Inspection on 05/10/07 for Jennifer`s Lodge

This inspection was carried out on 5th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 24/04/06

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 SE6 1HN Lead Inspector Sean Healy Key Unannounced Inspection 5th October 2007 11:00 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.V347700.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jennifer`s Lodge Address 105 Wellmeadow Road Catford London SE6 1HN 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 0208 461 1944 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.V347700.R01.S.doc Version 5.2 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 21st March 2007 (Random Inspection) 24th April 2006 (Key Inspection) 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. 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 5/10/07 the homes fees range from £350- per week to £400- 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. The reasons given by the manager for the difference in fees are that one resident has a larger bedroom and has higher support needs. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 5th October 2007, and was concluded on the 10th October 2007, having received information requested regarding maintenance and policy reviews. 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. A range of documents were examined and a tour of the building took place. I met three of the current residents, and spent time with three residents, two of whom were able to express their views on the service provided at the home. Four residents information files were examined for information about assessments, care planning, risk assessments and complaints. Five staff files were examined for information about employment training and supervision. Discussion also took place with CSCI Regional Team regarding whether there was a need to have a variation to registration included to reflect one resident having a mental health support need and another having a Learning Disability. It was decided that the primary care need of old age and dementia was sufficient and that a variation is not necessary. What the service does well: The home is laid out in a domestic style and residents have use of the ground floor as well as access to a large and attractive garden. Bedrooms have been converted to be en-suite. The home is welcoming of visitors and the atmosphere is relaxed and friendly. Contact with family and friends is encouraged and a most residents have regular visits at the home and go to their relatives for short visits. Residents say that the staff are friendly and helpful, and the manager is at the home almost every day, and listens whenever they have any problems. The staff and manager are quick to involve relevant health professionals and social services whenever their support is needed. This was observed to be the case during the inspection. Health care needs are well met and residents commented that the food is good and they are generally happy that they get food they like. The registered manager is experienced and is open about areas where the home needs to improvements. There is a commitment shown by the manager and owner to act on requirements and recommendations made by other professionals and by the residents. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Contracts for one resident needs to be updated to show why higher charges are being made. There are reasons for the higher charge, which is for higher levels of support being provided and the resident having a larger room, which must be included in the contact. The home needs to clarify resident’s wishes regarding end of life care in their care plans or record when any resident does not want to have their wishes documented. The home should consider providing a larger TV remote control with larger buttons and numbers to allow residents to more easily be independent in its use. Soft furnishings for the dining area should be considered for periods when residents are watching TV in that area. Consideration should be given to helping some residents who do not currently have many friends or family to establish more regular social contact with friends from the day centre if the residents concerned are agreeable to this approach being made. The home must ensure that an Enhanced CRB is on file for all care staff. It is recommended that the home training for staff include working with Learning Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 7 Disability, challenging behaviour management, non-verbal communication, and end of life care. Staff training must include end of life care and learning disability support needs so that staff can be more skilled in providing support for residents in these areas. The home must implement the planned audit system and include resident’s views in the development plan for the home. 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`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to make a decision about whether to live at the home. Resident’s contracts do not adequately explain the reasons for the difference in charges made to one resident. All residents care needs are properly assessed before moving in to the home. Intermediate care is not provided. EVIDENCE: There was a requirement made at the last inspection for the home to update the Statement of Purpose and Service Users Guide to include all of the information required by this standard including the fees to be paid by residents and the reasons for any differences in fees. This has now been done. There was also a recommendation made at the last inspection for the home to change the size of the print in the Statement of Purpose so that residents can easily read this document. This has now been done. The homes Statement of Purpose and Service Users Guide now reflect most of the information needed, but the home provides some support for people who have mental health and learning disability support needs, and this information Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 10 must also be made clearer in the Statement Of Purpose and Service Users Guide. (Refer to Recommendation OP1) All residents have contracts, which have been signed and dated by them, describing the terms and conditions for living at the home. However some resident’s charges are £350 per week while others are £400 per week, but the reason for this difference is not made clear in the contracts. The reason given is that larger bedrooms and higher-level support are provided for the resident who is charged a higher fee, and also a there is some additional transport provided. This needs to be made clear in the contract for this resident. (Refer to Requirement OP2) All residents have full and detailed assessments of need on file. There was a requirement made at the last inspection for the home to liaise with CSCI to ensure that the certificate of registration accurately reflects the correct categories of support provided in relation to mental health and learning disability. This requirement is now met and an application for a variation to the registration had been submitted to CSCI, and the home was awaiting a decision. Following the inspection the CSCI Regional Registration Team clarified that the homes current category of old age and dementia is the primary care need, but that an additional Learning Disability category needs to be added for one resident who currently lives at the home. Intermediate care is not provided at the home. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 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 end of life care needs to be addressed in the care plans. Health care needs are being met, and medication is well managed. Residents are treated in a respectful manner ensuring their privacy is respected. EVIDENCE: There was a requirement made at the last inspection for the home to ensure that there is sufficient evidence to show that monthly care reviews are happening, and that residents are involved in these reviews. This is now being done this requirement is now met. There is a new form for recording monthly reviews, which show details discussed and these are dated and signed by the staff and relatives and residents. I saw three of these care review forms and good recording is happening. Six monthly reviews are also happening with very clear notes been kept of decisions made. It is recommended that additional sections be included in the review forms for personal care and medication issues, so that the information discussed is more clearly recorded. (Refer to Recommendation OP7) Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 12 The care plans do not currently include a section for end of life care showing in the expressed wishes of residents. The home must include end of life care in care plans for residents, and sensitively complete information for those who wish to have is included in their care plans. Where residents reuse to have this information recorded this should be noted on the care plan. This should include where they want to live should they become seriously ill, resuscitation, who needs to be informed if they fall ill, and who will be responsible for making necessary arrangements. (Refer to Requirements OP7) There is clear and substantial health care information included in all residents care plans now. This includes details of GPs, physiotherapist, chiropodist, noting support provided and involvement from the district nurse and tissue viability nurse when needed. One resident has been supported by the home through a difficult period having undergone surgery, and the homes records and care plans showed good detail about how this person should be supported throughout the recuperation. The resident concerned commented that the home had supported them well throughout this process. There is an up-to-date medication policy, which was last reviewed in July 2007. All the residents are supported by the home to administer and store their medication. There is a signed agreement in place for all residents showing that they have agreed for the home to do this for them. Medication is stored in a locked cabinet in the lounge area and all residents’ medication is supplied by the local pharmacy on a monthly basis. The home collects prescriptions from the GP on behalf of the residents. None of the current residents self medicate, and all have been assessed as to their abilities and wishes to do so. Each resident has a file, which contains information about their prescribed medication, which includes a photograph to help, avoid mistakes being made. Good records of medication administered are kept in a separate book and records showed medication received and returned. Records are being kept when medication is refused and it is recommended that the system for recording when and why medication is refused be reviewed and improved. (Refer to Recommendation OP9) All residents have a personal care support plan included in the care plans. These are clearly written and kept up-to-date. All residents currently residing at the home need support with bathing and dressing, and some higher-levels of support are required for one resident. There are good details in the care plan describing how this is to be done. Personal care plans are reviewed monthly, with a more in-depth review every six months come and an annual review would social services. Residents said that the staff are helpful and sensitive when helping them in personal care. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle in the home support they needs well, and contact with family and friends is welcomed and supported. Residents are given choices and are supported to make informed decisions about their lives. Good food is provided in a comfortable dining area. EVIDENCE: Daily activity routines for residents are a clearly written in their care plans. Each resident has a description of activities that they most like to do and there is a system used for writing down activities people have taken part in to help insure they are given good opportunities to do things. This system enables the manager to more easily oversee the activities are happening. Some residents attend a day centre, a social club, have outings to parks and shops and attend their local church with the support of the homes manager staff, who also provide transport for them when they need it. Church representatives also visit the home regularly to visit some residents. All residents can have visitors any time of the day and night and the home’s policy does not restrict visitors in any way. Two residents said that they have family visit very regularly and they are made to feel welcome by staff. One Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 14 resident does not have any family involvement at all, and attends the day centre three days a week. Staff at the moment are not aware of who this resident meets at a day centre or whether there are people there they would wish to develop a relationship or friendship with. It is recommended that the home in consultation with this resident explore possibilities for this resident to actively develop friendships through any opportunities provided by outings or visitors to the day centre. (Refer to Recommendation OP13) The residents manage their own financial affairs with support from either family or social services or the Court of protection. Information is available in the home regarding how to contact external professionals such as CSCI, social services, and advocacy services should they need to. Residents have their personal possessions in their rooms and their rooms were seen to be well maintained and well decorated. I met with one resident in her room and she confirmed that staff are respectful when entering her room and leave her to spend time on her own when she chooses to. The home provides food, which is nutritious and fresh, and which is cooked daily in the home. All staff have food hygiene training and one staff member who most often does the cooking was able to show that the health and safety in the kitchen is well managed. Residents say that the food is generally good and is hot and freshly made. Some residents suggested that they might want to have more choice in what they eat and that although the food is good there are some favourite meals that are not often included. The staff and manager said that daily food choices are offered and care plans do clearly show each residents preferred meals. It is recommended that the home explore further whether all residents are happy with the food provided and whether choices are being offered in a way that they can easily understand. (Refer to Recommendation OP15) Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that their complaints will be listened to and acted upon. The home’s written Adult Protection policy does not adequately show how residents 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 confirmed that they have been informed how to complain if they need to and that the manager is always available to discuss problems with. The home has a written Adult Protection policy, which needs to be updated to be in keeping with the Local Authority’s policy. This was a requirement of the last inspection and was partially met. The home now has a copy of the local authorities revised policy and the staff have been briefed on its contents. Two staff were able to adequately explain how to deal with any concerns about residents welfare and safety. The homes own policy still needs to be updated to reflect the local authority policy, which should include a simple flowchart explaining the role of the staff, the manager and the local authority. (Refer to Repeated Requirement OP18 partially met) There was a requirement at the last inspection for the home to ensure that the manager and staff be briefed in their responsibilities under the local authority adult protection policy. As discussed above this requirement was met, and all of the staff and manager have had POVA training in September 2007. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 16 There have been no referrals to the adult protection team or to the POVA register since the last inspection. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well maintained and is clean pleasant and hygienic. EVIDENCE: There was a recommendation made at the last inspection for the owner to consider as part of the homes development plan, a means of avoiding a family members and friends who may be visiting the home using the residents hallway entrance for personal use. (The owners live on the top floor of the premises) It is now met and the order has discussed this with residents and their relatives, who felt that this would be beneficial for them. The owner is now considering how to best achieve this by use of the side entrance of the building, and by constructing a stairway to the rear of the building. This has not yet been agreed but is in the development stage. The home is an older building and adequately meet the needs of the residents. All of the older residents reside and sleep on the ground floor of the premises. The home is kept in a good state of repair and furniture is a good standard. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 18 The staff and residents said that although the living room area is small there is an alternative use made of the dining room area for watching television. However the furnishings in the dining area do not comfortably facilitate watching television for any lengthy period, and it is recommended that the home provide a means for residents to comfortably sit in the dining area when watching TV. (Refer to Recommendation OP19) The living room area has a television, which is very regularly watched by one or more residents. However there is no video or DVD player and in use with his television. This is the most comfortable place for residents to sit and relax while watching TV, and it is recommended that a video player and/or a DVD player be considered for use in the lounge area. (Refer to Recommendation OP19) A number of residents regularly watched TV but it was noticed that the television remote control is a type that has small numbers and lettering. The resident watching TV on the day of the inspection clearly had problems in changing the channels and in identifying the numbers on the remote control. It is recommended that the home purchase are a remote control which is more user-friendly, with larger letters and numbers, and give some time to teaching residents had to use it independently. (Refer to Recommendation OP19) The home is adequately equipped with toilet and bathroom facilities for the existing residents use. However the toilet door on the ground floor is sticking and could not be independently used by some residents. This should be rectified as soon as possible. (Refer to Recommendation OP19) All of the electrical in gas equipment is maintained and has up-to-date maintenance certificates. The fire equipment is consistently serviced and well maintained. The portable appliance tests are now due and the manager is in a processor for ensuring that they are retested. The home is maintained to a good level of cleanliness, and a cleaner visits the home and number of times a week to ensure bathrooms and kitchens and hallways are kept clean. Laundry facilities are separate from the kitchen and there are no incontinence issues and the home. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers and skill mix of staff and staff are qualified to the appropriate NVQ level. Improvements have been made to ensure that residents are protected by the homes recruitment practices, but more improvement is necessary in order to fully protect them. The staff training provided by the home needs to include more key resident support areas to ensure that staff are 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. There is a rota showing that there are always two staff available to provide support to four residents. Sometimes the manager fills one of the two support staff roles and there is a rota for the manager and the owner to provide sleep-in and emergency support if needed. Three of the five staff are qualified to NVQ level 2/3 and this meets the 50 qualified staff requirement. Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 20 Five staff files were examined and were seen to be largely complete and in order regarding recruitment and employment information. The files are now well organised and all staff were recruited and inducted in a fair and methodical manner. All had two references and two a completed induction checklist, which is in keeping with Skills for Care requirements. Two staff confirmed that they had been fairly interviewed and inducted over three days. The files showed that all but one member of staff had an up to date CRB checks done which included a an enhanced POVA check. There was a requirement at the last inspection for the home to ensure that all staff had an up to date enhanced CRB on file and while the manager has done this for almost all between July and September 2007 there is still one outstanding and this requirement is repeated. (Refer to Repeated Requirement OP29) 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. All staff receive an induction over a three-day period and are subsequently schedules for NVQ training if they do not already have this qualification. All staff are receiving more than three days training per year and have an individual training plan. Current training plans include: COSSH, food hygiene, first aid, POVA/adult protection training, fire safety and medication. Given that all residents have high care needs regarding care of the elderly and end of life care, and one resident has learning disability support needs these areas would normally be expected to be found in the training schedule for the home. However these areas are not currently included in the routine training for the home and must be included. (Refer to Requirement OP30) Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 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 the lack of formal annual quality audit system and development plan. Resident’s financial interests are safeguarded, and staff are now consistently supervised about their work. Health and safety is well managed and the safety of residents and staff are 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.V347700.R01.S.doc Version 5.2 Page 22 The manager has made 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. The staff and residents records are now ell organised and contain the majority of information needed. Comments from residents and staff about the management are good and the manager and owner are available in the home on a daily basis. The home now has a system for surveying residents, families and healthcare professionals views about how the home is managed and is awaiting feedback from some people before producing the results of the current survey. Questions in the survey include views on food, staff attitude, staff ability to do their job, activities and communication. The manager and owner are available in the home daily and provide hands on support to residents. There is a formal quality assurance audit system in development but this has not yet been implemented. There are a number of systems for finding out about how residents and others feel the home could improve but there is currently no annual development plan for scheduling improvements, although the home does this partially in less formal ways. There was a requirement at the last inspection for the home to put in place systems for seeking resident’s views about the running of the home and also to introduce an annual quality audit system. This was partially met in that the home is now effectively asking residents and families views, and the requirement is now changed to require the home to ensure that there is an Annual Quality audit system and an Annual Development Plan put in place and actively used. (Refer to Requirement 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. Two residents confirmed that this is how their financial affairs are managed and said that they are confident in the systems for consulting and supporting them in any areas needed. Health and safety is now well managed in the home, and there is a fire alarm system and fire risk assessment to protect against the risk of fire. Resident’s files have a range of personal risk assessments, which take account of personal care support needs and risk of falls. All certification regarding electrical appliances and the electrical wiring and gas are up to date and the manager is currently updating the portable appliance tests for the home. The annual quality assurance audit form returned to CSCI showed that the home does not currently use the Department of Health “Essential steps for assessment of management of infection control” guidance and given the level of personal care support provided it is recommended that the home get a copy for reference purposes. (Refer to Recommendation OP38) Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 24 Yes 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 OP2 Regulation 5 Requirement The registered provider and manager must ensure that that resident’s statements of terms and conditions or contracts include the reasons for higher charges being made in comparison to other residents as discussed in this report. The registered provider and manager must ensure that residents are asked about their wishes regarding end of life care and that subject to their permission they are included in their care plans The registered manager must ensure that the homes policy on Adult Protection is reviewed to reflect changes in legislation and that of the local authority. This is a repeat of a requirement made at the last inspection, Timescale 30/09/07 partially met and now repeated. Timescale revised. Failure to meet this requirement may result in enforcement action The registered manager must ensure that all of the staff have DS0000025597.V347700.R01.S.doc Timescale for action 29/02/08 2 OP7 15.1 31/03/08 3 OP18 12 29/02/08 4 OP29 19 29/02/08 Jennifer`s Lodge Version 5.2 Page 25 5 OP30 18 © (i) 6 OP33 24 an up to date enhanced CRB done, which includes POVA checks as discussed in this report. This is a repeat of a requirement made at the last inspection, Timescale 30/09/07 partially met and now repeated. Timescale revised. Failure to meet this requirement may result in enforcement action The registered provider and 29/02/08 manager must ensure that the homes staff training plan includes training in the areas of Learning Disability and End of Life Care as discussed in this report The registered provider and 31/03/08 manager must ensure there is an effective quality assurance system and quality monitoring systems, which include an Annual Quality Audit and an Annual Development plan, and that these systems are implemented in the home. 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 OP1 OP7 OP9 Good Practice Recommendations The Registered provider should include more information about mental health support and Learning disabilities support provided in the homes Statement of Purpose The Registered provider should include additional sections for personal care support and medication issues in the homes annual care review system The Registered manager should review and improve the system for recording when and why medication is refused in the homes medication management practices DS0000025597.V347700.R01.S.doc Version 5.2 Page 26 Jennifer`s Lodge 4 5 6 7 8 9 OP13 OP19 OP19 OP19 OP19 OP38 The Registered manager should explore options for one resident to develop friendships as discussed in this report The Registered provider should provide more comfortable seating arrangements for residents who choose to watch TV in the dining area of the home The Registered provider should ask residents views as to whether they would like a video or DVD player available to them in the homes lounge area The Registered provider should find a more user friendly remote control for the TV in the lounge area as discussed in this report The Registered provider should make the ground floor bathroom door more easily openable by residents The Registered provider should secure a copy of the DOH “Essential Steps for Assessment of Management of Infection Control” as a reference for the home in preventing cross infection Jennifer`s Lodge DS0000025597.V347700.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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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