Inspection on 03/09/07 for Jerome House

This inspection was carried out on 3rd September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jerome House 30/05/06

Jerome House 07/12/05

Jerome House 03/06/05

Jerome House 04/10/04

Jerome House 02/06/04

Jerome House 05/02/04

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

CARE HOME ADULTS 18-65 Jerome House 71 Randall Avenue Neasden London NW2 7SS Lead Inspector Julie Schofield Key Unannounced Inspection 3rd September 2007 09:30 Jerome House DS0000017485.V346227.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 Jerome House DS0000017485.V346227.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. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jerome House Address 71 Randall Avenue Neasden London NW2 7SS 020 8450 8544 020 8452 8544 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 Lucille Rabor Mrs Lucille Rabor Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: Jerome House is situated within walking distance of the shops at Neasden. Randall Avenue is close to a bus route and there is access at one end of Randall Avenue to the North Circular Road. The nearest underground station is Neasden. It is a large semi-detached house with a small area at the front of the house and a garden at the rear of the property. The house has a driveway providing on site parking. There is also parking space available on the street outside the house. The home is registered for 4 adults with mental health problems and there are bedrooms on both the ground, first and second floor with bathing and toilet facilities on all floors. Communal space is situated on the ground floor and consists of an open plan lounge and dining area, which leads to a small, indoor smoking area. There is an office on the first floor. At the time of the inspection there was one vacancy. Information regarding the level of fees charged is available, on request, from the manager of the home. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Monday in September. The inspection started at 9.30 am and finished at 6.15 pm. During the inspection a site visit took place, records and policies and procedures were examined, case tracking was carried out, discussions with the registered manager, the general manager for the company, the assistant manager of the home, members of staff and residents took place and the preparation of a meal was observed. The Inspector would like to thank everyone for their assistance and for the comments that they gave as part of the inspection. What the service does well: What has improved since the last inspection? Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 6 During the previous key inspection in May 2006 there were 9 statutory requirements identified. Of these 9 requirements, 5 have now been met. Records are now kept of the visits made to the home by the prospective resident during the transition plan. The records include the observations of managers and staff, reactions by existing residents and feedback from the prospective resident. The ground floor shower room is odour free and paper towels are provided at the wash hand basin. Staff have receive training in supporting residents with mental health problems. The home has a copy of a valid Landlords Gas Safety Record available for inspection. The home has received advice in respect of the positioning of fire extinguishers in the home. What they could do better: During the inspection 8 statutory requirements were identified and 4 of these were outstanding from a previous inspection(s). When money is left in the home on behalf of a resident it must be kept in a safe and secure place. All staff administering medication need to be trained by an accredited trainer and the content of the course must give staff the depth of knowledge necessary to support residents. The need for the hours worked on site by the manager to be recorded on the rota is outstanding from 2 previous inspections. The requirement that references are addressed to the manager or proprietor of the business and sent to the business address is outstanding from a previous inspection. When references are taken they must be taken from an independent source and not from a family member. It is essential that a reference is taken from the applicant’s last employer. An enhanced CRB disclosure is needed for each member of staff and an application for a CRB disclosure must be made when new members of staff are employed. Prior to starting work in the home a pova first check must be received before the member of staff works under close supervision, pending the return of the CRB disclosure. This requirement is outstanding from a previous inspection. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 7 Feedback obtained from quality assurance systems must be used to plan and develop services so that changing needs of residents are recognised and met. This requirement is outstanding from 2 previous inspections. 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. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 8 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 Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 9 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, 4 People who use this service experience good outcomes in this area. A comprehensive assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. A programme of preadmission visits to the home enables the prospective resident to sample life in the home and to decide whether the service provided is acceptable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an admission procedure and since the last inspection one new resident has been admitted to the home. The case file was examined and it was noted that information had been received from the funding authority. This information included a copy of the assessment form, the risk screening form, an OT report, a discharge summary and an acute ward multi disciplinary care plan. There was also evidence that a representative of the home, an RGN had visited the prospective resident in hospital and had carried out an assessment. A statutory requirement was identified during the previous inspection that records are kept of the visits made to the home by a prospective resident during the transition plan. These records are to include the observations of Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 10 managers and staff, reactions by existing residents and feedback from the prospective resident. The case file included evidence of a programme of introductory visits to the home, which were recorded, and included an overnight stay. The forms used to record the visits included the details of the date, the assessment of need, comments from the members of staff on duty, residents’ comments and the new service user’s comments. This requirement is now met. The new resident confirmed that he had the opportunity to visit the home prior to admission and said that the staff had been very helpful and had helped him to settle in. He had been made to feel welcome. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 11 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 People who use this service experience good outcomes in this area. Comprehensive care plans have been drawn up for each resident so that the service provided can meet the individual needs of the resident. The home is able to demonstrate that changes in the needs of residents are identified and addressed through a system of regular review meetings. The resident’s right to make decisions about their life in the home is respected. Arrangements for keeping money on behalf of a resident must assure the resident that money is safe. Responsible risk taking contributes towards the resident leading an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. It was noted that each contained a care plan that focuses on the mental health needs of the resident. There were also care plans covering personal care needs and general health needs. Monthly Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 12 evaluations are carried out and it was noted that these were up to date. Files contained an OT treatment plan. There was evidence that regular CPA meetings took place, although one had been postponed and the resident said that it had been rescheduled for the week following the inspection. The resident gave details of what they wanted to say during this review meeting. There were also regular review meetings convened by the home and placement reviews by the funding authority, although a meeting convened by the funding authority was due but no date has been given yet. None of the residents receive support from advocacy services although they may receive assistance and support from a member of their family. No one from the company is an appointee for any resident as each resident (or their relative) has control over their finances. It was noted that money had been left by a relative for the use of one of the residents. This was not kept in a safe and secure place and this was brought to the attention of the manager, during the inspection. Records were in place in respect of items of expenditure and were up to date, with a running total. The home will help a resident if the resident is having problems with their benefits etc. Each file contained risk assessments, tailored to the individual needs of the residents. The hazard was stated, identified risks listed, a risk rating was awarded and the action to be taken was specified. Risk assessments covered areas including not taking medication, using the stairs, smoking in the bedroom, and self-neglect. Risk assessments were subject to regular evaluations, which were up to date. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 People who use this service experience good outcomes in this area. Using community resources gives residents the opportunity to enjoy an interesting and purposeful lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents are offered a varied and wholesome diet, which meets their religious and cultural needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents follow their own individual lifestyles although they are encouraged to keep regular hours and to get some exercise by going out to do their personal shopping etc. Residents choose whether they want to attend drop in centres etc. One of the residents has started to attend a day centre, twice a week. An OT runs group and 1:1 sessions in the home and in the community for Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 14 residents on 2 days per week. Sessions include arts and crafts, shopping and outings. A resident said that they were also doing cookery and computer skills with the OT. Residents use community facilities and resources including the cinema, shops, the library, pubs, the leisure centre or the church. Residents travel independently in the community or with a member of staff escorting them, if this is necessary. They use taxis, public transport or the manager may use her car to transport a resident. The names of residents are entered on the electoral roll and they vote if they wish, either in person or by using a postal ballot. Within the home residents are able to choose whether they want to socialise with other residents or whether they want to take part in any activities. Residents do sit together and talk with each other and there was a good rapport between 2 residents sitting in the open plan lounge/dining area. They also watch television or videos in the lounge or they can watch television or listen to music in their rooms, although 1 resident said that they did not have a television in their room. The manager said that the resident was saving up to purchase a television. There are board games and cards if they wish to play a game. The home has previously tried to arrange a holiday for residents but residents have declined to go. Group outings have also met with little success. However, 1 of the residents is saving towards a family holiday abroad to meet some of his relatives. The home encourages residents to maintain contact with their family members and some residents go to visit their families, occasionally staying with them overnight. Family members also visit residents at Tanfield House and a resident said that he could entertain visitors in his room or sit with them in the lounge. The manager said that if a member of staff accompanies a resident when they go out it is to encourage the resident to get out of the home more, to get to know the neighbourhood and to use public transport. A resident said that the staff were helping him to prepare for independence and that he was now putting in a greater input into being independent. One resident has recently left the home for independent living. Residents are encouraged to take part in the domestic routines in the home and each resident is expected to keep their own room clean and tidy and to do their laundry. Some of the residents will help with the preparation of a meal, after encouragement and motivation by the members of staff on duty. The home has a no smoking policy within the main building and it was noted that residents observed this and went into the small smoking area when they wished to smoke. A resident said that his privacy was respected when he is in his room. It was noted that residents had keys to their bedroom doors and used these, when they wished. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 15 During the inspection the serving of a meal was observed. The meal had been cooked in one of the other care homes within the company. (Each of the 4 care homes is in the same road and the company has been advised by the Environmental Health Officer regarding the safe method of transporting cooked food between the care homes). The meal consisted of chicken, pasta and vegetables. Portion sizes were good. One of the residents does not like pasta and requested chips. These were cooked for him in Jerome House. The member of staff serving the meal confirmed that she had attended food hygiene training. There are individual menu sheets for each resident with space to record what the resident consumes. Residents are offered a cooked meal in the evening and a lighter meal at lunchtime. Choice is available and the menus include food to meet the cultural needs of the residents. Two residents said that the meals served in the home are good. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 16 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 People who use this service experience good outcomes in this area. Discreet and caring support is given to residents by staff so that the privacy and dignity of the resident is respected. The health and well being of residents is promoted through regular health care checks and appointments. Residents’ general health and well being is promoted by staff that assist residents to take prescribed medication in accordance with the instructions of the resident’s GP and psychiatrist. Accredited training for staff would assure residents of the competence of staff in dealing with medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are self -caring and no direct assistance is required with personal care tasks. Sometimes staff may need to prompt a resident so that they maintain a clean and tidy appearance and this is carried out discreetly and with regard to the feelings of the resident. One of the residents has a history of self-neglect so staff are encouraging him to take a pride in his appearance. The staff team consists of male and female members of staff and includes Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 17 African and African-Caribbean staff. The home provides each resident with the support of an occupational therapist that visits the home twice a week. The home has a system of key working. One of the residents is overweight and his care plan includes the need to maintain a healthy lifestyle and diet. He was pleased that he has lost weight over the last year, at a sensible rate. It was noted that a record of the weight of residents is kept on a monthly basis, provided that the resident wishes to be weighed. The GP had visited one resident where there were concerns regarding his weight loss. There was evidence on the case files of access to health care services in the community including the GP, the psychiatrist, the optician, the community nurse, the podiatrist, the chiropodist and the dentist. There was access to routine screening and residents were supported to attend out patient appointments at the hospital, if necessary. Residents had an annual medical check up and their medication was reviewed on a regular basis. Medication records were inspected and it was noted that they were complete and up to date. The storage of medication was safe. Medication is administered from weekly disposable dossette boxes. It was noted that the empty compartments were in accordance with the time of day and the day of the week that the boxes were examined. Although all members of staff administering medication have received training it is not accredited and the record of the content of the training given does not demonstrate that staff are given a basic knowledge of how medicines are used and how to recognise and deal with problems in use. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 18 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 People who use this service experience adequate outcomes in this area. Residents are aware of their right to complain if the care that they receive is not satisfactory. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents but recruitment practices need to protect the safety and welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place in the home. New residents receive a service user guide, as part of the admission procedure and copies are also on display throughout the home e.g. on the back of bedroom doors, in the kitchen and in the entrance hall. The manager said that no complaints have been received since the last inspection. Residents confirmed that if there was something that they were not happy with they could speak to someone in the home and residents came to the office to talk to staff during the inspection. The home prefers to deal with matters before complaints develop and has a system of meetings, which are recorded, taking place between the resident and manager and/or key worker. A protection of vulnerable adults procedure is in place. The manager said that no allegations or incidents have been recorded since the last inspection. There was evidence on the staff files that protection of vulnerable adults training had taken place. A refresher course for members of staff took place in July 2007 Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 19 and certificates of attendance were on the staff files examined. External training has been booked for all staff on the next course to be run by the local authority. The company has also purchased a training video. A member of staff had previously worked in the home but when they were reemployed in 2005, after a 12 month break, a new enhanced CRB disclosure had not been obtained. Another member of staff, that also works in one of the company’s other care homes, had been working without a pova first check, pending the return of a satisfactory enhanced CRB disclosure. The pova first check has since been obtained after a discussion with the manager of the other care home. Concerns were also raised in respect of the taking up of references. (See Standard 34). Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 20 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 People who use this service experience good outcomes in this area. Residents live in a home, which is comfortably furnished and provides a pleasing environment for residents to relax in and enjoy. Good standards of cleanliness provide residents with hygienic surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a site visit took place and each of the 3 bedrooms in place were seen. It was noted that the home was decorated and furnished in a “homely” manner and that the maintenance of the home was good. 30 A statutory requirement was identified during the previous inspection that the ground floor shower is odour free, that paper towels are provided at the wash hand basin and that the waste bin is a pedal bin. Residents expressed satisfaction with their rooms. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 21 A statutory requirement was identified during the previous inspection in May 2006 that the ground floor shower room must be odour free and that paper towels are provided at the wash hand basin. It was noted during the inspection that all areas of the home inspected were clean and tidy and free from offensive odours and that paper towels and liquid soap were provided adjacent to wash hand basins. This requirement is therefore met. Laundry facilities are sited on the ground floor and are accessed through the open plan lounge and dining area. The home does not service incontinent laundry. There was evidence that staff have undertaken training in infection control procedures. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 People who use this service experience adequate outcomes in this area. Residents benefit from a service provided by carers that have demonstrated their skills and understanding through NVQ training. The rota failed to demonstrate that the manager’s hours spent on site are sufficient to supervise staff and to monitor the standard of care. Recruitment practices compromise the safety and well-being of residents. The training programme for staff helps to encourage good working practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statutory requirement was identified during the previous inspection that staff receive training in supporting residents with mental health problems. A previous timescale of the 31st December 2005 had not been met. It was noted that staff have now received this training and the requirement is now met. A discussion took place with the manager regarding the progress made towards achieving the target of 50 of staff working in the home holding an Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 23 NVQ level 2 or 3 qualification or equivalent. Checking the names of staff recorded on the rota (9) it was noted that 1 member of staff has the NVQ level 3, 4 staff have the NVQ level 2, 2 staff are qualified nurses, 1 member of staff has successfully completed 2 of a 3 year nursing qualification and 1 member of staff is part way through their RMN training. The home has exceeded the target and is to be commended. A statutory requirement was identified during the previous inspection that the hours worked by the manager in the home are recorded on the rota. A previous timescale for compliance of the 1st February 2006 had not been met. As the manager is also the manager of another of the company’s care homes, in the same road, she is expected to work a minimum of 17.5 hours on site, each week. A copy of the rota for the 4th to the 10th of September was supplied. It was noted that that the manager was recorded under the column “senior on call”. This requirement remains outstanding. The manager said that during the early shift and during the late shift there were 2 members of staff are on duty and at night there is 1 member of staff, asleep but on call. These staffing levels are sufficient to meet the needs of the residents. Two statutory requirements were identified during the previous inspection. The first was that references are addressed to the manager or proprietor of the business and sent to the business address. The second was that Jerome House obtains an enhanced CRB disclosure for each member of staff and for new members of staff prior to their employment in the home. Three staff files were examined. The staff files of other carers, that worked in more than one of the company’s care homes, had been examined during an inspection in August 2007 at another of the company’s care homes. It was noted that on one file a reference was from a referee who lived at the same address as the applicant and when asked to comment in what capacity the applicant was known to them wrote “family”. The concerns about the validity of references remains therefore the requirement is outstanding. It was noted that 1 of the files inspected during this inspection did not contain a valid enhanced CRB disclosure. The member of staff had previously worked in the home but when they were re-employed in 2005, after a 12 month break, a new enhanced CRB disclosure had not been obtained. During an inspection of another of the company’s care homes in August 2007 a member of staff that also works in Jerome House had been working without a pova first check, pending the return of a satisfactory enhanced CRB disclosure. The pova first check has since been obtained after a discussion with the manager of the other care home. The requirement relating to enhanced CRB disclosures therefore remains outstanding. Files contained proof of identity and right to reside or to work, as required. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 24 There is an induction training package for new members of staff and this was seen on the staff files examined. Staff files included training profiles. There was evidence on staff files of attendance certificates for infection control, manual handling, food hygiene, first aid, protection of vulnerable adults and fire safety training. Staff have also undertaken training in mental health issues. There is a training plan for the home and this includes listing a course of training, deciding who needs this training and within what timescale, who can provide the course, the cost, how the effectiveness of the training is to be evaluated and the progress made. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 25 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 People who use this service experience adequate outcomes in this area. The registered manager continues to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. However the support that staff and residents require has been compromised by not responding to requirements for tasks to be carried out within the timescales allocated. Incorporating information obtained through quality assurance systems into the planning and development of the service would ensure that it continues to meet the needs of the residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that all items are in working order and safe to use. This judgement has been made using available evidence including a visit to this service. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager has completed her Registered Manager’s Award and has shown evidence of this on a previous inspection. Since the last inspection she has attended training in respect of the Mental Capacity Act. She has also attended an IT training course. As she is the registered manager of 2 care homes and a nurses agency and the proprietor of 4 care homes and the nurses agency, a post of general manager for the company has been created to support all of the 4 care homes within the company. The post of assistant manager has been created in each of the care homes. It is of concern that a number of statutory requirements (4) identified during previous inspections remain outstanding, particularly as they affect the supervision of staff, responding to the changing needs of residents and keeping residents safe. A statutory requirement was identified during the previous inspection that information obtained from quality assurance systems is used in drawing up a development plan for the home. A previous timescale for compliance of the 1st April 2006 had not been met. The manager said that it is difficult to hold residents meetings because residents may choose to go out instead of attending a meeting. A resident confirmed that a residents’ meeting had not taken place for some time. Therefore feedback is obtained on a 1:1 basis, either with the manager, deputy manager or key worker. A new survey form is being developed for use in the home and a copy was previously made available. The home already has a form that is used to review the assessment process. A survey form will also be offered to professional visitors to the home. Residents are completing the new form. Progress has been made in respect of obtaining feedback from quality assurance systems and this part of the requirement is met but until the information is used in the planning and development of the service the second part of the requirement remains outstanding. Two statutory requirements were identified during the previous inspection. The first was that the home forwards a copy of a valid Landlords Gas Safety Record to the CSCI. There was a valid certificate dated August 2007 and so this requirement is met. The second requirement was that the home contacts the Fire Officer and asks them to confirm that they are satisfied with the positioning of fire extinguishers in the home. An action plan following the previous inspection confirmed that action was taken. There was evidence in the training records that staff have received training in safe working practice topics. There were valid certificates for the servicing/checking of the fire extinguishers, the fire alarms and emergency lighting, the portable electrical appliances and the electrical installation. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 27 Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 28 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 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 4 33 2 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 29 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA7 Regulation 12(1) Requirement Timescale for action 01/10/07 2 YA20 3 YA33 4 YA34 The registered person must ensure that when money is left in the home on behalf of a resident it is kept in a safe and secure place. 13(2) The registered person must ensure that all staff administering medication are trained by an accredited trainer and that the content of the course gives staff the depth of knowledge necessary to support residents. 17(2)S4(7) The registered person must ensure that the hours that she works on site (a minimum of 17.5 hours) are recorded on the rota to demonstrate that staff and residents have the opportunity to benefit from her guidance, support and supervision. (Previous timescales of 1st February 2006 and 1st July 2006 not met). 19(1) The registered person must ensure that references are addressed to the manager or proprietor of the business and sent to the business address to DS0000017485.V346227.R01.S.doc 01/12/07 01/11/07 01/11/07 Jerome House Version 5.2 Page 30 5 YA34 19(1) 6 YA34 19(1) 7 YA34 19(1) 8 YA39 24.2 confirm the authenticity of the reference so that unsuitable persons do not work in the home. (Previous timescale of the 1st July 2006 not met). The registered person must ensure that family members do not act as referees to assure residents that an independent person has confirmed the competence and integrity of the applicant. The registered person must ensure that references are taken from the most recent employer so that unsuitable persons do not work in the home. The registered person must ensure that each member of staff has an enhanced CRB disclosure, naming the company as the employer, prior to commencing work or works under close supervision, with a pova first check, pending the return of the CRB disclosure so that unsuitable persons do not work in the home. (Previous timescale of the 1st August 2006 not met). The registered person must ensure that feedback obtained from quality assurance systems is used to plan and develop services so that changing needs of residents are recognised and met. (Previous timescales of 1st April and the 1st September 2006 not met). 01/11/07 01/11/07 01/11/07 01/01/08 Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 31 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 YA6 Good Practice Recommendations That the home contacts the funding authority 4 weeks before an annual review is due to request the date for the meeting to be held. Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Jerome House DS0000017485.V346227.R01.S.doc Version 5.2 Page 33 - 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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