Inspection on 28/02/06 for Jesmond

This inspection was carried out on 28th February 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jesmond 27/04/07

Jesmond 12/07/06

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 Davina McLaverty Unannounced Inspection 28th February 2006 10:00 Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 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.V284757.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V284757.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Jesmond Address 23 Jesmond Close Merton Mitcham Surrey CR4 1EQ 0208 646 8319 0208 646 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.V284757.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five Adults (M/F) with Learning Disabilities Date of last inspection 1st August 2005 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 DS0000027210.V284757.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. The inspector met four of the five residents, the manager and one member of support staff. A number of records were examined, which included residents care plans, medication records, staff and residents meeting minutes and staff records. A tour of the communal areas took place and two residents bedrooms were seen. Two of the residents were spoken to at some length and both were very positive about the home and the support received. Comments made were “ I like living here”, “staff are okay” and “I get to do what I want a lot of the time”. What the service does well: What has improved since the last inspection? What they could do better: Some of the information contained in the care plans was seen to require updating. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 6 Staff supervision needs to be recorded and must take place at least six times a year to ensure that staff have the support and direction to carry out their job safely and efficiently. The Registered Persons must address requirements, which have been outstanding since August 2005. 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 DS0000027210.V284757.R01.S.doc Version 5.1 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.V284757.R01.S.doc Version 5.1 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 the following standard(s): 1&2 The home has a Statement of Purpose and Service User Guide both of which must be updated. Threshold has an adequate assessment procedure in place. EVIDENCE: The Statement of Purpose and Service User Guide requires updating now that a new manager has been appointed. Since the last inspection a new resident has been admitted. Documentation was seen regarding the assessment of this resident by the social worker and the home’s manager. On examination of the documents the resident did not meet the registration category as detailed on the homes registration certificate. An application for variation must therefore be submitted to the Commission. The Registered Persons must ensure that any future admissions are within the registered category unless a variation for the category has been agreed by the Commission for Social Care Inspection. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Support plans are in place but require updating and regular review. Residents are involved in making decisions about their lives and offered appropriate support. Individual risk assessments were not in place potentially placing residents at risk. EVIDENCE: Two support plans and files of residents were examined. Care seen was adequate but needs to be developed further. The manager stated that the home is moving towards Person Centred Plans (PCP’s) and that new plans would soon be drafted which will clearly identify circles of support and make full use of photographs and images. Resident’s involvement will be central throughout the plan. PCP’s will supplement current care plans. Support plans seen identified goals and included resident’s strengths and weaknesses. However, individual support plans were not always evaluated on the date stated and on some of the plans there was no date of review. The same applied to Risk assessments, which had not progressed since the last inspection. In discussion with the manager he acknowledged that these were areas that needed to be improved upon. From the information seen it was Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 10 possible to get a pen-picture of residents support needs, which would be useful to any new staff working in the home. The home must ensure that information detailed in Schedule 3 of the care homes regulations is available for each resident. On one of the files examined there was no photograph and very little personal information including contact details for the resident, which in an emergency would be very problematic. From discussion and observations of residents, they stated that they got to choose what they wanted to do. One resident has an advocate who supports her in doing various tasks. The staff member spoken with was very positive about the residents and how the home supports them to develop new skills. The manager reported that this is an area that the staff team they will be focusing on to ensure that the residents are always making decisions and supported by the staff team as needed. The home operates a key worker system and both residents spoken with were aware of who their key worker was and their role. Residents are consulted about how the home is run and meet as a group on a regular basis. Minutes of these meetings were seen. Both the manager and the staff spoken to demonstrated a good knowledge of the residents’ individual needs and a commitment to supporting residents in making informed decisions about their lives. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13, 14, 15 16 & 17 This home continues to ensure that links with the community are good and this helps to support and enrich resident’s work and social opportunities. Staff have a good understanding of residents support requirements ensuring these needs are addressed. Staff encourage and support residents to eat healthily and have a varied diet. EVIDENCE: Residents continue to participate in a variety of activities both inside and outside of the home. Residents are encouraged to pursue individual activities such as horse riding, training spotting and supporting their football team. On the day of the inspection, one resident had decided to meet a friend and watch his football team play. Another resident spoke to the inspector about his love of films and trains. This resident leads a fairly active life and said that he enjoyed living at Jesmond as he got to do what he wanted as well as trying new things e.g. going to the gym where he used the rowing machine. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 12 Resident’s day care packages varied. One resident attends a Day Centre 4 days a week and this resident told the inspector that they enjoyed going as they see their friends. As stated residents 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 were seen to have their own equipment in their bedrooms. Daily living skills continue to be encouraged and residents are being encouraged and supported to do more for themselves and to acquire new skills. Two of the residents spoke positively about what they could do. A copy of the menu was seen which appeared, varied and nutritionally balanced. In discussion with the manager he stated that healthy eating was being encouraged and staff were supporting residents in making healthier choices. Individual cooking was being encouraged as well as residents being actively supported to plan and prepare their own meals. A new fridge had been purchased which would enable residents to have more space to keep their own foods. The inspector noted that the resident at home for the day made her own drinks as well as a sandwich for lunch. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 Health care needs are being met and there is evidence of multi- disciplinary input from health and social care professionals. A medication policy is in place but risk assessments were found not to be in place for residents who self medicate, which must be addressed. EVIDENCE: Evidence was seen in the care plans of multi disciplinary input from health care professionals including GP’s, physiotherapists, opticians and dentists. The manager and staff member demonstrated a good knowledge of each individual requirement. A medication policy is in place, which addresses the receipt storage and handling of medication. Two of the residents currently self medicate. One of whom collects his own medication from the pharmacy. The other resident dispenses her own medication into a dosette box each week and has responsibility for taking it. This is monitored by staff. Risk assessments in respect of both these residents were not found to be in place. The manager stated that he was in the process of addressing this. This must be done as a matter of urgency. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 22 & 23 The home has a complaints procedure in place. Policies and procedures are in place to protect residents from abuse and harm. EVIDENCE: The manager reported that no formal complaints had been received since the last inspection. The two residents spoken to both stated that they were happy living at the home and had no complaints. Both said that they would talk to staff if they were not happy or their family. A copy of the organisation’s adult protection policy is available to staff as well as the organisation’s whistle blowing policy. The staff member spoken to was aware of both policies and would take appropriate action if the need arose. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 24, 25, 26 27 28 & 30 The premises continues to be homely and was in a reasonably good state of repair. Bedrooms seen were personalised and reflected resident’s personality. The home was seen to be clean and tidy on the day of the inspection. EVIDENCE: The premises remains the same as at the last inspection. A homely atmosphere was apparent. The two residents spoken with were clearly happy with their rooms, both of which were a good size. Both were personalised reflecting the resident’s personality and taste. The inspector noted in one of the rooms that one of the drawers in the chest of drawers was broken. This must be repaired/ replaced. Both residents said that they had the keys to the house and to their bedrooms. Residents are encouraged to lock their bedrooms. Bathrooms seen were satisfactory. Adequate communal space is available. The lounge is large as is the kitchen. The lounge opens out onto a large garden which one of the residents said is well used during the warmer weather. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 16 The home was seen to be adequately clean on the day of the inspection. A separate laundry room is available with a locked cupboard where COSHH materials are stored. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 & 36 Records relating to staff recruitment, supervision and training was found not to be in place. EVIDENCE: The manager had access to records of two staff at the time of the inspection. Both these records were incomplete in that they did not confirm that all the checks required in Schedule 2 of the Care Home Regulations had been complied with. The organisation has a centralised human resources department where all staff records are kept. In discussion with the manager confirmation must be available in the home to evidence that the relevant checks has been carried out. Supervision is currently verbal. Supervision sessions must be recorded and available for examination. Supervision should take place at least six times a year. Staff training records were not available although the manager said that one staff member had completed the NVQ level 2, and that two staff were currently on the NVQ 2 course. Records relating to core training was not available in the home although the staff member spoken to stated that she had undertaken all relevant courses since working for threshold. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 & 39 The manager has a good understanding of the areas of the home requiring improvement. EVIDENCE: The manager started work in the home in October 2005. An application to be the registered manager must be submitted to the Commission For Social Care Inspection. The manager reported that he is currently undertaking his NVQ Level 4. The staff member spoken to stated that the manager’s style is open, positive and inclusive. She stated that he had introduced a number of changes, which were having a positive effect for the residents and the staff team. The organisation has a quality assurance system in place but it was not clear how resident’s views were being formally used. Residents meetings were seen to be taking place. Regulation 26 visits reports are still not being forwarded to the Commission and in discussion with the manager it appeared that reports are not always produced. Failure to comply is in breach of the regulation. The Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 19 requirement made at the previous inspection has been repeated. Also outstanding from the previous inspection is a record of the hot water temperature, which was still not being maintained. The manager stated that a new thermometer had only recently been purchased and that a system for checking the hot water temperature was to be re-introduced. The requirement made has therefore been re-stated. Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 20 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 2 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 3 25 2 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X 2 3 2 X X 2 X Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 21 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 YA 1 Regulation 6(a) Schedule 1 14 Requirement The Registered Persons must ensure that the Statement of Purpose and Service User Guide are reviewed. The Registered Persons must ensure that the assessment of needs of resident is compatible with the homes Registration of the home. A request for a variation must be submitted in respect of the last resident admitted. The Registered Person must ensure that care plans are updated regularly. (Timescale of the 30/08/05 not met). The Registered Person must ensure that risk assessments are regularly updated. (Timescale of the 30/08/05 not met) 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. (Timescale of the 15/08/05 not met). The Registered Person must repair/replace the broken drawer in one of the resident’s DS0000027210.V284757.R01.S.doc Timescale for action 30/04/06 2 YA 2 15/04/06 3. YA6 15(1) (2) 30/04/06 4. YA9 13(4) 15/04/06 5. YA20 13(2) 15/04/06 6 YA 25 16(2) (c) 30/04/06 Jesmond Version 5.1 Page 22 bedrooms. 7 YA 34 19(1) Schedule 2 The Registered Persons must ensure that evidence is available in the home regarding recruitments checks carried out on all staff in the home and be available for inspection. The Registered Persons must ensure that each staff has a training record. The Registered Person must ensure that staff receive formal supervision six times a year. The Registered Person must submit an application to the Commission to be the Registered Manager of the service. 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. (Timescale of the 30/08/05 not met) The Registered Person must ensure the organisations quality assurance system is in place and evidence seen of residents/ relatives and stakeholders views being incorporated. The record of the hot water temperatures must be recorded weekly. (Timescale of the 01/08/05 not met). 30/04/06 8 9. 10 YA 35 YA36 YA 37 18(1) 18(2) 9(1) 30/05/06 30/04/06 30/04/06 11. YA39 26 30/04/06 12 YA 39 35 30/06/06 13. YA42 13(4) 01/04/06 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.V284757.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jesmond DS0000027210.V284757.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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