Inspection on 27/04/07 for Jesmond

This inspection was carried out on 27th April 2007.

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

The inspector found 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jesmond 12/07/06

Jesmond 28/02/06

Jesmond 01/08/05

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 Merton Mitcham Surrey CR4 1EQ Lead Inspector Janet Pitt Unannounced Inspection 27th April 2007 10:30 Jesmond DS0000027210.V337315.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 Jesmond DS0000027210.V337315.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. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jesmond Address 23 Jesmond Close Merton Mitcham Surrey CR4 1EQ 020 8646 8319 F.P 020 8646 8319 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) www.thresholdsupport.org.uk Threshold Housing & Support Ms Valerie Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five Adults (M/F) with Learning Disabilities Date of last inspection 15th May 2002 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. At the time of this inspection the manager reported that the weekly fees were £869.19 per week. Additional charges are made for some outings and holidays. Residents are made aware of the inspection report at the residents meeting. Jesmond DS0000027210.V337315.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 during the time period 27th April 2007 to 11th May 2007, to allow time for surveys. One inspector made two unannounced site visits. Surveys were left for each person who uses the service and their next of kin. Unfortunately no surveys were returned within the timeframe. Care plans, staff records and medications were examined. A tour of the premises was also undertaken. On the first site visit there was no one at home and a message was left to say the inspector had called. On the day of the second visit three and a half hours was spent at the service. Two people who use the service were spoken with and the manager. What the service does well: What has improved since the last inspection? What they could do better: Support plans have been reviewed and are structured to make sure that relevant information is collated. However, the home need to make sure that all documentation is completed fully to identify need and detail how needs are to be met. Staff files must contain information as required to make sure that people who use the service are protected from harm. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 6 People who use the home need to be confident that staff received appropriate training ton support them. There needs to be a clear audit trail in place to make sure that medications are handled appropriately. 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. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service consults the assessment information to see if they can meet the prospective individual’s needs. These are generally undertaken in a satisfactory manner, but care is needed to make sure that individual’s needs are fully identified. EVIDENCE: Comprehensive assessments of need are completed on people who use the service prior to moving in and on admission. In the two assessments examined there was evidence of involvement of the people who use the service. Assessments covered aspects such as physical, physiological, social, education/employment, communication and financial needs. Health action plans were in place and individualised risk assessments. Care needs to be taken to make sure that assessments are completed fully and relevant background information is included. For example one person’s assessment identified lack of awareness of ‘stranger danger’, but its relevance was not detailed. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives. EVIDENCE: Plans for persons who use the service lead from assessments. Strengths are identified and plans indicate where support is required to develop independent living skills. The manager said that one person who uses the service would soon be ready to live independently. Support is given to people who use the service in areas such as housework, laundry and cooking skills. Two of the people who use the service were attending day centres and were waiting for transport when the inspector arrived. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 10 It was evidenced that people who use the service are involved in their plans and reviews. The structure of plans would enable staff to be able to provide care in a consistent way, if they were fully completed. There were however clear directions on how to meet needs on those plans that were completed. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling people who use the service to develop their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals and work to achieve them. EVIDENCE: People who use the service are able to participate in appropriate activities if they chose. One person is a volunteer in a nursery and another is undertaking cooking courses at a college. Social activities include Church groups, numeracy skills and arts and crafts. Contact with family is maintained and it was noted that one person visits their family at weekends and their sibling visits the home regularly. Sexuality is addressed when the person who uses the service wishes to discuss this area. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 12 The manager stated that people who use the service have a right to take risks and should be supported in doing this. One person was being supported to visit the post office and bank, within a risk assessed framework, as there were issues with road safety and managing money. Care has been taken to enable people who use the service to develop skills in a planned way, to make sure that they become confident in managing their lives. Meals within the home are flexible depending on activities. Each person who uses the home has a space in one of the fridges for their own personal food, so they are able to have snacks when they want. People who use the service are encouraged to chose a healthy diet and assist with food preparation. The menus are worked out weekly with all people who live in the home having input. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service have access to health care services both within the home and in the local community. Action is needed, as medications systems do not always follow good practice or safe practice guidelines. EVIDENCE: Evidence in support plans indicates that people who use the service are supported with personal care. Detail of same gender care preferences are recorded and acted upon. Support plans cover physical, emotional and health needs of people who use the service. However, as mentioned previously these need to be completed fully to make sure that needs are evidenced as met. Medications were examined and there were some areas, which need attention to make sure that people who use the service are protected from harm. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 14 The home uses a monitored dosage system. All but one of the medication records (MAR) did not have a photograph of the person on them. One person who uses the service self medicates. Their medications are dispensed into a Dosette box from the blister pack. It would be safer practice for the person to learn how to dispense from the blister pack, to avoid secondary dispensing. This person who uses the service has a medication as required, but there was not record of it being supplied. It was noted that ‘as required/’ medication did not have clear instructions on when they needed to be given. Paracetamol prescribed for when needed did not have safe limits detailed. Topical creams were not consistently signed as being given. However, there was reference to same gender care for supervision or application of creams. One cream was to be applied at night, but had been written up for four times per day. There were gaps in recording on one MAR sheet. Health needs of people who use the service are addressed and there is evidence of visit by other health professionals. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 15 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 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home allows people who use the service to express their views. The complaints procedure is supplied to everyone living at the home. There have been no Protection of Vulnerable Adult investigations. EVIDENCE: There have been no Protection of Vulnerable Adults investigations or complaints since the previous inspection. The home has a clear complaints policy, which is in a format that is easily understood. This is accessible to people who use the service. People who use the service are able to attend Merton’s People First meetings where they can hear guest speakers discussing issues such as crime and bullying. A recent report into abuse in a care institution has also been discussed. This approach makes sure that individuals are informed of possible risks and how to deal with them. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is comfortable and homely, but a planned programme of redecoration and refurbishment is needed to make sure that maintenance is proactive rather than reactive. EVIDENCE: People who live in the home have their own rooms and there is suitable communal space available. All persons have their own key to their room and the front door of the house. It was noted that on the second site visit, people who live in the home, had locked their bedroom doors when they went out. Some areas of the home have been decorated to a good standard. There is new carpeting in the hallways and stairs. However, the flooring in the lounge needs replacing, as it is old and worn. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 17 One person’s room was viewed and had personal items and was decorated to their taste. Meetings held with people who live in the home showed that they are consulted on décor schemes. Their views are acted upon. Minor repairs are needed to make sure the home is maintained and safe. The area around the boiler in the kitchen needs painting. There were scuffmarks on skirting boards around the home. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People who use the service need to be confident that the homes recruitment procedures protected them from harm. The service does not support or encourage the development of a competent staff team. Training provided is patchy and not targeted at individuals. There is no comprehensive training plan and no reliable records of staff training. EVIDENCE: The duty rota indicates that there are adequate numbers of staff to support people who live in the home. However, staff are not aware of the importance of timekeeping. One member of staff, who had been on a sleep in, was not relieved of their duties at the appropriate time. Staff files examined did not contain all the information required in the Regulations and Schedules. One file did not have an application form. Appropriate checks had been made on candidates, such as Criminal Records Bureau checks and references. There was some good practice evidenced, in the form of interview notes. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 19 A request for the forthcoming training programme was made, but this information was not forwarded to the CSCI. The home has recently been taken over by another provider, and the manager stated that he was in the process of collating training needs. People who use the service and staff need to be confident that training is given which will make sure that needs are met. Supervision if staff has been patchy and the manager is aware of the need to make sure that it occurs as stated in the standards. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 20 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 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home and is aware of the need to keep up to date with practice. Lack of formal training courses for staff does not underpin practice within the home. The service needs to make sure that they provide information to inform the inspection programme. EVIDENCE: Pre inspection information was requested, but not provided to CSCI. The service must be proactive in providing information to CSCI in a timely manner. This will make sure that CSCI can be confident that the home is run well. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 21 The manager is in the process of applying for registration with CSCI. The staff team are proactive in making sure that people who use the home have a say in how it is run. Windows in the home have restrictors, but it was noted that these are not consistently used. The manager stated that some people who live in the home prefer to be able to have their windows open wide. It is important that this is documented appropriately on a risk assessment, to demonstrate this is the person’s choice. The inspector was concerned on the first site visit that upper windows were left open and there appeared to be no one in. The number on the answer phone was incorrect. These issues need to be addressed. There are no restrictions on staff going out with people who live in the home, however, emergency contacts need to be current to make sure that those who are at day centres can be assisted if required. Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 1 32 X 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 X Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 23 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. 2. Standard YA2 YA6 Regulation 14 15(1) (2) Requirement The registered person must ensure that assessments fully detail needs. The Registered Person must ensure that care plans are reviewed and updated (Timescale of the 30/08/05,30/04/06 & 30/09/06 not met). The Registered Person must ensure there is a clear audit trail for medications. As required medications need specific instructions on when they are to be used. The Registered Person must ensure that good practice is followed when a person self medicates and there is no secondary dispensing of medications. The Registered Person must ensure that all medications are sign for when given. The Registered Person must ensure that the carpet in the DS0000027210.V337315.R01.S.doc Timescale for action 30/09/07 30/09/07 3. YA20 13(2) 30/09/07 4. YA20 13 (2) 30/09/07 5. YA20 13 (2) 30/09/07 6. YA24 23(2) (b) 30/09/07 Jesmond Version 5.2 Page 24 lounge is replaced. 7. YA26 23 The Registered Person must audit resident’s bedrooms and devise a maintenance plan (previous timescale of 30/12/06 not met) The Registered Person The Registered Persons must ensure that individual staff record are maintained as per requirements of Schedule 2 & 4 of the Care Homes Regulations 2001.This includes written confirmation as to all checks carried out on agency staff. (previous timescale of 30/09/06 not met) The Registered Person must ensure that all staff has a training plan, which includes evidence of when core training was attended. The Registered Persons must ensure that all new staff receive induction training to national ‘Skills for Care’ specification. Full records must be maintained to evidence this. (previous timescale of 30/09/06 not met) 10. YA37 17, Sch 3 &4 The registered person must ensure that information is produced to inform the inspection process in a timely manner. The registered person must ensure that if window restrictors are not used then there is a risk assessment in place to demonstrate choice. The registered person must ensure that there are suitable emergency procedures in place. 30/09/07 30/09/07 8. YA34 19(1) (b) 30/09/07 9. YA35 18(1)(c) 30/09/07 11. YA42 4 (a) 30/09/07 12. YA42 4 (c) 30/09/07 Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Jesmond DS0000027210.V337315.R01.S.doc Version 5.2 Page 27 - 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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