents can expect the home to assess their needs prior to moving in. However, they cannot be certain that the home will then meet their health and welfare needs consistently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home applied to the CSCI to increase the number of residents living at the home. This followed the completion of an extension that added four new bedrooms. Because of a lack of communal space for fourteen residents (see section Environment) the Registered Manager decided to increase the home’s registration to thirteen instead of fourteen places and convert a downstairs bedroom into another lounge or dining area to provide additional communal space. The Statement of Purpose and Service User Guide displayed in the entrance hall of the home included all the elements required by regulation, but did not include information about the additional communal area. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 9 The records of two residents were examined and included evidence of local authority assessments and pre admission assessments undertaken by the home. The Roper, Logan and Tierney model of assessment had been used and covered twelve activities of daily living: maintaining a safe environment, 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. Four out of five residents who returned a questionnaire said that they “Always” receive the care and support they need. However, other sections in this report (Health and Personal Care, Daily Life and Social Activities and Staffing) include significant shortfalls that relate directly to how the home addresses resident’s health and welfare needs. Examples include lack of evidence of training, shortfalls around the records of medication and it was not evident that the home was staffed appropriately at all times. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is poor. Shortfalls in care planning and record keeping, (including medication) does not evidence that people living at Jeian will receive a consistent service that meets their health and welfare needs and safeguards them appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents care records were examined during the inspection. Each had an assessment in place and “Key Care Plans” for areas such as Personal Hygiene and Mobility. They had details of aims and actions for the provision of care. One of the plans had not been completed in full as the resident had only been living at the home for five days. Although they had a full assessment prior to admission, there was no information about their medication. The second resident had been at the home for a longer period of time and records were completed in more detail. Information on the care records did not always reflect the care required. For example a nutritional risk assessment had been completed and indicated a Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 11 “low” risk. However, other documentation showed that the resident’s weight needed to be monitored every two weeks (this had not been completed consistently). In addition they were prescribed supplement drinks, but Medication Administration Records did not record when or if they had been given. There was no evidence that the resident’s nutritional intake was being monitored or that any action had been taken following continued weight loss. The care plan for diet and nutrition stated “to ensure (resident) has a healthy well balanced diet”. However, (as noted in the following section Daily Life and Social Activities) the home had no planned menus and there was no evidence that they had consulted with qualified professionals in this area. The manager was asked to provide further information regarding this situation following the inspection. Both Healthcare Professional surveys returned were generally positive but one commented that the service could improve by ”regular training- diabetic, carb control, moving of patients”, and they were not sure if carers knew the reason behind carrying out some tasks. It was noted that where residents had identified needs around smoking, incontinence and skin viability, the risk assessments in place did not include guidelines for staff to reduce risks and promote health and welfare. It was observed that a resident who was clearly anxious about a situation, was not comforted or reassured by staff. A medication round was observed during the lunch time period. There were gaps in the Medication Administration Records (MAR). This was discussed with the Registered Manager and an immediate requirement was made for MAR sheets to be completed in full along with the reasons for any gaps. As noted above there was no record of prescribed supplement drinks being administered for one resident. The majority of residents spoken with and those who returned a questionnaire felt that the staff at the home were respectful. All five residents who returned a questionnaire said that staff “always listened and acted on what they say”. A Professional Health survey commented that there was, “Not always sufficient space to see resident’s privately”. It was noted that one resident was unable to get the attention of staff (except by calling for help) because they did not have access to a call bell. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 12 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 poor. It cannot be assured that residents will receive a wholesome, appealing and balanced diet. Further they cannot expect the home to take account of their individual abilities or actively promote their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback about activities and events at the home were varied. Three residents who returned a survey said that there were “Always” activities arranged that they could take part in, two said this was “Sometimes” the case. One staff survey said they thought that more activities and outings would improve the home. Two residents spoken with at the inspection said that they couldn’t join in sometimes because there was not enough room in the lounge area. This area was seen to be quite crowded during the inspection with no spare armchairs. Staff led the activities during the day and were seen playing dominoes, singing along with music and played a ball game with residents which they were seen to enjoy. There was no programme of activities displayed, although residents did say they did something “most afternoons”. Two residents were seen in Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 13 wheelchairs in the garden during the morning. As noted in the section Environment, there was no risk assessment to reflect that a third of the garden had been cordoned off with plastic building material and there were gaps in the fence, which allowed access to the garden from the main road. This could have posed a risk to residents, as they could not be seen from the main building because drying washing obscured them. One was cold and wanted to be taken inside but was unable to alert staff. In addition a resident who was smoking would have been unable to move independently or alert staff if they had an accident. Residents and their families/representatives raised no concerns about visiting and maintaining contact with friends. Previous concerns have been raised by CSCI regarding the home’s arrangements for the provision of food and staffing (also see the section in this report called Staffing). At this inspection the Registered Manager confirmed that a cook attended the home seven days a week between 10.00 and 13.00 and cooked the midday meal. Care staff still prepared and served tea/supper. Despite this a cook had not signed in on four out of the last nine days. The Registered Manager was unsure who had prepared the meals on these days. They stated that two cooks were employed with one working six days and the other covering on their day off. Both had food hygiene certificates, but no further training around nutrition and cooking for older people. The cook on duty said there was no planned menu but residents had a choice of whatever was available. On the day of inspection this consisted of a choice of frozen ready meals. For example chicken pie, lasagne and ham and chips. The choices of residents were recorded on a list kept in the kitchen. Records of resident’s choices for tea were mainly bread based (toast, sandwiches etc). Concern was fedback to the Registered Manager about the cleanliness of the kitchen, the incomplete food hazard analysis and that there was no record of cooked meat temperatures. The majority of residents stayed seated in armchairs in the lounge for their meals, while two sat in the conservatory, where there were tables and chairs. There was not enough room for all residents to be seated either in the lounge or the dining room at the same time. However, two residents spoken with said they liked to stay in their armchairs for meals. Of the residents who returned a survey two said they “Always” liked the meals at the home, two said this was “Usually” the case one said it was ”Sometimes” the case. The home had responded in part to an audit from an outside company in September 2006 where feedback from residents and relatives indicated that they would like more fresh vegetables, fresh fruit and salads. Although fruit was available in the kitchen, three residents spoken with did not know they could ask for it. One resident said it would be helpful if there was a sign up to tell them what they could have. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 14 As noted in this section and Health and Personal Care some care records and assessments did not show how residents were encouraged to exercise choice and control over their lives. Whilst more independent residents were seen to be able to ask for help or information, those who were less able did not have the same opportunities. For example one person did not have access to a call bell and another said they did not like their sandwiches but didn’t know they could ask for something else. They then said they felt they were being “awkward”. Jeian DS0000047113.V345513.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 adequate. Residents and their family/representatives know about and are generally satisfied with how the home deals with complaints. However, shortfalls in recruitment practices do not ensure that residents will be safeguarded from unsuitable staff and thereby protected from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Random Inspection on the 19th October 2006 recorded that the complaints procedure had been updated to reflect the fact that the National Care Standards Commission had been replaced by the Commission for Social Care Inspection. The local authority procedures for the Protection of Vulnerable Adults were in place and records required for inspection purposes were accessible. All five residents who returned a questionnaire said that they knew who to speak to if they were not happy and they knew how to make a complaint. Eight out of eleven relatives/representatives said that they knew how to make a complaint with nine also stating that that the home “always” responded appropriately. One person commented: “A few teething problems… but all sorted out now.” The homes AQAA submitted in May 2007 stated that no complaints or Protection of Vulnerable Adult (POVA) referrals had been made in the previous Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 16 twelve months. However, the CSCI had received concerns, elements of which were looked at during the last key inspection and were recorded in the published report 10th June 2006. In addition the Random Inspection on 19th October 2006 looked at concerns raised about the home, which included concerns around staff conduct and numbers and were discussed with the Registered Manager. They advised that all but one of the concerns raised had been reported to them. Thorough discussion with the manager and copies of correspondence seen indicated that they had responded appropriately to the concerns, however records did not clearly evidence action taken. There was no information at the home that defined what it considered a complaint to be or how staff should record it. All but one member of staff who returned a questionnaire stated they knew about abuse, protection and Protection of Vulnerable Adult (POVA) issues. However, as noted in the section called Staffing there were shortfalls in recruitment practice and records and a lack of evidence of training around protection. Jeian DS0000047113.V345513.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, 22, 24 & 26. Quality in this outcome area is poor. Whilst the majority of residents are satisfied with the accommodation, shortfalls around training and health and safety do not ensure that resident’s live in a consistently safe and wellmaintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As noted in the previous section of this report Choice of Home, a bedroom had been converted into a communal area, for all residents to access if they wished. On the day of inspection the Registered Manager opened this room for the inspector to work out of. There was a dining table and chairs in place but the rest of the bedroom furniture remained, for example the bedside cabinet, sink and wardrobe. No residents came into the room during the visit and none had a meal there. The wardrobe contained shampoo cleaner an old mirror and some cabling. In addition a fire escape route was signed through the room’s Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 18 back door, however, this had a security chain attached, which meant the door, could not be opened quickly in an emergency. Some areas of the home had a “shabby” feel. For example MDF radiator covers had not been painted and were ill fitted. There was another conservatory beyond the managers office, however a freezer, storage, medication trolley and cupboards in the adjacent corridor made it difficult for residents to access. The four new bedrooms and en-suites were completed to a high standard and looked welcoming and homely. This was in contrast to some of the older bedrooms that needed some redecoration. The Registered Manager shared further plans to develop the home and landscape the garden area. It was noted that a third of the garden had been fenced off by plastic building material. The manager stated that this part of the garden was not owned by Jeian and was being prepared for building work. The area was easily accessible to residents and whilst the manager stated he had asked the builders to erect a secure and safe fence there was no evidence of this or that an appropriate risk assessment was in place to alert and protect residents and staff. There was no evidence that staff had undertaken training around Infection Control. The Registered Manager stated that if staff had completed Food Hygiene training they did not need to do further infection control training. We discussed the difference between the two areas and the knowledge staff needed to deal with body fluids, continence pads, infectious diseases etc. This was also important because the staff roles and responsibilities at Jeian include domestic cleaning, laundry, cooking and personal care (sometimes in the same shift) which are all areas where cross infection could occur. The CSCI has raised previous concerns about the staff roles and responsibilities with the home (see the following section Staffing). As noted in the section Daily Life and Social Activities issues around the cleanliness of the kitchen, the incomplete food hazard analysis and lack of record of cooked meat temperatures were fed back to the Registered Manager. Jeian DS0000047113.V345513.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 poor. People living at the home cannot be assured that there will be sufficient numbers of staff on duty at all times or that they will have received all the appropriate training to ensure resident’s needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last Key Inspection (10th June 2006) identified concerns around staffing numbers roles and responsibilities. A Random Inspection 19th October 2006 found that it could not evidence that the home was suitably staffed at all times and care staff were also continuing to undertake domestic and cooking duties. Whilst the manager felt that staffing was adequate feedback gathered during the inspection did not support this. A further Random Inspection took place 2nd April 2007 which noted that the inspector was advised that care staff would no longer be relied on to prepare and cook main meals or be responsible for the cleaning of the home. The inspector was advised that a cook and domestic had been recruited and were ready to start work. At this inspection it was noted that staff were still completing domestic tasks and preparing meals. As noted in the previous section Daily Life and Social Activities, the staff signing in book did not evidence that a dedicated cook or domestic staff were on duty each day. Further the Registered Manager was unsure of who had cooked when there was a gap. It was observed that one Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 20 carer preparing the teatime meal, could not hear a resident who needed attention. The other carer was unavailable because they were assisting someone with personal care. The inspector rang a call bell in the lounge area to alert staff to the resident, however no one responded. Therefore the inspector asked the manager to observe the situation and respond to the needs of the resident, which they did. Whilst residents raised no specific concerns about staff and were generally complimentary, they did comment that staff were “always busy”. One said “they are always running through here (the lounge) to somewhere”. The home has two deputy managers who share responsibilities. One was on duty at the time of the inspection and confirmed they had a job description and had regular supervision with the Registered Manager. They had a National Vocational Qualification (NVQ) level 2. This was the only NVQ certificate the manager could find, although he did show the inspector confirmation letters to confirm some staff had enrolled on courses. The Registered Manager was asked for a training plan for the home. There was no overall plan but a record of staff training and induction was available. The manager was unsure if the home’s induction was in line with the Skills For Care Common Induction Standards. The AQAA submitted by the home made no references to specific training but stated that: “Service Users needs are met by the skill mix of staff. Many staff doing their NVQ II and III. Good Induction to new staff. Staff are trained and competent to do their jobs.” Four staff training files were looked at on the day of inspection. Training certificates were in date and on files for Moving and Handling, Food Hygiene, Administration of Medication (where applicable) and First Aid. Two of the four files had Abuse Awareness training certificates; one had evidence of Fire training. Whilst the home had advised the CSCI that training had taken place around Dementia none of the four files seen had evidence of this. As noted in the section Environment none of the staff had training around Infection Control. The Daily Life and Social Activities section of this report identified that staff who cooked meals at the home had basic Food Hygiene training, but no additional training around nutrition for older people. Three staff personnel files were seen. They included application forms references and records of Criminal Record Bureau (CRB) Disclosures. All three had gaps in the work history and there was no evidence that the reasons for this had been discussed with the applicants. There was no record about the decision to employ a staff member who had a disclosure on their CRB. Jeian DS0000047113.V345513.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, 37 & 38. Quality in this outcome area is poor. Information provided by the home cannot be relied on to be wholly accurate and shortfalls in key areas such as record keeping, health and safety and training, do not ensure that the home provides a consistent service or that residents will be safeguarded as far as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The proprietor is also the homes Registered Manager. All staff who returned a survey said that they felt the manager gave them enough support and met with them regularly. No specific concerns where raised about the manager or deputies during the inspection. Staff commented that they had to work as a team and “help each other out”. Comments from residents and relatives were generally positive about the management of the home. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 22 Previous inspections identified that all residents maintain control of their own finances, with the support of their families where appropriate. The inspector was not informed of any changes regarding resident finances and the AQAA submitted by the home did not refer to it. An outside organisation completed a “Residents and Relatives Satisfaction Survey” in September 2006. A report was provided to the home and the inspector was given a copy. The results corresponded to the improvements identified in the AQAA submitted by the home to the CSCI. Whilst the survey was generally positive, suggested improvements were identified around social activities food and staff numbers at night. The home had submitted an AQAA (a requirement as part of its ongoing registration). Feedback was given to the Registered Manager about the quality of the information provided and the expectation of the CSCI. The information provided was not detailed enough to show or evidence how National Minimum Standards were met or how good outcomes are achieved for people living in the home. Information was not provided on all the Key Standards and as noted in this report, some elements could not be relied upon to be accurate or a true reflection of the homes operation. The manager was advised to read further guidance about how important the AQAA is to their registration and regulation and where to find guidance about its completion (CSCI website). The Random Inspection on 2nd April 2007 found that appropriate health and safety certificates were available for inspection. The manager advised that there had not been visits by a Fire Officer since the extension had been built however appropriate equipment had been installed and a fire risk assessment was in place. The home had a new shaft lift fitted, this was situated within the new extension and enabled access to all bedrooms on the first floor. Water temperatures were thermostatically controlled and window restrictors had been fitted in the new first floor bedrooms. During this inspection the manager was asked to remove a chair blocking the kitchen door, which was also a fire route, and to ensure that fire exits could be opened immediately (i.e. without the need to use a key or slide a bolt/lock). Previous sections in this report have highlighted areas of concerns around aspects of health and safety, for example infection control, fire safety, staff numbers and environment. There were also concerns around the kitchen’s incomplete hazard analysis and no records of cooked meat temperatures. In addition it was noted that whilst there were certificates for electrical wiring, there were no records of PAT testing for the equipment used in the home. Other records were also incomplete for example around recruitment and there were significant gaps in medication records (see section Staffing and Health and Personal Care). Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 23 Jeian DS0000047113.V345513.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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 X 2 X 3 X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP27 OP4 Regulation 4(b)12(1) (a)18(a) Requirement The Registered Manager must ensure that the home is suitably staffed at all times. This is to ensure that the needs, health and welfare of residents are met consistently and they are safeguarded from potential harm. Timescale for action 15/09/07 2 OP9 OP4 13(2) 3 OP7 OP8 OP4 13(4) 4 OP8 OP10 OP19 OP22 OP38 OP4 12, 23(2) This is a repeat requirement from the last two inspections. When prescribed medication is 09/07/07 given to a resident Medication Administration Records must be completed in full to evidence that their health and welfare needs are being met. Where there is an identified risk, 15/08/07 a detailed plan of care must be in place that reflects the action to be taken, monitored and maintained to ensure that the resident’s health and welfare is safeguarded as far as possible. Residents must have means of 10/07/09 alerting staff when needed so that they feel safe and secure. Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 26 5 OP4 OP8 OP15 12(1) 16(i) 6 OP30 OP27 18 Residents must have the opportunity to choose from a menu that offers good quality, wholesome, varied, appealing and balanced diet in order to safeguard their health and welfare. All staff must receive training that reflects the needs of residents and their roles and responsibilities, so that their practice does not place people living at the home at risk. Requirements around training from the inspection 19 October 2006 have not been fully actioned. 15/09/07 30/09/07 7 OP8 OP12 OP14 OP18 OP26 OP27 OP30 OP38 OP18 OP29 18(1), 19(5) 8 7, 9, 19 Sch. 2 9 OP16 22 10 Jeian OP19 13(4) A training and development programme and budget must be completed to show how the home will ensure that on an ongoing basis staff will have the qualifications, skills and experience to meet the health and welfare needs of people living at the home. The home must have all the elements of Schedule 2 for new employees This includes full employment history, (together with a satisfactory written explanation of any gaps) and two written references (including a reference relating to the last period of employment of not less than three months duration which involved work with children or vulnerable adult). This is to ensure that residents are safeguarded against unsuitable staff. Complete records of complaints and how they have been addressed must be available at the home. All areas of the home including DS0000047113.V345513.R01.S.doc 15/09/07 15/08/07 30/09/07 31/08/07 Page 27 Version 5.2 OP38 23(2) 11 OP15 OP26 OP38 12, 13, 16. 12 OP19 OP38 12, 23(4) the garden must be used and maintained appropriately so that residents live in a safe and secure environment. Health and safety records must be kept to ensure people living at the home are protected from harm and are safe. (For example food hazard analysis, cooked meat temperatures and PAT testing). Fire routes and exits must be accessible and not locked or blocked to ensure that residents and staff can exist the building quickly and safely at any time. 15/08/07 10/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Residents should be consulted about their social and cultural interests to inform a programme of individual and/or group activities. Staff should undergo appropriate training to help them promote stimulation promote choice and offer a wider range of leisure opportunities. Further consideration should be given to how the home will ensure that less able residents are enabled to make choices about their daily lives. The home should ensure that there are enough dining room tables and chairs to seat residents during meal times. The room on the ground floor which is no longer a bedroom should be cleared, furnished appropriately and promoted to encourage residents and/or visitors to use it. The home should separate domestic and care responsibilities during shifts to further safeguard residents from potential risks such as infection control. 2 3 4 5 OP14 OP15 OP20 OP27 Jeian DS0000047113.V345513.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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.V345513.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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