Inspection on 20/08/07 for Jendot

This inspection was carried out on 20th August 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Jendot 3 Little Field Abbey Mead Gloucester GL4 4QS Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 20 and 21st August 2007 11:45 th Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jendot Address 3 Little Field Abbey Mead Gloucester GL4 4QS 01452 535963 F/P 01452 535963 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) Cardell Care Limited Mrs Carol Dorothy Dyer Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC Two service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability - (Code LD) Mental disorder - (Code MD) The maximum number of service users who may be accommodated is 3. First Inspection 2. Date of last inspection Brief Description of the Service: Jendot is a small home for up to three people on an estate in Abbeymead in Gloucester. It is close to community facilities and public transport. A detached house it provides each person with a bedroom and en suite facilities, with either an additional lounge or space for a sitting area. Shared communal areas include a lounge, kitchen/dining room and meeting room. There are pleasant gardens to the rear of the property. Fees for the home range from £1,352 to £1,500 based on individual needs. Copies of the Statement of Purpose and Service User Guide are displayed in the entrance hall. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in August 2007 and included two visits to the home on 20th August and 21st August. The registered manager and responsible individual were present for part of each visit. There were two people living at the home and a meal was shared with them. Three staff were spoken to. The responsible individual completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. Surveys and comment cards were distributed and returned during the visit. A selection of records were examined including care plans, staff files, health and safety records, some policies and procedures and medication systems. A number of records were being kept electronically. What the service does well: What has improved since the last inspection? This is the first inspection of this service. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 6 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. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to the information they need enabling them to make a decision about whether they wish to live at the home. An assessment of their needs and wishes are taken into consideration before offering them a place. EVIDENCE: The home has a Statement of Purpose and Service User Guide that have been produced in a format that is appropriate to the needs of people living there making good use of pictures and photographs. People wishing to move into the home were being supplied with copies of these documents. Two people moved into the home when it opened. They moved from a home which was closing and staff who had worked there with them were employed at Jendot. Several people were looking at the home with a view to taking up the third place. People living at the home described how they were being involved in the admission process meeting with prospective people during visits and overnight stays. A third person had moved into the home for a trial period when it became evident that the needs of the person could not be met by the home, falling Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 9 outside of the home’s category of registration. The person was quickly found alternative accommodation by their placing authority. During this time the management had been in contact with us about this admission. There was evidence that the home completes an assessment of each person’s needs using their own assessment process. This collates information during all stages of admission, visits to the person, visits to the home, discussions with placing authorities and family or carers. An assessment of care needs and care plan was obtained from placing authorities. The registered manager described how permission had been obtained from one person wishing to move into the home to obtain further information from healthcare professionals involved in their care. They agreed that where the needs of a person could be met this would be formally confirmed in a letter. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A person centred approach to care planning enables people to take control of their lives. People’s needs are being assessed and they are being supported to makes decisions about their lifestyles. Risks are being managed safeguarding people from possible harm. EVIDENCE: The care for both people living at the home was looked at in depth. This included reading their care plans, examining medication and financial records, and talking to them about the service they were receiving and to staff about the care they provide. People said they had been involved in the care planning process and had signed their care plans. Management confirmed that these documents were accessible to them and that plain English was used to endeavour to make them easy to read. Although there was an assessment in place for one person wishing to move to the home there were no copies of the assessment for the other two people on their files. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 11 Each person has a ‘Thumb sketch’ providing an overview of their personal details and a photograph. This is laminated and provides essential information that might be used if the person becomes missing. Care plans were in place for a range of physical, intellectual, emotional and social needs. For instance one person would like to go out independently of staff. He was being supported by staff to learn how to use public transport and to identify key buildings on his way home. Staff were heard going through this process with him prior to a trip out. This care plan referred to a risk assessment “Out Alone” which management confirmed would be in place when the time came for him to go out unsupported. Another care plan for one person referred to techniques to be used for staff to reassure people and indicated where this could be found. A record entitled ‘Challenging thoughts’ placed at the back of the file provided this information. Staff were observed following these guidelines during the visits. The registered manager said that each person would have a personal copy of ‘My Lifebook’ which provides information that is important to them. Daily notes were being kept for each person which include reference to each person’s identified needs and provided staff with a snapshot of their day whilst also referring them to other documentation they may wish to see. There was evidence that records were being kept on a daily basis upon the request of the local Community Learning Disability Team and that ABC and other monitoring charts were in place. Management stated that for one person there would be a three-month placement review but that the placing authority for the other person had said this was not necessary. The AQAA confirmed that ‘the individual is offered a three month period of assessment and a review at the end of that period’. People living at the home said that there were no restrictions in place and management confirmed this. Staff stated that people do not have formal advocates but that they choose to refer to their parents when they need advise. The AQAA confirmed that people have said they do not want an advocate. Information about the mental capacity act was displayed in the office and an easy read version was available. There were risk assessments in place that have been developed from care plans. Where appropriate the care plan refers to this. Some of the risk assessments were copies of documents from the previous placement. The responsible individual explained that these documents were in the process of being reviewed. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. Monitoring the nutritional content of meals will ensure that a healthy diet is being provided. EVIDENCE: People said that staff were supporting them to get to know their new neighbourhood. They said that they go to local shops and have been to a nearby pub. They were observed discussing bus routes and how to recognise which stop to get off at. They said that they continue to go to the town where they used to live and to the college there. One person had just received a certificate for a course that they had completed. Staff stated that they would be looking into college courses for the new term at the college in Gloucester. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 13 Staff support one person in a paid job, delivering newspapers. People said that they enjoy going to local football matches and to watch the cricket. They had recently been to Bristol to watch Gloucestershire Cricket Club play. They have also planned a holiday to Southport to take in a tour of Liverpool and Manchester United Football Clubs. Management stated that they held an open day prior to opening the home and invited neighbours to the house. They gave them information about how to express concerns should they have any and contact numbers including those of the Commission. People are supported to maintain contact with their relatives. One person was visiting their mother during one of the visits. There is a meeting room if they wish to meet people in private. One person has maintained contact with a member of staff from their previous home. People were observed helping to keep a clean and tidy home, cleaning communal areas as well as their own rooms. They also help with their laundry. One person said they like to help with the baking and preparation of meals. They were observed clearing the table after a meal and putting their dishes into the dishwasher. People were observed using keys to lock their bedrooms and choosing when to stay in their rooms and when to be in the company of staff. People were being involved in the choice of daily meal. Staff said that they go shopping each day and buy fresh ingredients when needed. There were apples available during the visit. Staff said that people do not eat much fruit; bananas were popular for a time but then have not been eaten for a while and would then go off. Meal choices were being recorded on the daily notes and indicated for a two-week period in August that there was a mixture of healthy and nutritional food such as lasagne and salad or roast and vegetables, and fast food such as burger or sausage and chips. During one week chips were provided four times. When spoken to staff appeared surprised and said that this would be monitored and alternatives would normally be provided. They said that they try to ensure that vegetables and salad are provided wherever possible and that people like spinach and broccoli. According to the notes over the two-week period the former had not been provided and the latter had been eaten once. People were observed having a lunch of their choice of rolls, tomato, crisps and a chocolate bar. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and wellbeing are being met helping them to stay well. There are inconsistencies in the way in which medication is administered that do not protect people from the risk of error or possible harm. EVIDENCE: The ‘Thumb sketch’ provided for people gives a summary of their likes and dislikes. Their care plans indicate the way in which they would like to be supported with activities of daily living. Management confirmed that they have continued to receive input from healthcare professionals based in their former locality. People living at the home have said that they do not mind whether female or male staff help them with their personal care needs. Daily notes indicated that times for going to bed and getting up were flexible and dictated largely by each person’s schedule of activities for the day. Staff sleep in but people choose when they wish to go to bed. Guidelines were in place should staff want to go to bed before people living at the home. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 15 Management confirmed that people were having access to a range of healthcare appointments although it was difficult to find this information. Record sheets were being completed for each appointment with an outcome of the meeting. It was not immediately clear from these records who the appointment had been with. The records were being archived with the daily notes. Records were eventually found confirming regular contact with doctors and an optician. Staff confirmed that people have access to the dentist and chiropody. Upon arrival at the home it was observed that medication had been put into pots and was placed by each person’s placemat on the dining room table. The medication administration record was checked and this had been signed before people had taken their medication. This is unsafe practice. It was also noted that the medication administered to one person for the day before had not been signed as given. A monitored dosage system is used and staff spoken with on a different shift explained the process for giving medication. The practice they described was satisfactory. They were also questioned about the procedure for investigating gaps on the medication record and their response was appropriate. The storage of medication and monitoring of stock levels was satisfactory. An ‘as necessary’ medication had just been prescribed for a person but a protocol had not been put in place. The communication book indicated to staff the reason for this and how often the medication was to be given. The temperature of the medication cabinet was not being recorded. Consent to administer medication forms were in place but had not been signed. The registered manager had copies of an assessment of competency that she was going to use with staff. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure that is clearly displayed in the entrance hall. People living at the home said that they would talk to management if they had any concerns. Regular house meetings and individual meetings with management and staff provide the opportunity for people to express any concerns they may have. One complaint was received recently from a person living at the home and was dealt with to their satisfaction. A record of the outcome of the complaint was kept and had been stored in the meetings file. A complaints folder was to be set up. Staff spoken with had a good understanding of abuse and the organisations whistle blowing procedure. They confirmed that they had completed training in the safeguarding of adults as part of their induction. Management said that they had completed training in the safeguarding of adults with the local adult protection team. Information in relation to local safeguarding procedures and the Department of Health guidance were available in the home. The homes safeguarding adults procedure was still to be put in place. (See also Standard 40) Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 17 Physical intervention was not being used in the home and care plans clearly indicated that this was not to be put into practice. Management stated that staff would be completing training in Crisis and Aggression Limitation Management (CALM) to provide them with the skills to use diversion, distraction and diffusion. Some staff have already completed this training but would need a refresher course. Staff were observed using diversion and distraction during the visits effectively. Financial records were examined and there was evidence that a robust recording system is in place. Care plans indicate the support needed by one person to manage their personal budgets. Financial records are maintained and receipts obtained for some purchases. Management said that they closely monitor financial records and any changes to spending habits would be noted. Records are signed as correct when checked. Bank statements were also being checked although there was no evidence of this. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is safe, clean and well maintained which promotes their independence and complements their lifestyle. EVIDENCE: Jendot is a detached house in a cul-de-sac position on a large housing estate. The home blends in with other houses in the vicinity. There is parking to the front of the property and a large secluded garden to the rear of the house. Each person has their own bedroom with en suite facilities that includes either a shower, bath/shower or bath and separate shower. All rooms have a sitting area or separate lounge adjacent to them. People said they have brought their own fixtures and fittings with them, for which inventories were in place. Communal areas are pleasantly decorated and fitted out with good quality furnishings. People have said that they would like to start decorating them with their own pictures and photographs. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 19 At the time of the visit the home was clean and tidy. One room had an unpleasant odour. Staff confirmed that they were in the process of dealing with this. The floor in the room had been laminated so that it could be washed and the appropriate bedding was provided. There was no liquid soap or paper towels in the laundry although all other communal hand washbasins had been supplied with these. There were plans to eventually convert the double garage into an additional room. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a satisfactory training programme that provides them with knowledge and skills to meet the diverse needs of people living at the home. The practice of working several shifts without a break may impact on the quality of care being provided. Failure to implement recruitment and selection checks on volunteers is not safeguarding people living at the home from harm or abuse. EVIDENCE: As mentioned previously most of the staff moved with the two people from their previous residence. They have considerable experience working with them, and knowledge and understanding of how to meet their needs. Of the staff team of five, three people have a NVQ in Health and Social Care and another person was completing their qualification. This exceeds the National Minimum Standards. The rota indicated that at times staff are lone working and at other times there is an additional person on shift so that people can go out separately if they Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 21 need to or wish to. A lone working policy and procedure was in place as well as an on call system. It was noted that two staff work very long shifts including one or two sleep-ins. This is not good practice and was discussed with management. They indicated this was the choice of staff. They must bear in mind the working time regulations and advice given by the Department of Health. They must consider the impact of working long shifts on both the people living at the home and staff. Staff confirmed that they have a job description and a contract of employment in place. Copies were inspected. All staff files were examined and contained information as required under the National Minimum Standards apart from the following: • • There were two references in place for one person but one was not from their former/last employer. One person had started before receipt of a Criminal Records Bureau check and although a risk assessment was in place, there was no evidence of a povafirst check being completed. Management stated that verbal confirmation had been given to them that the Registered Counter signatory Body had received this. During the visits it became apparent that people were helping out at the home in a voluntary capacity. There was no evidence that they had received Criminal Records Bureau checks or that an application form or references had been obtained for them. A training database was being set up so that management can monitor when refresher training was due. Each person had completed a Learning Disability Award Framework Induction provided by an external provider. Staff spoken with said this was an excellent course, providing mandatory training in addition to learning disability specific courses such as autism, epilepsy and sign language. They have a workbook to complete before they obtain a certificate. Training was also planned in the Mental Capacity Act, and challenging behaviour. Training was being arranged for the administration of midazolam. Management have completed an advanced Food Safety Award. Management stated that supervision sessions had recently started. There was evidence that each member of staff had a supervision contract in place and a copy of their first supervision. Supervisions are planned every two months. Staff meetings were also being scheduled and handover meetings were observed to be in place. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 and 42. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect. An improvement in key aspects of administration will ensure that people are safeguarded from possible abuse. Effective quality assurance systems were being developed involving people who live at the home. Health and safety systems protect people from possible harm. EVIDENCE: The registered manager has considerable experience working in this area of care and was previously registered as manager of another home in the area. She has the Registered Managers Award and NVQ Level 4 in Health and Social Care. She has a person centred approach and staff confirmed that she was developing a service that responds to the needs of the people living there. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 23 There were a number of areas that urgently need a management review including the administration of medication, recruitment and selection of volunteers and the hours worked by staff. A quality assurance system was being developed. The first unannounced Regulation 26 visit to the home had taken place and a copy of the report forwarded to the Commission. A health and safety audit has been developed and management said that this would be completed monthly. They also indicated that the quality assurance system would involve people living at the home and people involved in their lives. The Annual Quality Assurance Assessment had been supplied to us prior to the inspection and identified future improvements for the service such as ‘continuing to discuss with people the use of advocates, ongoing training for the manager and staff and ensuring detailed assessments are obtained from care providers.’ The AQAA identified that some policies and procedures were still to be put in place. Management stated that they had prioritised policies and procedures to be put in place. Several were sampled and these were satisfactory. The Commission for Social Care Inspection guidance on the administration of medication was given to management. Satisfactory health and safety systems have been put in place to regularly monitor the following: • • • • • • • Fridge and freezer checks Temperatures of hot food Water temperatures of outlets around the home Fire equipment and system checks Electrical installation Gas boiler servicing Hazardous products A comprehensive fire assessment was in place as well as an environmental risk assessment. Recommendations from an environmental health visit have been actioned. Jendot DS0000069863.V343279.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 2 X 3 X Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 25 NA 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. Standard YA17 Regulation 16(2)(i) Requirement The nutritional content of people’s diet needs to be monitored to ensure that they have access to healthy and wholesome food. Medication must be given directly to people and once they have taken it, the medication record must be signed. This is to safeguard people from possible error or harm. Medication administration records must be completed correctly and any gaps investigated to ensure that people receive the correct medication. Staff must not work long hours without a rest or break. The health and welfare of people living at the home must be promoted at all times. A reference from the last employer must be obtained and evidence of a povafirst check being completed must be provided. This is to protect people from possible harm or abuse. Any people helping out at the DS0000069863.V343279.R01.S.doc Timescale for action 30/09/07 2. YA20 13(2) 31/08/07 3. YA20 13(2) 31/08/07 4. YA33 12(5)(b) 30/09/07 5. YA34 19(1)(c) Sch 2.3,7 31/08/07 6. Jendot YA34 19(4) 30/09/07 Page 26 Version 5.2 Sch. 2 7. YA39 24 home must have full recruitment checks in place including a Criminal Records Bureau check and two references. This is to protect people from possible harm or abuse. A quality assurance system must be put in place that involves people living at the home in a review of the service they receive. 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA6 YA19 Good Practice Recommendations Assessments should accessible and should be reviewed. Where the placing authority does not wish to be part of a three-month review the home should continue with this meeting to confirm the placement. Healthcare records should be accessible so that appointments can be monitored. Records should clearly state who the appointment was with. People should sign the consent for staff to administer medication records. The temperature of the medication cabinet should be taken regularly to ensure that medication is stored at the correct temperature. An ‘as necessary’ protocol should be put in place for this medication giving staff guidelines about its use. 5. 6. YA22 YA23 A copy of the British National Formula should be obtained. A complaints folder should be put in place to keep complaints, concerns and compliments together so that they are accessible. Financial records should be signed and dated when they are checked, providing evidence that these checks are being carried out. DS0000069863.V343279.R01.S.doc Version 5.2 Page 27 4. YA20 Jendot 7. 8. 9. YA30 YA35 YA40 The sink in the laundry should have liquid soap and paper towels, to prevent the risk of infection. Mental Capacity Act Training should be provided in addition to information already available in the home. Policies and procedures should be put in place in line with the guidance in the National Minimum Standards. Jendot DS0000069863.V343279.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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