Inspection on 28/12/05 for Jesmund

This inspection was carried out on 28th December 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

Jesmund 16/10/07

Jesmund 07/04/06

Jesmund 16/08/05

Jesmund 20/12/04

Jesmund 10/08/04

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

CARE HOMES FOR OLDER PEOPLE Jesmund 29 York Road Sutton Surrey SM2 6HL Lead Inspector Alison Ford Unannounced Inspection 28th December 2005 11:00a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Jesmund Address 29 York Road Sutton Surrey SM2 6HL 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) 020 8642 9660 020 8642 9662 Mrs Abbie Shiels Mrs Abbie Shiels Care Home 25 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified residents under the age of 65 to be admitted. 16th August 2005 Date of last inspection Brief Description of the Service: Jesmund is a nursing home, registered with The Commission for Social Care Inspection, to provide care for up to 25 residents with a history of dementia or mental disorder. It is situated on a quiet residential road in Cheam Surrey about 1.5 miles away from the station and the shopping facilities of central Sutton. There is a substantial well-kept garden to the rear of the property and off street parking to the front. Ramps at both the front and rear doors provide wheelchair access. Bedrooms are arranged over the ground and first floor and most of them have en-suite facilities. There is a large sitting room on the ground floor with an additional dining room, kitchen and office facilities. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/2006 and was an unannounced visit lasting two and a half hours. At the last inspection the majority of the standards considered by The Commission to be key to the inspection process were assessed and this visit concentrated on reviewing the progress that had been made to comply with the requirements made at that time. A partial tour of the premises was also undertaken and several residents were spoken with. A sample of care plans and the medication records were also viewed. The lunchtime meal was served during the inspection and the home was still decorated for Christmas. Residents all said how much they had enjoyed the recent celebrations and their Christmas dinner. This report should be read in conjunction with the one produced following the inspection on 16th August 2005. What the service does well: This home provides clean, comfortable and well-maintained accommodation for up to twenty-five residents with dementia or other mental health issues. The premises are suitable for their purpose and all areas of the home are accessible to residents including those who rely on wheelchairs. They have been encouraged to personalise their rooms with familiar objects and pictures from home and these reflect their individuality. There are pleasant gardens to the rear of the property, which are enjoyed by residents in the warm weather. The local authority places the majority of residents and they are subject to their assessment and review processes. In addition all residents have an individual care plan, which describes the support that they require although these would benefit from more regular review to ensure that they reflect the interventions currently being delivered. Communication is difficult with many of the residents who on the day of the inspection, all looked clean and well cared for, although those who were able commented that “staff were kind” and “it was nice living in the home” and “they had enjoyed a lovely Christmas”. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Residents that are admitted through a Care Management arrangement can be sure that a comprehensive pre-admission assessment will ensure that the home will suit their needs. This home does not offer intermediate care: this standard does not apply. EVIDENCE: As before, all residents funded by the local authority have comprehensive assessment and review procedures in place. A previous requirement was issued for the staff in the home to compile a preadmission assessment tool to be used for privately funded residents. This has not yet been done and must now be complied with, although no new residents have been admitted since the last inspection. How this will be complied with will need to be outlined in the action plan that is produced by the home following this report. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9, Individual care plans are in place for all residents although these do not always reflect the care and support currently being delivered. Medication procedures are not always accurate enough to safeguard residents wellbeing. EVIDENCE: All residents have an individual care plan and a commercially available system “Standex” is in use. At the last inspection it was noted that improvements had been made to these plans. At this visit however, there was not always evidence to show that the plans have continued to be reviewed regularly to ensure that they reflect the care and support currently being given. These must be updated on a regular basis. Medication records were seen and omissions were noted in administration recording. The system currently used for dispensing medication makes it impossible to check whether individual tablets have been given. The procedures must be reviewed to ensure that staff are able to identify whether or not medication has been administered. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 10 The management team must include in their action plan, details of how they will ensure that there is evidence that care plans are regularly reviewed and how they will ensure that there is a method for checking whether medication has been given when signatures have been omitted from the record sheets. These must also be audited regularly to ensure that medication is being administered as prescribed. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents can be sure that they will receive a balanced and varied diet, which suits their needs and preferences. EVIDENCE: The lunchtime meal was served during the visit it was well presented and looked appetising. Menus were seen and were varied and nutritionally balanced. The cook, who is new, explained how meals were slightly varied to suit one resident from an ethnic background and how she was intending to become more interactive with residents in order to establish their preferences. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents and their relatives cannot always be confident that their complaints are dealt with appropriately. EVIDENCE: The home has a complaints procedure however; the complaints book was not available for inspection as evidence that any issues had been dealt with in a timely and appropriate manner. Concerns that had apparently been raised by a relative had not been documented in their care plans. In future, all complaints must be documented and there must be evidence of the action taken to resolve them and the outcome. The management team must include, in their action plan, the steps that they will be taking in order to ensure that his happens. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Residents cannot be sure that there is sufficient training in place to ensure that staff are competent to meet their needs. EVIDENCE: A previous requirement for at least 50 of care staff to undertake an NVQ level 2 qualification has still not been met. Those members of staff that are not in receipt of this qualification must be encouraged to enrol on a suitable course within the next academic year so that this standard will be met. The Registered Provider / Manager must identify how this standard will be met in the action plan prepared in response to this report. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36,38 Residents in this home cannot always be certain that their health, safety and welfare will always be protected or that they will be able to influence the running of the home. EVIDENCE: The Registered Provider/ Manager is a trained nurse with many years experience of working with this client group. She is able to demonstrate an insight and awareness of the problems experienced by the residents however is not always able to produce the documentary evidence to support the care that is being delivered. She and two of her senior nurses are currently undertaking an NVQ level 4 qualification. Previous inspections have highlighted the need for a quality assurance programme to be introduced. This has still not happened and, although they Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 16 are always able to approach the management team with any concerns, views of residents and relatives are still not audited. This requirement is repeated. A business plan, that reflected the reality of issues that were going to be dealt with, was previously requested but has still not been done and the requirement is repeated. The Registered Provider has responsibility for money for two residents. At the previous inspection a requirement was issued to make records of transactions made easier to understand and validate in order to safeguard the residents interests. This has not been done and the requirement is repeated. Staff supervision is still not being undertaken on a regular basis to ensure that staff understand the philosophy of care in the home and that their training needs are identified. This must be in place for all staff at least six times a year and the requirement is repeated. Certificates of worthiness of equipment were seen and were in order however there was no evidence available to reflect periodic fire drills. A record must be made available for inspection. The action plan prepared in response to this report must reflect how these requirements will be complied with. Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 2 2 X 2 Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP31 Regulation 24(1)&(2) Requirement The Registered Provider must supply the Commission for Social Care Inspection with an action plan outlining how all of the following requirements will be met within the specified timescale. The Registered Provider must ensure that a tool is developed to assess the healthcare needs of self-funding residents prior to their admission. (Previous timescale 30/11/05 not met) The Registered Provider must ensure that care plans are reviewed regularly and reflect the care and support that is currently being delivered. The Registered Provider must ensure that medication record sheets are audited regularly to identify any mistakes being made and to ensure that medication is being given as prescribed. The Registered Provider must ensure that there is a method in DS0000019100.V263274.R01.S.doc Timescale for action 30/01/06 2 OP3 14(1)(a) 30/03/06 3 OP7 15(2) 30/03/06 4 OP9 13(2) 30/03/06 5 OP9 13(2) 30/03/06 Jesmund Version 5.0 Page 19 6 OP16 Schedule4 7 OP28 18(1)(a) use to make it possible to identify whether medication has been given as prescribed when there have been omissions in recording. The Registered Provider must 30/03/06 ensure that there is a record of all complaints made including details of any action taken and the outcomes. The Registered Provider must 30/03/06 ensure that sufficient numbers of care staff are enrolled on an NVQ level 2 courses to meet the standard of at least 50 . (Previous timescales 30/1/05 & 30/11/05 not met) The Registered Provider must ensure that a quality assurance tool is developed to monitor the opinions of residents and relatives. (Previous timescale 30/11/05 not met) The Registered Provider must provide The Commission for Social Care Inspection with a business plan, which reflects the intended plans for the home. (Previous timescale 30/11/05 not met) The Registered Provider must ensure that records of resident’s finances are clear and easily interpreted. (Previous timescale 30/11/05 not met) The Registered Provider must ensure that all care staff receive supervision at least six times a year. The Registered Provider must ensure that there is a record of all fire drills that are carried out DS0000019100.V263274.R01.S.doc 8 OP33 24(1) 30/03/06 9 OP34 25(2) 30/03/06 10 OP35 24(3)(a) 30/03/06 11 OP36 18(2) 30/03/06 12 OP38 Schedule 4 30/03/06 Jesmund Version 5.0 Page 20 in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Jesmund DS0000019100.V263274.R01.S.doc Version 5.0 Page 22 - 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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