Inspection on 24/04/06 for Jennifer`s Lodge

This inspection was carried out on 24th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Jennifer`s Lodge 03/10/08

Jennifer`s Lodge 05/10/07

Jennifer`s Lodge 20/12/05

Jennifer`s Lodge 15/09/05

Jennifer`s Lodge 29/03/05

Jennifer`s Lodge 06/09/04

Jennifer`s Lodge 10/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Jennifer`s Lodge 105 Wellmeadow Road Catford London SE61HN Lead Inspector Sean Healy Unannounced Inspection 24th April 2006 10:00 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 Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 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. Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Jennifer`s Lodge Address 105 Wellmeadow Road Catford London SE61HN 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) 0208 4612516 Mr Eric Blackwood Mrs Jennifer Blackwood Mrs Jennifer Blackwood Care Home 4 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. up to 3 persons aged 65 years and above, one of whom may be suffering from dementia to include one person aged 55 years or above 20th December 2005 Date of last inspection Brief Description of the Service: Jennifer’s Lodge is a small, privately owned care home providing support and accommodation for four older people. Mr and Mrs Blackwood are the proprietors, and Mrs Jennifer Blackwood is the registered care manager. The home is located on a residential road with direct access to public transport and a short distance from the main shopping area of Catford. There is on street parking available but no off road parking. The home is laid out on the ground floor and first floor of a detached house, and provides a service to four older people. Each resident has their own bedroom, which has been adapted to have en-suite toilet facilities. Changes are required to ensure that the current Certificate of Registration accurately reflects the categories of residents that the home can admit. Services are provided for some residents who have mental health and learning disability support needs, which are not reflected in the Certificate of Registration. The provider’s email address is: jenniferbp@hotmail.co.uk Information about the service provided is made available to current and potential service users in the homes Statement of Purpose, Service Users Guide and in the homes brochure. The recent CSCI report is given to service users with the Statement of Purpose at the time of admission, and a copy is kept in the main entrance hall. At 24th April 2006, the homes fees range from £330- per week to £4oo- per week, which covers all of the homes charges including food. Residents have to pay for other personal expenses such as hairdressing, transport and personal shopping. Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 24th April 2006, and was concluded on the 5th May 2006, having received important comments from a number of professionals, and resident’s family members. The Registered Manager and two care staff were involved in the inspection, and three residents gave their views of their experience of living in the home. Two social workers involved in placing people at the home, and a health professional, who visits the home very regularly, also provided comments for this report. A range of documents were examined and a tour of the building took place. The inspector met all four current residents, and spent time with three residents who were able to express their views on the service provided at the home. There are currently no vacancies. What the service does well: What has improved since the last inspection? Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 6 There is now a good revised Adult Protection policy in place, which reflects the requirements of the local authority’s policy and better protects residents from risk of abuse. Care plans have improved and these now include social and leisure care needs for each resident. Though more improvement is needed to get more information onto these plans, the plans are clear and more easily understood by residents and family. Residents said they are asked their opinions about changes being made and are happy that personal leisure interests are being included. The manager has tried to make sure that all residents have had annual care reviews with social services, and reviews have been planned for completing all reviews by the end of June 2006. One service users who needed help from an Occupational Therapist has had an assessment, and the home has bought in Advocacy support for any resident who needs it. There is now better recording and receipting of small amounts of money held by the home for resident’s personal expenses. The dining area has been extended and is bright and easily accessible. One resident was asked if he’d like to move to another room instead of being at the end of a hallway away from others. Having agreed to this suggestion he was helped to move to a larger more central room. This resident said he was very happy with the move. The fire safety officer and Water Board’s recommendations have been met, making the home safer. Staff training has improved and there is good progress on staff becoming qualified in NVQ level two qualifications. What they could do better: The home’s Statement of Purpose and Service Users Guide and brochure need to have additional information included about mental health and Learning Disability support currently provided, so that anyone who intends to move to the home in future can make an informed decision. The Mental Health and Learning Disability services provided must be agreed as adequate by relevant social workers and if agreed included in the home’s Registration Certificate. More work needs to be done to include more specific information in care plans about details of activities for individual residents, and some plans or guidance for staff need to be written so that these activities are supported by staff and recorded. Better guidance for staff is needed about how best to help residents during personal care, in order to avoid risk of falls or injury. Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 7 The home should provide information for service users and relevant family members about annual care reviews, and always invite them to reviews, or offer other ways of having their views included if they prefer not to attend. The key-working system needs to be put in place, and staff need to have formal training in key working so that individual residents needs are consistently met. More detailed records of some health issues should be kept such as dietary issues and mental health, and recommendations made by the Occupational Therapist need to be included in the relevant residents care plan. The home’s staff rota needs to show more clearly the times when a second member of staff is on shift to provide support and the times the manager is available to provide such support. As part of the planned annual care reviews the home needs to formally agree with social workers that staffing levels are adequate. All staff need to have a clear job description showing what is expected of them and whether they are employed as paid staff or volunteers. Resident’s views on the quality of care need to be formally recorded and a quality assurance system needs to be put in place, to maintain and improve the quality of care provided. 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. Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have all the information they need to make an informed choice, as support provided for mental health and learning disabilities is not included in relevant documents. The home’s registration certificate continues to need to be updated to reflect more accurately the care provided. EVIDENCE: The following information was included in the last inspection report and continues to remain relevant: “The home is registered to provide care to four older people, who may have dementia. The manager discussed this with the inspector, and explained that she had made efforts to have this changed, as it was never intended that the home would provide care to people with dementia. It should instead have been people with mental health problems, which is relevant to one of the current residents. The registered manager must continue to liaise with the Commission to ensure that the Certificate of Registration is amended to show the correct categories. However, one of the current residents has significant Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 10 learning disabilities, and registration issues around this must be also clarified with the Commission. The manager was aware of the need to ensure that the home accepts only those people referred who meet the categories of registration.” Since the last inspection the manager had located a more up to date registration certificate which did include providing services for residents from age 55 years and upwards, but did not include Mental Health or Learning Disabilities. Adequate attempts had been made to arrange annual reviews for all service users to clarify whether the home does provide adequately for these support needs, before seeking to have the registration certificate amended. However, some reviews had been postponed due to outside parties not being available, and dates have now been set for formal annual care reviews for all residents. The manager confirmed that clarification will be sought at these reviews as to whether the home is appropriate for providing care in these areas, and subsequently action will be taken to have the registration certificate amended if appropriate. (Refer to repeated Requirement - partially met) The home has a social services care assessment for all residents and uses this to devise and review care plans. Work is in progress to update these to include more information regarding social, leisure and religious support needs. Comments from a number of social services and a health care professional suggested that the home provides a reasonable standard of support for all of the current residents. Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and personal care needs are well set out in care plans but social care planning though improved needs further improvement. Health care needs are being met, and medication is well managed. Service users are treated in a respectful manner ensuring privacy is respected. EVIDENCE: All service users care assessments are reflected now in individual care plans, with the exception of social care and leisure needs. The home uses two systems for care planning, one which primarily relates to health care support needs, and a second which was introduced since last inspection which deals with social and leisure care needs. There are regular outings facilitated by the home such as church and social club activities, but while generally all residents are happy with the level of outings offered, one person feel that she would like to go out more often without staff. It is clear from advice from other professionals involved that there is a level of risk in trying top facilitate this, but given the importance of this request to the individual concerned, who does not have family involvement, it is important to keep this request on the planning agenda and explore ways of facilitating outings with support from Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 12 others not employed by the home. It is accepted that this would take time to deal with but it is recommended that this request be recorded in this residents care plans and worked towards facilitating over a period of time. (Refer to Recommendations OP 7) While there is an improvement in social care planning, and it is clear that the home has made considerable effort to improve this planning, there are two shortcomings in approach being used. The first is that there is a need to be more specific in the care plans about what is meant by descriptions such as “ One to one reading support”, “watch TV”, “reading books and magazines”. For example what sections of the newspaper will the resident like to have read to them, what TV programmes will they individually want to watch, what is the best time for these activities to happen. There also needs to be better monitoring of whether these plans are implemented and if the activities don’t happen some review system in place to question why this is. (Refer to Requirements OP7) The second are which needs improvement in relation to care planning is that the home needs to introduce a workable system for key-working, where each service users has an allocated member of staff who will progress the implementation of care plans and act in a monitoring, and ensure that plans are always led by the individual resident. This was a requirement of the last inspection and had not been met. Some work had been done to draw up a key-worker role description. On examination this looked similar to a general support worker job description and needs further work before training staff in this role. (Refer to Repeated Requirement OP7 and OP32) Risk assessments are in place for all service users and these are being reviewed regularly. However there is a need to support risk assessments with some specific written guidance for staff in how to support individuals during moving and handling, and during personal care. This is to ensure that the right type of support is being offered to maintain as much movement independence as possible while keeping the resident safe. (Refer to Requirements OP7) The home has made reasonable efforts to meet the requirement from last inspection to ensure that all residents has a formal care planning review involving social services. All reviews have now been scheduled to be completed by the end of June 2006. (Refer to repeated Requirement OP7) Information received from some sources during this inspection process suggest that the home should be a little more proactive in producing information for six and twelve monthly care planning reviews and provide this information to relevant family members who cannot attend or who may not feel comfortable Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 13 at meetings, and ask for their views before the meeting, which can then be included in the review meeting. (Refer to Recommendations OP7) An Occupational Therapist has now been involved in carrying out an assessment of need in relation of one service user as required at last inspection. Bathroom and living room seating has been changed in order to comply with recommendations made, and further recommendations regarding exercise and use of specialist exercise equipment are being followed up and will be included in this residents care plans in due course. All residents have their own bedrooms and commented that the staff are very respectful of their privacy and always speak to them and about them in a respectful manner. These comments were also made by a number of visiting professionals. These professionals also commented that the home generally provide well for service users needs and are good at reporting to them when needing advice or input from them. Their view was that care is managed adequately well with possibly a need for some improvement in recording systems for mental health and continence management. Some records for all service users regarding continence management are kept in a single shared file and should be kept in individual files for each service user. (Refer to Recommendations OP10) Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Social care planning has improved but needs further improvement to ensure activities and contact in the community is specific to each service users needs. EVIDENCE: The home has shown improvement in this area, and has taken action to ensure that resident’s wishes about their preferences of activities, both in the home and outside, have been written down and have developed a weekly planning system for all residents. There are a range of activities in the community that residents are included in ranging from church visits which are specifically related to each service users needs. All residents are either Church of England or Roman Catholic and there is adequate access to these churches. (Refer to Standard 7 requirement regarding improving specific details for each resident about how they like to participate and the support required) One resident for health reasons has asked for limited trips outside of the home and this ha been respected. There is a visitor’s policy in operation in the home allowing service users to have visitors at times suitable to them without restriction. Each resident can have visitors in their own rooms and rooms are large enough for this purpose. Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 15 Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relatives are confident that their complaints will be listened to and acted upon and that their legal rights are protected. Service users are protected from abuse. EVIDENCE: The home has a clear and up to date complaints policy which all residents have a copy of in their rooms, and there were no complaints made since the last inspection. Residents and relatives confirmed that they have been informed how to complain if they need to and that the manager is always available to discuss problems with. It was a requirement of the last inspection that advocacy services should be made available to residents, and this has been done, and is paid for by the home. Information about this service has been given to al residents. All residents are supported in their financial affairs by either family or solicitors and not by the home. The home only looks after small amounts of money, up to £40- usually, which they have now ensured is properly recorded and receipted for as a response to a request at the last inspection. The home has updated the Adult Protection policy, which is now in keeping with the Local Authority’s policy. This policy is well written and staff demonstrated an adequate working knowledge of how to report under this policy. However the homes procedures for carrying out CRB checks on new staff, and checking against the POVA list/referring to POVA when necessary is Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 17 not yet included in the policy. It is recommended that these issues should be included in the policy. (Refer to Recommendations OP18) Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 and 26 Quality in this outcome area is good. The owner has made good improvements to the homes dining room and bedroom accommodation. The accommodation is suitable to the needs of all service users, and is safe, well maintained, clean and hygienic. EVIDENCE: The home is laid out over three floors. The basement is accessed by a steep staircase, which is protected by a gate at the top (to prevent accidental falls). The basement is converted to accommodate a laundry area, and staff office space. There are three bedrooms on the ground floor. All have been converted to be en-suite by providing a toilet and sink area, which, in some rooms, is separated from the bedroom by a curtain. There is a separate toilet/bathroom, and a lounge for the use of the four residents. There is also a small kitchen open to service users at all times, and a now adequate dining area. A Requirement was made in reports of previous inspections that the dining area be enlarged and this work was completed and the dining area is now of Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 19 adequate size, has good natural light and is wheelchair accessible. There is access to a large well-maintained garden to the rear of the building. The first floor is mainly given over to the areas used by the registered persons and their family. Over the last two inspections, it was noted that one of the residents who’s room is on the first floor, had to go through this area to access his bedroom and small communal room. A Recommendation was made that the owner needs to consider ways in which service users areas in the home would not be infringed upon by the owner’s family living there. In response to this, the owner has in discussion with this resident, converted another room for this resident’s use, which benefits him, by improving access and privacy, and also it is larger than his current bedroom. The home was clean and in a good state of repair. A new industrial standard washing machine and non-returnable valves have been installed, in response to the water boards recommendations for management of waste products. The owner whose family live on the premises currently use the same front entrance and stairway access to the first floor, as that used by residents. This sometimes causes a bit of congestion in hallways and detracts from the perception by residents of the home being their home, (comfortable and homely) and may also lead to a feeling of lack of privacy from the public eye. This was discussed with the manager and it was agreed to include looking at ways of solving this problem, in the homes development plan, in the medium to long term. It was felt consideration to create a separate entrance for the owner’s family and guests to use might be a viable option for discussion. (Refer to Recommendations OP19) Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. It is not yet clear whether service users needs are fully met by the numbers of staff available. Service users are in safe hands at all times, and although improvements have been made to ensure that service users are protected by the homes recruitment practices, more improvement is necessary in order to fully protect them. Staff are trained and competent to do their jobs. EVIDENCE: The home is staffed by a full time manager, and a staff team of five part time support staff, who are experienced in the care support necessary to provide support to the current residents. The manager/owners family are resident on the premises and provide night support and some day support. The manager is almost always available at the home and residents and some health care and social care professionals commented that the manager and staff are good at providing the support the residents need and are good at speaking with other professionals outside of the home when professional, help is needed. However while the rota showed one member of staff always working, with another member of staff “on call”, the times when this “on call” member of staff was to be working was not made clear, and did not show how they would be supporting the residents activities. The times when the manager of the home is available to provide support as opposed to doing managerial work is also not clear from the rota. The rota needs to reflect the times when a second member of staff is available, whether it is the manager, family or Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 21 another support worker. This should match times when resident’s activities are being provided. (Refer to Requirements OP27) It was not possible to be sure that the current staffing levels are fully reflective of residents support needs, as all residents have not had recent Care Management reviews. The residents Annual Care reviews involving social services are overdue, and should include including these staffing levels being discussed and agreed by each resident’s social worker. (Refer to Requirements OP27) There is a staff training and development programme in place, which meets the National Training Organisation workforce training targets. The system for staff to access training includes local authority training and NVQ qualifications. By the end of this month four out of five staff employed will have achieved NVQ level 2/3 in care, which meets requirements for this training. A Requirement was made in reports of previous inspections, that the registered person must ensure that all documentation required by regulation is received before staff begin working in the home. The manager has now received a second reference for the member of staff who did not have one at these previous inspections. However a relative of the manager works part time at the home, and although she has been CRB checked by an external agent, this was more than six months old when taken up. The home needs to carry out a CRB check on this worker. (Refer to Requirements OP29) The individual referred to above works in providing a range of support for residents including night support when necessary. However there is no documentation in place to define her role and there is no formal contract of employment in place showing terms and conditions, contacted hours, or whether employed on a voluntary or paid basis. The provider must formalise the arrangements for employing this member of staff and ensure that she has a job description, and contract of employment as required by the Care Standards Act in place. (Refer to Requirements OP29) Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 38 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a person who is fit to be in charge, and who provides adequate leadership for the staff who work there. The home does not yet demonstrate that it is run in the best interests of the service users who live there, mainly due to lack of formal consultation and planning. Service users financial interests are safeguarded, but some improvements in health and safety are needed to fully demonstrate that the safety of service users is fully protected. EVIDENCE: The home is managed by and experienced and qualified person who is registered with the Commission for Social Care and Inspection, and who holds the required NVQ 4 qualification in Care and Management. Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 23 The manager is making improvements in how the home communicates with staff and residents, and there is now a better system in place for staff training and development, and for holding team meetings and supervision of staff. However the home does not have a formal system in place for asking service users views on the running of the home, or for publishing the results of any such surveys. Neither is there an Annual Quality Audit system in operation, to allow the homes a management to properly self assess the care provided. There is an annual development planning system, which needs to have a greater range of development activity included, based on annual audits and other information such as complaints and staffing issues. (Refer to Requirements OP33) All residents are supported in their financial affairs by either family or solicitors and not by the home. The home only looks after small amounts of money, up to £40- usually, which they have now ensured is properly recorded and receipted for as a response to a request at the last inspection. A Requirement was made at the last two inspections that the registered provider and manager must ensure that the requirements of the LFEPA fire officers report as described in YA Standard 38 are addressed by the due date of 14/02/06. This included: 1. Undertake a risk assessment and formulate an emergency plan. 2. Develop an ongoing training programme for staff and record attendance. 3. Get certificates of maintenance for the fire alarm system annually and keep inspection results on the premises. 4. Ensure that all exit routes are free from obstruction and that all exit doors are easily open-able without using a key. 5. Ensure that all fire doors have self-closing mechanisms 6. Emergency signage to conform to Health and Safety regulations. The home now addressed all of the above issues. Further to that a requirement from the Water Board to have non-returnable valves and a suitable sluice facility for disposal of waste has been also met. A new industrial washing machine has been installed. There is a range of certificates available to show that health and safety issues are being properly addressed in the home. However there was not a Portable Appliances test certificate or a five-year electrical wiring certificate available at the home for inspection. The manager agreed to have these issues addressed as soon as possible. (Refer to Requirements OP38) Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 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 2 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 2 Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 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 OP1 Regulation 4&5 Requirement Timescale for action 01/09/06 2 OP3 6 3 OP7 15 The registered provider must ensure that the home’s Statement of Purpose and Service Users Guide are revised to reflect fully the category of care provided, particularly in relation to Learning Disability and Mental Healthy support. 01/09/06 The Registered Manager must liaise with the CSCI to ensure that the Certificate of Registration accurately reflects the categories of service user that the home provides care for. The manager must ensure that this is used to inform the assessment and admission of residents in the future. (Registration Regulations) This is a repeated requirement from last inspection Timescale 01/04/06, partially met. The registered manager and 01/07/06 provider must ensure that all individual service users care plans contain sufficiently detailed information about each service user’s social and leisure support activities, and better guidance DS0000025597.V289283.R01.S.doc Version 5.1 Jennifer`s Lodge Page 26 4 OP7 10, 12(1), 18(1) 5 OP7 10, 12(1), 15 for staff about how to support service users risk management. The Registered manager must implement a Key Working system in the home, (or other care planning system), that will (a) enable care staff to be clearer about their role in working with residents and to undertake more of the day-today tasks (b) Clarify the role of the manager and enable her to give due attention to management tasks and responsibilities. This is a repeat of a previous requirement Timescale 01/04/06 partially met. The Registered Manager must ensure that each service user in turn is made the focus of a care planning review, until each service user’s care plan is reviewed and brought up to the standards specified in the National Minimum Standards and best practice in this area. This to include Risk Assessments, assessments of activities and medication, and Reviews. Systems for on-going care recording, linked to these plans, are to be put in place. 01/07/06 30/06/06 6 OP27 18.1 a 7 OP27 18.1 a This is a repeat of a previous requirement Timescale 30/06/06 partially met, still within timescale. The home’s rota must reflect the 01/06/06 times when a second member of staff is available, showing whether it is the manager, family or another support worker. This should reflect times when resident’s activities are being provided. The registered manager must 01/07/06 ensure that as part of the DS0000025597.V289283.R01.S.doc Version 5.1 Page 27 Jennifer`s Lodge 8 OP29 18 9 OP29 19.1 a&b 10 OP33 24 11. OP38 13.4 a b c planned Care Management reviews process, agreement is reached and recorded, with each service user’s individual social worker, regarding the appropriateness of current staffing levels The registered manager must ensure that all staff are in possession of a clear statement of their terms and conditions of employment, to include relatives of the registered provider, if involved in care provision, as required by this standard and as described in the main body of this report. The registered manager must ensure that a current CRB check is carried out on the member of staff described in Standard 29 and a record of this kept on this person’s file at the home. The registered provider and manager must ensure there is an effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. This should include an Annual Quality Audit, and regular service user satisfaction surveys, the results of which should be published within the home. The registered manager must ensure the health, safety and welfare of service users and staff. In doing this written proof that Annual Portable Appliance tests, and five yearly electrical wiring tests have been carried out, must be made available at the home. 01/07/06 01/07/06 01/09/06 01/07/06 Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered manager should involve all service users relatives where appropriate, in the 6 monthly and annual review of care plans, offering a means of contributing to these plans even when they cannot attend actual meetings Some records for all service users regarding continence management are kept in a single shared file and should be kept in individual files for each service user. The homes procedures for carrying out CRB checks on new staff, and checking against the POVA list/referring to POVA when necessary should be included in the homes Recruitment policy. The registered provider should as part of the development planning for the home, consider a means of avoiding family and guests use of the shared entrance to the home, impacting on service users. 2 3 OP10 OP18 4 OP19 Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jennifer`s Lodge DS0000025597.V289283.R01.S.doc Version 5.1 Page 30 - 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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