Inspection on 01/08/05 for Jesmond

This inspection was carried out on 1st August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Jesmond 27/04/07

Jesmond 12/07/06

Jesmond 28/02/06

Jesmond 29/09/04

Jesmond 21/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Jesmond 23 Jesmond Close Mitcham Surrey CR4 1EQ Lead Inspector Davina McLaverty Unannounced 1 August 2005 10:30 am st 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 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 Stationary 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. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Jesmond Address 23 Jesmond Close Mitcham Surrey CR4 1EQ 0208 646 8319 0208 646 8319 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Threshold Housing and Support Ms Valerie Smith CRH Care Home 5 Category(ies) of LD Learning Diability (5) registration, with number of places Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five Adults (M/F) with Learning Disabilities Date of last inspection 29TH September 2004 Brief Description of the Service: Jesmond is a care home providing residential care and accommodation for residents with learning disabilities.The home is owned by Threshold Housing and Support and is located close to shops, pubs and other amenities. It is a three storey domestic style property. All accommodation is provided in single rooms.The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 10.30 am and concluded at 4.45 pm. The inspector met four of the five residents, the manager and three support staff. A number of records were examined, which included residents care plans, medication records, staff and service users minutes and health and safety records. A tour of the communal areas took place and two residents bedrooms were seen. The manager informed the inspector that the Threshold Housing and Support had merged with another organisation “Open Door” and that the company was now known as “Threshold Support”. The Commission must be formally notified in writing of this change to allow for a new certificate to be issued. What the service does well: What has improved since the last inspection? The manager of the home has started to put in place the organisations quality assurance system and was in the process of evaluating the service provided. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,& 4 The home had a satisfactory Statement of Purpose and Service User Guide. There are appropriate procedures for the admission of residents, which included visits and an overnight stay. EVIDENCE: A Statement of Purpose is in place, which contains relevant information regarding staffing levels, supporting residents, care planning, personal support, hobbies and interests. A Service User Guide is also available providing residents/ and or their representatives, with the information they need to make an informed choice about residing in the home. All residents are given a copy of the guide. The organisations ‘referrals and admissions’ procedure ensures that prospective residents needs are assessed. However, not all assessment documents were seen on the file of the newest resident. The manager stated that she had received details and had carried out her own assessment, which was seen on the file. A copy of the core assessment would be sought. In discussion with the resident he confirmed that he had visited the home with his representative prior to the admission. He confirmed that his views had been listened to. He stated that he really liked living at Jesmond Close as he had a nice room and liked the staff and other residents. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 9 Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Staff on duty had a good understanding of resident’s support needs and involve residents as far as possible in the process. However, support plans seen require updating as did the majority of risk assessment documentation seen. EVIDENCE: Care plans for three residents were examined. The care plans included details regarding personal needs, health care and social support and detailed how the residents needs are to be met. The inspected noted that residents sign the care plan and are involved in the care and support provided. However, two of the three plans seen were not up to date. The senior support worker stated that this was due to staff shortages within the home and use of agency staff who are not all familiar with the care planning system. A key worker system is in place and the home is working towards a person centred approach to care planning. Residents spoken to were on the whole, aware of their key worker and the person’s role although they said they could Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 11 talk to any staff about anything. Staff respect the right of residents to make decisions and this is reflected in the information seen. Differences were noted in the activities residents prefer. Residents are supported to take risks within a risk management framework. Risk assessments were seen to be in place, however, review of these assessments was outstanding on two of the three records seen. All four residents spoken to individually reported that they were satisfied with the overall service provided. Comments included ‘I like living here’ ‘ I get on well with the other residents and with staff ’ and ‘ I can go out on my own’. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 13, 14, 15 & 16 The home has appropriate activities in place, which reflect resident’s choices and promote independence. Links with the community are good and these support and enrich resident’s social and educational opportunities. EVIDENCE: Residents participate in a variety of activities. One resident reported that they attended a Day Centre 4 days a week. Residents are supported to engage in activities both inside and outside of the home environment. The lounge was seen to be equipped with television and music equipment, although residents also have their own equipment in their rooms. One resident enjoys playing games on their computer. Daily living skills are encouraged and residents spoke of what they did individually within the home e.g. taking responsibility for their laundry, tiding their room. One resident was supported by a staff member to prepare their tea. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 13 Staff reported that evening activities such as walks, pub visits and visits to the cinema take place. Service users attend the local Gateway club every fortnight. Three of the residents travel there independently, whereas the bus picks up one. Two residents attend church and one goes horse riding regularly. Details of interests and preferences are documented in the care plans seen. Four of the service users have some contact with their family. This varies from occasional visits to overnight stays. Residents spoke of their visitors being made welcomed in the home. The home encourages all residents to hold a key to their bedrooms and front door. Residents appeared very much at home throughout the inspection, moving freely between the lounge, kitchen and their bedroom. Interaction between residents frequently took place and on the whole was seen to be positive. One resident spoken to reported that they had recently been on holiday to Portugal and had ‘really enjoyed this’. They were also looking forward to a further holiday in September to Dorset. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 The privacy and dignity of residents is protected with residents being involved in carrying out their own personal care as much as they are able. The health needs of residents are met with evidence seen in care plans of multi-disciplinary working taking place. Systems were seen to be in place in respect of administration of medication, with the exception of one risk assessment seen, which required a little more detail. EVIDENCE: Residents are quite independent and attend to the majority of their personal care needs themselves, with limited staff input. Residents confirmed that staff would knock on their doors before entering. Another said that they decide when they go to bed. Residents all have keys to their bedrooms and the front door. The inspector observed that clothes chosen by the resident reflect their individual personality. Evidence was seen in the care plans, of input from health care professionals including chiropodists, GP’s, dentists and opticians to ensure that individual physical health needs were met. Staff spoke of supporting residents as needed. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 15 One staff member stated that a lot of prompting is given to two residents to ensure that tasks get done. The receipt, storage and handling of medication reflected the policy that is in place in the home, ensuring that medicines are handled safely and given appropriately. Medications were seen by the inspector to be appropriately stored. All items were labelled with clear directions for administration. No gaps were noted in the medication administration sheets (MAR). However, the allergy section on the MAR sheet was not completed. A risk assessment seen required more detail to fully address the resident’s needs. The manager stated that all staff receive training from Boots pharmacist and will provide the home with advice as necessary. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 An adequate complaint procedure was seen to be in place. EVIDENCE: The complaint procedure seen detailed how to complain, and who to talk to if the resident is still unhappy with the outcome. The timescale for a response to the complaint is also detailed. The procedure also reflect CSCI details. No complaints had been recorded on the complaint forms. Although in discussion with the manager a complaint had been made and investigated. Details of this complaint was in the incident file and had been adequately addressed. In hindsight the manager stated that details of the incident should also have been recorded on a complaint form. Two of the residents spoken to expressed confidence in the staff sorting out any concerns they had and said that it was unlikely that they would want to make a formal complaint. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 , 25, 27 & 30. The premises are homely and were in a reasonably good state of repair. Bedrooms seen were personalised and reflected resident’s personality. The home was seen to be clean on the day of the inspection. EVIDENCE: The premises were seen to be homely and in a reasonably good decorative state as were the two bedrooms seen. Residents are encouraged to personalise their rooms as they wish. Residents spoken to were satisfied with their bedrooms. The furnishings in the lounge are domestic in style and the area has a ‘lived in’ feel to it. The lounge overlooks and leads to a good sized private garden, which was seen to be tidy with evidence of a recent barbeque having taken place. Natural and artificial lighting is available, which is adequate. The home has three toilets and two bathrooms, which adequately meets the needs of the residents. The laundry facility is located on the ground floor away from the kitchen facility. Appropriate washing and drying facilities are available with residents having access when they want. One resident said that the dryer was not working. This was confirmed by one of the staff who said that Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 18 someone was due to visit tomorrow to have a look at it, in the meantime clothes were being dried outside or put on clothes racks inside the home. The home was seen to be adequately clean on the day of the inspection. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 36 Regular formal supervision and staff meetings were not taking place resulting in staff development possibly being compromised. EVIDENCE: A minimum of two staff are on duty during the waking day. One staff member sleeps in. Staff maintained that this level of staffing meets the assessed needs of the residents. Residents spoken with said that there were sufficient staff around to help them when needed. Staff said that they the team functioned well despite recent changes, which they all felt, had not impacted on the residents. Formal regular staff meetings were found not to have taken place following the manager’s resignation, although staff stated that informal support was good. Only one staff meeting had taken place between April and July. One staff member stated that due to changes with management within the home, supervision was not taking place regularly. However, three staff reported that they are a close-knit team and they provide each other with informal support/supervision. The senior support staff spoken to said that he had received support from the organisations care services manager when there was no manager in post. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 20 Staff were all positive about the organisation training programme and were aware of the procedures in place for dealing with physical aggression towards staff. Comments received from residents regarding the staff included ‘I like the staff’ and ‘they are nice to me and help me to do some things’. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 & 42 Staff take their responsibilities seriously to ensure the health and safety of residents and systems are in place to monitor this. An organisational quality assurance system is in place, which the manager is in the process of implementing to ensure that the service is meeting the needs of the residents. EVIDENCE: The manager informed the inspector that there have been staff changes within the home. She reported that she had resigned and left the home at the end of March. A new manager had been appointed and started within the home only to have to leave (due to personal reasons) within a couple of weeks. The home was then without a manager for almost three months when Threshold approached her and she agreed to return part time at the end of June. She stated that another manager has been appointed although it is not clear Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 22 exactly when this person will start. At the time of the inspection the Commission had not been notified regarding the above changes. Subsequently these details have been received. An organisational quality assurance system is in place. The views of stakeholders are being obtained. The manager stated that work in this area is ongoing. The inspector saw documentary evidence in regards to the quality assurance system in place and the steps taken by the manager to date in implementing the system. Residents meetings should take place monthly, however the record indicated that no meeting had taken place in May or June. This was due to staff changes within the home. Two meetings had taken place in July. The inspector suggested to the manager that consideration could be given to seeking resident’s views, which could them feed into the quality assurance system. Regulation 26 visit reports do not appear to be taking place as no reports except one this year (2/2/05) was available in the home or sent to the Commission. The senior staff stated that in the absence of a permanent manager a lot of support had been provided by the care services manager within the organisation. However it was acknowledged that reports had not been received. Residents are protected by the Health and Safety systems in place at the home. The Fire Safety Officer visited during the inspection and was satisfied with the fire safety systems within the home. Environmental services visited the premises in May and the recommendations made have been addressed. The gas safety certificate was seen and COSHH assessments were in place. The COSHH cupboard in the laundry room was locked. The Portable Appliance tests are overdue and hot water tests were not consistently being carried out weekly. The hot water tests must include wash hand basins in resident’s bedrooms unless a risk assessment is put in place. Jesmond G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 3 x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 2 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Jesmond Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 Page 24 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 2 Regulation 14(1) Requirement The Registered Person must ensure that assessment of residents needs are obtained and available on residents files. The Registered Person must ensure that care plans are updated regularly. The Registered Person must ensure that risk assessments are regularly updated. The Registered Person must ensure that where residents self medicate the risk assessment is in sufficient detail to identify how the risks has been minimised. The Registered Person must ensure that regular staff meetings take place ( minimum six per year) are recorded and actioned. The Registered Person must ensure that staff receive formal supervision six times a year. The Registered Person must ensure that monthly visits are completed and that a copy of the written report is kept in the home as well as sent to the Commission. The Registered Person must ensure that the electrical Timescale for action 30/9/05 2. 3. 4. 6 9 20 15(1) (2) 13(4) 13(2) 30/8/05 30/8/05 15/8/05 5. 33 12(5) 30/8/05 6. 7. 36 39 18(2) 26 30/8/05 30/8/05 8. Jesmond 42 13(4) 01/08/05 Page 25 G54-G04 S27210 Jesmond V241435 010805 Stage 4.doc Version 1.40 portable appliances are checked for safety. The record of the hot water temperatures must be recorded weekly. 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. 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