Inspection on 11/04/07 for Jennifer Residential Care Home

This inspection was carried out on 11th April 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jennifer Residential Care Home 06/04/06

Jennifer Residential Care Home 09/09/05

Jennifer Residential Care Home 05/05/05

Jennifer Residential Care Home 02/08/04

Jennifer Residential Care Home 21/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Jennifer Residential Care Home 17 Pemberton Road Haringey London N4 1AX Lead Inspector Peter Illes Unannounced Inspection 11th April 2007 09:00 Jennifer Residential Care Home DS0000010718.V333057.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 Jennifer Residential Care Home DS0000010718.V333057.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. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jennifer Residential Care Home Address 17 Pemberton Road Haringey London N4 1AX 020 8967 7001 020 8352 2658 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) Mrs Reva Dhyll Mrs Reva Dhyll Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Limited to 6 people of either gender who have a mental disorder, excluding learning disability or dementia (MD) or a learning disability (LD). One specific service user who is over 65 years of age may remain accommodated in the home. The home must inform the regulating authority at such times as the specific service user vacates the home. 6th April 2006 Date of last inspection Brief Description of the Service: The Jennifer Home is a privately owned care home, registered to provide personal care for six younger adults who are assessed as having mental health needs or learning disabilities. The registered provider is also the registered manager. The premises consist of a large three-storey terrace house with a small garden at the front and a large garden at the back. There are four single bedrooms and one double bedroom. None of the bedrooms have en-suite facilities although bathrooms and toilets are readily accessible in all areas of the home. The main communal facilities comprising the kitchen, lounge and dining room are all situated on the lower ground floor. The home is situated in a residential area of Haringey and close to the shops, pubs, restaurants, transport facilities and other multicultural amenities of Wood Green. The stated aim of the home is to offer people living there the opportunity to enhance their quality of life by providing a safe, manageable and comfortable environment with the necessary support and stimulation to help them maximise their potential physical, intellectual, emotional and social capacity, all within a homely atmosphere. The provider organisation must make information available about the service, including CSCI inspection reports, to people considering living at the home and other stakeholders. The current weekly charge starts from £800 depending on the assessed needs of the service user. Additional charges may be made for items such as toiletries and newspapers. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took approximately six hours with the registered manager being present or available throughout. There were five people accommodated at the time of the inspection with the home having one vacancy. No new people had been admitted to the home since the last key inspection The inspection included: discussion with three service users, two of them independently; discussion with the registered manager, deputy manager and one member of the care staff independently and a tour of the premises. Further information was obtained from a tour of the premises and documentation kept at the home. What the service does well: What has improved since the last inspection? What they could do better: Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 6 Ten requirements are made at this inspection in the following areas: reviewing people’s care plans; records relating to meetings with health and social care professionals, reviewing risk assessments; contacting the relevant statutory authorities to assist an identified person enjoy more appropriate day time activity; further promoting the healthcare of people living at the home; staff qualification training; staff refresher training in core areas; staff supervision; quality assurance and an identified health and safety issue. A good practice recommendation is also made for the home to explore more social and recreational activities for people to try in the community. 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. Jennifer Residential Care Home DS0000010718.V333057.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 Jennifer Residential Care Home DS0000010718.V333057.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a policy and procedures in place to ensure that the assessed needs of prospective new people to be accommodated are known before they are admitted to the home to assist staff in addressing these needs. EVIDENCE: No new people had been admitted to the home since the last inspection. The files of four people were inspected and each showed that the required assessment information had been made available to the home at the time of their admission and that the person had been involved in the assessment process. The home’s admission policy was seen and indicated that full assessment information was required before new people were admitted to the home. The registered manager confirmed that this was the case. The inspector noted that annual reviews by relevant health and/ or social care professionals for some people were overdue and that the registered manager had written to the local mental health service to request that the reviews take place. It is important that these reviews take place to ensure that the home has access to information and the views of these professionals. The registered manager stated that the home continues to monitor any changing needs. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 9 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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs and how these are to be addressed are recorded in their care plans although the recording of how these are reviewed needs improving so that all concerned can be confident that the information shown is up to date. People are supported to retain and maximise their independence by making as many decisions as possible for themselves. People are supported to take responsible risks although the documentation regarding these also needs improving to show that the information shown is up to date. EVIDENCE: The four people’s files inspected contained clear care plans that related to assessment information available. It was noted that there was no record to indicate that the care plans had been formally reviewed by the home since the last inspection i.e. no signatures to indicate that the goals had been reviewed and none of the goals had been amended in the past year. The registered manager stated that the care plans were kept under review although accepted Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 10 that there was no record to evidence this or to confirm that all the goals shown on the care plan were still current. A requirement is made regarding this so that people accommodated, staff and other stakeholders can be confident that the care and support provided by the home is based on current information. People accommodated spoken to indicated that they were satisfied with the care and support they received at the home. It was noted from the visitors book that a number of health and social care professionals had visited the home to see people accommodated over the past three months. However, there was no record of these meetings in people’s files or what the result of those meetings had been. A requirement is made that a record of such meetings is kept in the person’s file and, where appropriate, what had been agreed to ensure that any additional guidance or information is recorded on individual’s care plans and is available to staff. The registered manager stated that people accommodated are encouraged to take as much responsibility as they can for themselves regarding their daily lives. Areas where people exercise choices or have their rights limited are recorded on their care plans. Limitations recorded included the need for identified people to be accompanied when out in the community. The registered manager stated that the home looks after bank account books for three people accommodated. These were shown to the inspector and it was noted that the bankbooks were in the individual’s names. The two other people accommodated manage their own finances. The registered manager confirmed that the home did not hold any cash for anyone accommodated. This included their weekly personal allowance that was given to them when received. People spoken to indicated that they were happy with how they were being assisted with their financial arrangements by the home. Adequate risk assessments were seen on the files inspected. However, like the care plans there was no evidence to show that these had been reviewed or amended since the last inspection. Again, the registered manager stated that the risk assessments remained current. A requirement is made regarding this. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 11 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, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people accommodated enjoy a range of activities including within the local community. However, more options for other people need exploring to further enhance their personal development and/ or their quality of life. Contact with relatives and friends is maintained and encouraged in accordance with the wishes of people accommodated. People’s rights and responsibilities are respected with any limitations appropriately discussed and agreed with them. They also enjoy balanced and varied meals of their choice that reflect their cultural preferences. EVIDENCE: Two people continue to attend external day services. One of these is Afro Caribbean and attends a day service that caters for people from that community. Two other people do not want to attend day services and confirmed this with the inspector. The fifth person told the inspector that they would like to attend an external day service or educational college and this was Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 12 recorded in their care plan. The inspector was also informed that the placing authority had agreed in principle for funding for external day services when this resident was admitted to the home. However, the registered manager stated that despite continuing enquiries being made by the home a suitable service could not be identified. It was noted that this continued to be a long term assessed need for this person and that it had remained outstanding since they were admitted to the home before the last inspection. It was further noted that the home had recently written to the local mental health service to request a review for the person including to explore day service opportunities further and was still awaiting a response. A requirement is made that the home contacts both the referring authority and the local mental health service to request a multi-disciplinary meeting as a matter of priority to progress this person’s need for appropriate day time activity. Evidence was seen that the placing authority for another person had arranged for an assessment for daily living skills to explore the possibility of this person moving on to more independent accommodation. One person continues to be fully independent regarding travelling and a second remains able to travel independently to identified destinations including their day services. The three other people need support from staff with travelling with this restriction being recorded on their files. People accommodated stated that they used local shops and other resources such as the hairdressers. The registered manager stated that two people would sometimes attend church and that they were supported to do so by staff, those people spoken to confirmed this. People accommodated are supported to undertake activities of their choice within the home. One of them told the inspector that they liked reading and using a dictionary to learn new words but would also like to go out to a day service or college to learn new things. The inspector was informed that watching television remains a favourite pastime for people. However, the majority of people accommodated do not regularly attend any social or leisure activities outside of the home in the day or the evening. The inspector was told that this was their choice and that people were even less keen to go out to such activities in the winter. People accommodated indicated that they were happy with their existing routines. A good practice recommendation is made that the home explores relevant options for all people accommodated to enjoy more social or recreational activities in the local community and that they are encouraged and supported to try these. Three of the people accommodated continue to have varying contact with their relatives and those spoken to confirmed this. This contact varies from one person seeing a relative most weeks with others having telephone contact and occasional visits throughout the year. Two people have no contact with relatives. The registered manager confirmed that relatives and friends are welcome and encouraged to visit the home. Staff were seen to interact appropriately with people accommodated and individual’s preferred form of address was recorded on their care plans. Three Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 13 people need some assistance or supervision with bathing and/ or washing their hair and this is recorded. People accommodated are encouraged to undertake household tasks where agreed and this is also recorded. Records of the meals supplied in the home were seen. These were satisfactory and included a range of options to meet the varying cultural preferences of the people accommodated, e.g. rice and peas. Three people are Afro-Caribbean and two are white, the registered manager stated that all of them continue to enjoy trying different food. The registered manager was observed having a conversation with one person about the need to have varied and healthful meals when that person was requesting chips with more main meals. People accommodated indicated that they enjoyed the meals at the home and were involved in deciding what meals they preferred. Three people were having breakfast when the inspector arrived at the home and were able to choose what they wanted. The kitchen was clean and tidy, the food was stored satisfactorily including being within its use by date and there was a good supply of fresh fruit and vegetables available. Jennifer Residential Care Home DS0000010718.V333057.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People accommodated receive appropriate personal support in accordance with their needs and preferences. They are supported in meeting their physical and emotional healthcare needs although an improvement in recording in this area would further assist health promotion. People accommodated are protected by the homes procedures relating to medication and by its effective administration. EVIDENCE: Two people remain generally independent with their personal care although the registered manager confirmed that they sometimes needed verbal prompts regarding their personal hygiene. The other three people needed some direct assistance with their personal care including assistance with bathing/ hair washing. Two people who received this direct assistance indicated that it was undertaken in a sensitive way that met their needs and preferences. One person stated that they felt comfortable with the support they received regarding their personal care. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 15 Evidence was gathered from records kept in the home, including the visitors book, that people accommodated receive support with their physical and emotional health from a range of health care professionals. This included evidence of contact with GP’s, hospital outpatient departments and check ups with a dentist and optician. People accommodated confirmed this. However, the home has a record sheet in each persons file to record any health care appointments they had attended. In two of the four files inspected no entry had been made on these sheets since the last inspection. The inspector was informed that those people had attended various healthcare appointments but that this had not been recorded on their file. A requirement is made that there is an up to date record kept in each persons file to show all healthcare appointments attended, and a record of the outcome where that is appropriate, to assist the staff in monitoring the overall health of people accommodated and to assist in positive healthcare promotion. The home has an appropriate medication policy that was seen. Records of medication received and disposed of by the home were sampled and were satisfactory. Medication and medication administration records were inspected for three people accommodated and were also satisfactory. Jennifer Residential Care Home DS0000010718.V333057.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People accommodated are able to express their views and concerns and have these acted on appropriately. They are also protected by a satisfactory adult protection policy and procedures that staff are familiar with. EVIDENCE: The home had a satisfactory complaints procedure that was seen to include the details of the Commission and that complaints would be responded to within twenty-eight days. The registered manager stated that no complaints had been received at the home since the last inspection. The registered manager stated that people accommodated were informed of the complaints procedure when they first moved into the home and could, and did, raise concerns with staff at any time. The inspector was pleased to see a copy of the complaints procedure was now displayed in the dining room of the home for information as was required at the last inspection. People accommodate indicated that they knew how to raise concerns when they wanted to. The home had a satisfactory adult protection policy and procedure, the home also had a copy of the local authority adult protection policy for the authority in which the home is located. The registered manager and staff spoken to were aware of the action they respectively needed to take should an allegation or disclosure of abuse be made to the home. The registered manager stated that no disclosure or allegation of abuse had been made to the home since the last inspection. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 17 Jennifer Residential Care Home DS0000010718.V333057.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is clean, well maintained, comfortable and that provides an environment that meets their needs. The home was clean and tidy throughout creating a pleasant environment for both those that live and work at the home. EVIDENCE: The home was seen to be suitably decorated and maintained throughout and met the needs of the people living there. The registered manager confirmed that the home had an ongoing maintenance and renewal programme with identified work to be carried out over the next twelve months. People were happy with their bedrooms that had been personalised as they wished. One person told the inspector that this home was much nicer than where they had previously lived. The home was clean and hygienic throughout during the inspection. Laundry facilities are kept separate from food preparing areas, and there was evidence that they were used regularly and appropriately. The inspector noted that a Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 19 repair to the laundry room floor had been completed as required at the last inspection. Jennifer Residential Care Home DS0000010718.V333057.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, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A relatively stable staff group support people accommodated although some staff need further training to ensure they have the up to date knowledge and skills to properly meet peoples assessed needs. People accommodated are protected by the home operating a robust recruitment procedure. Staff need to receive formal supervision to assist them further in understanding what is expected of them in their role and also to assist with their professional development. EVIDENCE: In addition to the registered manager the home was employing a deputy manager, two care workers and has access to an additional bank care worker when required. The deputy manager had started her national vocational qualification (NVQ) level 3 in care in 2005 but had taken a break from this. She stated at this inspection that she intended to restart this qualification course in September 2007. One of the two permanent care workers is currently undertaking NVQ level 3 in care. The national minimum standards require that at least 50 of care staff must achieve at least NVQ level 2 in care. A requirement is made regarding this. The staff rota was seen and was an accurate record of the staff on duty on the day of the inspection. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 21 At the last inspection a requirement was restated for the second time that the home must ensure that it has received two written references, including a verified last employer reference, for all prospective staff members before they start work in the home. The home had employed one new member of staff since the last inspection and the inspector was pleased to see that all the necessary documentation to evidence a robust recruitment procedure was available on that staff members file. The member of staff confirmed that the process was a positive one. Evidence was seen that staff had undertaken training or refresher training in some core subjects with a refresher course in infection control having just been completed. However it was noted that identified staff now need refresher training in safe administration of medication, first aid and food hygiene. A requirement is made regarding this to ensure that staff skills and knowledge remain up to date to assist in meeting people’s needs. The home has reviewed its supervision policy and the inspector was informed that this was now being implemented. However, there was only evidence of supervision notes for the deputy manager and it was noted that an identified member of staff has not received formal 1 to 1 recorded supervision in the past ten months; a requirement is made regarding this. That member of staff stated that they felt well supported by the managers in the home. Jennifer Residential Care Home DS0000010718.V333057.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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People accommodated, as well as staff employed, benefit from the home being managed by a qualified and experienced registered manager. However, further work is needed to assist the home in monitoring and improving the quality of the service it provides. Effective health and safety procedures contribute to protecting service users, staff and visitors to the home although these need reviewing with regard to fire safety. EVIDENCE: The registered manager has owned and managed the home for a number of years. She remains knowledgeable regarding the needs of the people living in the home, the provision of care to vulnerable adults generally and about the management issues involved in running a small care home. The inspector was pleased to learn that the registered manager has now completed her registered Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 23 manager’s award (RMA) and is currently awaiting her certificate in relation to this. However, the inspector’s view is that further management input is needed to both develop and evidence more robust systems in relation to reviewing people’s current needs via their care plans, staff training and staff supervision. At the last inspection the home had purchased a commercial quality monitoring system to assist in systematically consulting with and receiving feedback from people who use the service as well as other stakeholders such as relatives and health and social care professionals. Advice was given to the registered manager at that time about formalising this information when received into an annual development plan for the home. The inspector was disappointed to find that little progress had been made in this area. The inspector was informed that feedback was received from the people using the service on a daily basis and that the home also held meetings with them throughout the year. People living at the home and staff spoken to confirmed that meetings were held to consult on things such as Christmas preparations and meals that people prefer. However, no minutes or records of those meetings were available to show what had been discussed and/ or decided at the meetings. There was no annual development plan available for inspection. A requirement is made that the home must formally consult with people using the service, and with other stakeholders, and use this information to contribute to a written annual development plan to assist inform the home on how to further develop and improve the service it offers. A range of current documentation was seen to evidence the home takes health and safety seriously. This included: a gas safety certificate, an electrical installation certificate, a portable appliance certificate, evidence that the home’s water system was tested to minimise the risk of legionella and evidence that fire fighting equipment was regularly serviced. However, new fire regulations (Regulatory Reform -Fire Safety- Order 2005) have come into force from October 2006 and place increased responsibilities on owners and managers of registered care homes. A requirement is made that the home reviews its fire precaution arrangements and produces an updated fire risk assessment and an updated fire plan to ensure compliance with the new fire regulations The home must consult with the fire officer as part of this process. Jennifer Residential Care Home DS0000010718.V333057.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 X 2 2 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 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X Jennifer Residential Care Home DS0000010718.V333057.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 YA6 Regulation 15(2) Requirement Timescale for action 18/05/07 2 YA6 15(2) The registered person must ensure that the care plans of all people accommodated must show evidence that they have been reviewed at least 6 monthly so that people accommodated, staff and other stakeholders can be confident that the care and support provided by the home is based on current information. The registered person must 18/05/07 ensure that a record of meetings with health and social care professionals regarding people accommodated is kept in the person’s file and, where appropriate, what had been agreed to ensure that any additional guidance or information is recorded on individual’s care plans and is available to staff. The registered person must ensure that the risk assessments of all people accommodated must show evidence that they have been reviewed at least 6 monthly and risk management strategies recorded in people’s DS0000010718.V333057.R01.S.doc 3 YA9 13(4) 18/05/07 Jennifer Residential Care Home Version 5.2 Page 26 4 YA12 16(2) 5 YA19 13(1) 6 YA32 18(1) 7 YA35 18(1) 8 YA36 18(2) 9 YA39 24 care plans so that people accommodated, staff and other stakeholders can be confident that the risk management strategies are based on current information. The registered person must contact both the referring authority and the local mental health service for an identified person to request a multidisciplinary meeting as a matter of priority to progress this person’s need for appropriate day time activity. The registered person must keep an up to date record in each persons file to show all healthcare appointments attended, and a record of the outcome where that is appropriate, to assist the staff in monitoring the overall health of people accommodated and to assist in positive healthcare promotion. The registered person must ensure that at least 50 of care staff have achieved, or are registered on a course with the expectation that they will achieve, at least NVQ level 2 in care. The registered person must ensure that identified staff have update training in safe administration of medication, first aid and food hygiene. The registered person must ensure that all staff receive individual recorded supervision, at least six times a year, to assist them further in understanding what is expected of them in their role and also to assist with their professional development The registered person must DS0000010718.V333057.R01.S.doc 18/05/07 18/05/07 30/06/07 30/06/07 18/05/07 30/06/07 Page 27 Jennifer Residential Care Home Version 5.2 ensure that the home formally consults with people using the service, and with other stakeholders, and uses that information to contribute to a written annual development plan to assist inform the home on how to further develop and improve the service it offers. 10 YA42 23(4) The registered person must ensure that the home reviews its fire precaution arrangements and produces an updated fire risk assessment and an updated fire plan to ensure compliance with the new fire regulations The home must consult with the fire officer as part of this process. 18/05/07 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 YA13 Good Practice Recommendations The home should explore relevant options for all people accommodated to enjoy more social or recreational activities in the local community and that they are encouraged and supported to try these. Jennifer Residential Care Home DS0000010718.V333057.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Jennifer Residential Care Home DS0000010718.V333057.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. 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