Inspection on 24/07/06 for Jewish Care

This inspection was carried out on 24th July 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 no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jewish Care 01/11/07

Jewish Care 21/12/05

Jewish Care 25/05/05

Jewish Care 30/09/04

Jewish Care 20/05/04

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

CARE HOME ADULTS 18-65 Jewish Care 7b Mapesbury Road London NW2 4HX Lead Inspector Andreas Schwarz Key Unannounced Inspection 24th July 2006 09:30 Jewish Care DS0000017467.V305223.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 Jewish Care DS0000017467.V305223.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. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jewish Care Address 7b Mapesbury Road London NW2 4HX 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 8459 2569 020 8459 4855 Jewish Care * Vacant * Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (25), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (20) Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: 7b Mapesbury Road is a purpose built house with a very large well-maintained garden at the rear of the property. It is in a quiet residential road, but within walking distance of good public transport links and close to Kilburn High Road shopping centre. The home is run by Jewish Care and provides accommodation for 25 adults with mental health problems. The age of the service user ranges from 50 to 86 years. A registration variation has been applied for in order to accommodate those service users over the age of 65. All service users have good-sized single rooms and there are also five flats with en-suite facilities. There is a large dining/lounge area on the ground floor that opens out to a beautifully maintained garden and two further lounges on the first and second floor, one of which accommodates service users who smoke. There is off-street parking at the front of the property. Information on fees and charges can be obtained from the manager on request. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place during a day in July 2006 and lasted 8,5 hours. The inspector assessed all key standards during this unannounced key inspection. The acting manager Mr Prince Balwah and assistant manager Mrs Christine Foord were available throughout this inspection. One service user showed the inspector around the home, the inspector spoke to service users, staff, one community nurse and the operations manager, Mrs Aviva Trup, during this inspection. The inspector viewed files, documents and care plans during this inspection. The inspector would like to take this opportunity thanking everybody who was been involved in this unannounced key inspection. What the service does well: Ealon House (7b Mapesbury Road) is very well managed and staff as well as service users spoke very positive about the acting manager Mr. Prince Balwah. The acting manager has been in regular contact with the inspector throughout the inspection year. The home has a very experienced staff team supporting service users with mental health and age related problems. Service users are consulted regularly regarding the care and support received and a range of suitable activities is provided. The homes literacy group has published a book with poems and stories written by service users about their live and living in Ealon House, which is commendable. Service users care plans are of very good standard and residents’ involvement is evident throughout. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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. Jewish Care DS0000017467.V305223.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 Jewish Care DS0000017467.V305223.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1; 2 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New prospective service users receive detailed information about the home, prior to being assessed appropriately, to establish if the home is able to meet the needs of new prospective residents. There is however more work needed to the homes statement of purpose. EVIDENCE: The manager showed the inspector a welcome pack, which is given to new prospective residents. This welcome pack is of good standard and contains the majority of information required by National Minimum Standards. The home must review this welcome pack and produce a statement of purpose and service users’ guide to fully meet National Minimum Standards. The inspector informed the acting manager that the majority of information in the welcome pack could be used for the statement of purpose and service users’ guide. The inspector suggested asking service users, of what they think would be important for new prospective service users to know about Ealon House. The acting manager must send a copy of the service users guide and statement of purpose to the inspector once completed. The home has detailed needs assessments in place for new prospective service users. All four care plans viewed by the inspector confirmed this. Service users informed the inspector that they have been involved in the assessment process and the service users or their representative has signed all assessment Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 9 documents. Information from the assessment forms part of the care plan. The home has currently two vacancies and no new residents moved into Ealon House since the last inspection. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 the following standard(s): 6; 7; 9 Overall quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Care plans are of high quality and service users involvement is evident throughout all care plans. Residents can choose where to go, what to eat and evidence of this was observed during this inspection. The home has detailed risk assessments in place and service users are involved in the reviewing process. EVIDENCE: The inspector viewed four care plans during this inspection, all care plans have been of similar high standard and service users are involved in the care planning process. Residents confirmed of meeting regularly with their key worker to discuss care plans and records of these meetings are on file. The home is reviewing all care plans internally (three-monthly) and externally (six monthly). Residents are involved in all reviews and can choose to invite friends, family or health care professionals if they wish. The acting manager showed the inspector a new care plan document, which is based on the person centred planning model and is judged as beneficial to service users and staff once fully implemented. The home has a care planning policy in place and all staff has received training around care planning. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 11 The inspector observed service users making choices during this inspection. Residents meet every two weeks to discuss issues related to the home, such as food, activities, outings, etc. There was clear evidence of service users participation within the care planning process. The acting manager informed the inspector that the home has made contact with Brent Advocacy Concern and an independent advocate can be obtained if required. Residents are very verbal in Ealon House and the majority are able to advocate for themselves. The acting manager is not acting as an appointee for any service user and residents are supported around financial issues by staff. The inspector viewed financial records, but was not able to check individual finances due to monies being put together in one cash tin, which is locked in the office. The inspector informed the manager that he must change this system and must store service users monies individually. Limitations to service users human rights are clearly risk assessed and detailed guidelines are put in place. All care plans viewed by the inspector had detailed risk assessments in place. Risk assessments are reviewed regularly and residents are involved in this process. The home has a history of responding promptly to service users changing needs and will review risk assessments accordingly. The home has a detailed risk assessment policy in place. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 the following standard(s): 12; 13; 15; 16; 17 Overall quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home is supporting residents to live a full; culturally appropriate and stimulating life. Residents can choose where to go, what to do and what to eat and are involved in the planning of activities. EVIDENCE: The home is encouraging residents to access colleges or find appropriate employment. One resident told the inspector that she is working part time at a charity shop and is playing the piano in another Jewish Care service. The home has a yoga teacher visiting the home and therapy sessions can be accessed through the Brent Mental Health Team. Residents have been observed coming and going throughout this inspection and staff support residents around financial issues such as collecting benefits, opening a bank account, etc. As mentioned earlier residents living at Ealon House access the community regularly and did inform the inspector of going to restaurants, cinemas, theatres, libraries, etc. Residents can go to the local synagogue and Jewish Festivals are celebrated regularly. One resident told the inspector that she Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 13 could vote if she wishes. This is a Jewish home and the cultural background of the residents is reflected. The home offers different activities daily and an activity plan is in place. The homes literacy group has a book printed called “Echoes of the Mind”, which was done entirely by service users living at Ealon House. Some Residents have just returned from their annual holiday in Eastbourne and another group is planning to go on holiday the following week. The inspector observed residents using their room whenever they choose to and are able to pursue personal relationships if they wish. The home is however monitoring relationships and is putting risk assessments in place if needed. The home has a relationship policy and visitor’s policy in place. The inspector observed staff entering bedrooms only after knocking and mail is given to residents unopened. All residents have their own bedroom key and risk assessments are in place if residents do not have a front door key. Service users have been observed moving around freely and access all areas at the home. During mealtimes the inspector observed residents clearing the table and one resident informed the inspector that she is cleaning her room with staff support. The home has a smoking room and residents can smoke in their room depending on the risk. The inspector observed and sampled lunch during this inspection, the lunchtime was found to be relaxed and staff is involved and join residents during lunch. The meal was tasty and provided healthy options and dishes for service users with health problems. The home is providing a kosher diet following the Jewish way of live. Meals are prepared by the cook who is meeting regularly with residents to discuss meals. Fruits and drinks are available throughout the day. The home is planning cooking training for residents in the near future to support residents to gain greater independence. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 the following standard(s): 18; 19; 20 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health is managed appropriately and residents are encouraged to be as self-managing as possible. EVIDENCE: The majority of residents living at Ealon House are able to attend to their personal care independently. One resident informed the inspector that she receives some help getting in and out of the bath. Service users with higher support needs have detailed personal care guidelines in place. Thirteen of the twenty-five residents living in Ealon House are above the age of 65; the inspector informed the manager to start planning in how to meet the needs of residents in the future. The inspector discussed this with Mrs Aviva Trup during this inspection. The home has a medi bath, which is used for residents with age related mobility problems. Service users have been involved in interviewing staff employed at Ealon House and staff represents the cultural background of residents living in the home. The home has access to specialist services such as community nurse, psychiatrist, psychologist, etc. and residents are referred to these services if required or needs are changing. All residents are registered with their own GP and have been observed attending appointments and picking up some prescription independently. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 15 Residents visit the chiropodist, dentist, and optician regularly and visits are clearly recorded in care plans. Residents weight is monitored and recorded. The inspector observed how the community nurse is drawing up insulin in individual syringes for one week. This is not good practice and does not follow guidance from the Medicines Health Regulation Authority, National Patient Safety Agency and Royal College of Nursing, “For premixing and preloading of Insulin for patients at Home”. The inspector informed the manager to contact the community nurse at Kilburn Road Square Surgery and obtain training for staff and service users in how to use the insulin pen for injections in the future. The home is storing medication in a locked cupboard in the office. The deputy manager is responsible for the ordering and disposal of medicines. The home has clear records of this in place. One resident is self-medicating and clear risk assessments are in place. Some residents receive depot injection from the Community Psychiatry Nurse, who is responsible for recording this. The Medication Administration Sheet is of good standard; allergies are recorded. The inspector found on some Medication Administration Sheets medicines labels; this is against Royal Pharmaceutical Guidelines and this practice must stop. The home has a lockable medicines fridge, temperature recording for this were not available, which is required. The inspector found a number of eye drops in the fridge, which have been expired and must be disposed off. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 the following standard(s): 22; 23 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to raise their satisfaction and dissatisfaction of services and support received at the home and are protected from abuse neglect and self-harm. EVIDENCE: The manager has reviewed the complaints policy, which is now compliant with National Minimum Standards. The home has received three complaints from service users since the last inspection, which have been dealt with by the manager and outcomes as well as actions have been clearly recorded. Service users confirmed of being aware of how and who to complain to. The home has a very good track record of reporting serious incidences under Regulation 37 of the Care Homes Regulation 2001. The home has a detailed Protection of Vulnerable Adults policy in place and the majority of staff has attended Protection of Vulnerable Adults training. The home has an ongoing training programme and another Protection of Vulnerable Adults training course has been arranged for September 2006. The home must ensure that all staff have been trained in Protection of Vulnerable Adults issues. Staff the inspector has spoken to demonstrated knowledge of Protection of Vulnerable Adults related issues and how to report if allegations have been made. The home has Brent Protection of Vulnerable Adults guidelines in place, but guidelines from other funding authorities were not in place, which is required. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 the following standard(s): 24; 30 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a nice but dated environment, which is clean and free of any offensive odours. Service users personal possessions are displayed in rooms and in communal areas. EVIDENCE: One service user showed the inspector around the home. She informed the inspector that she is happy with her room and the home and had no concerns regarding the environment. During the tour of the premises, the inspector found that the home was clean and free of any offensive odours. On the ground floor is a dining room, office, a number of service users room and the kitchen, which is located in the adjoining building. A large and very well maintained garden can be reached from the dining room. On the first floor, which can be reached through a lift, is a smoking room and a number of bedrooms and toilets. The inspector noted that the wallpaper in the smoking room is torn and the room is in need for redecoration. On the second floor is a quiet lounge and a number of self contained flats. The inspector was invited in one of the resident’s rooms, which was clean and nicely decorated. Overall the inspector noted that the décor in the home is very worn and dated and the Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 18 whole home is in need of redecoration. Carpets are worn throughout, but appear to be clean. The tiling in the ground floor toilet came of the wall and the toilet must be retiled. The home has a separate laundry room, which is used by residents and has a professional dryer and semi professional washing machine. The home has a number of Health and Safety policies and procedures in place, which are judged of good standard. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 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): 32; 34; 35 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a diverse, experienced and skilled staff team. Appropriate recruitment policies and procedures protect residents from unsuitable staff. EVIDENCE: The inspector sampled four staffing files during this inspection; all files have been of good standard. Previous inspections provided evidence that over 50 of the staff is trained to National Vocational Qualification in Care Level 2 or above. The manager informed the inspector that the organisation has started working with a new National Vocational Qualification in Care centre and diary entries as well as training plans demonstrated that staff has attended National Vocational Qualification in Care training. The home has in house National Vocational Qualification in Care assessors to support candidates in achieving their qualifications. The home has no staff employed under the age of 18. The staff employed at the home reflects the cultural and religious background of service users. The inspector observed staff interacting with service users in a professional and caring manner. Service users informed the inspector that staff is listening and are supporting residents in solving their problems. The inspector viewed four personal files, which are of good standard and contain all required documentation. Staff informed the inspector of being given Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 20 the General Social Care Councils Code of Conduct prior to starting employment. Service users are involved in the recruitment process and the inspector has viewed records of this. The inspector viewed a wide range of training certificates during this inspection. All staff has a training and development plan and monies has been put aside in the budget to provide training. The home is currently assessing the literacy and numeracy skill of staff and the manager informed the inspector that the home would once all information is collected provide training to enhance care staffs numeracy and literacy skills. The manager informed the inspector of all staff having had their TOPPS induction, staff confirmed this, but some records were not available. The inspector informed the manager to ensure that induction records are on file for all staff. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 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; 39; 42 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager is skilled and qualified to manage the home. Residents are regularly involved and consulted in the running of the home. Residents Health and Safety is not compromised and safe working practices are in place. EVIDENCE: Staff and service users spoke very positivly about the acting manager Mr Prince Balwah. One service users told the inspector he is very friendly and always listens to what I have to say. Staff informed the inspector that he is a very good manager who listens and is encouraging staff attending training to gain more skills. The acting manager has his National Vocational Qualification in Care Level 4 and is currently completing his social work qualifications. The acting manager has applied for the permanent managers post, but was not successful. This was discussed with Aviva Trup who informed the inspector that recruitment of a new manager should be completed within the next three months. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 22 The acting manager sent a current service development plan to the Commission for Social Care Inspection prior to this inspection. It was evident during the assessment of this plan that service users views have been taken into account and are included. Service users are encouraged to participate in fortnightly in residents meetings, which are documented and have been viewed by the inspector. The staff, chef and manager attend these meetings and menu planning, outings; maintenance issues, etc are discussed. The home is sending regularly copies of monthly registered provider visits to the Commission for Social Care Inspection. The home has a detailed Health and Safety policy in place, monthly Health and Safety checks are undertaken by designated staff. The inspector viewed the following health and safety certificates, fire equipment check, Electrical Installation Certificates (Expires 22/10/08), Portable Appliances Test Certificate (Expires Sept 2006), Landlords Gas Safety Certificate (Expires 16/10/06), The lift has been tested on the 12/04/06 and the water has been tested for Legionnaires disease on the 22/09/05. All fire systems have been tested and serviced on the 19/02/06, the last fire drill has been conducted on the 04/05/06, fire points are tested weekly and a current fire risk assessment is in place. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 4 X X 3 X Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 24 NO 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 YA1 Regulation 4&5 Schedule 1 Requirement The home must review the Statement of Purpose and Service Users Guide, and send a copy of both documents to the Commission for Social Care Inspection once completed. The home must ensure money is stored for individual service users in separate folders or containers. (Completed) The manager must provide training for staff and residents in how to use the insulin pen for daily injections, as appropriate Medication Administration Sheets must not be altered or labelled. Fridge temperatures must be monitored and recorded daily. Expired medication must be returned to the pharmacist for disposal. The home must obtain Protection of Vulnerable Adults guidelines from all funding boroughs. All staff must receive Protection of Vulnerable Adults training. • Worn and stained carpets DS0000017467.V305223.R01.S.doc Timescale for action 31/08/06 2. YA7 16(2)(l) 15/08/06 3. YA19 13(2) 31/08/06 4. 5. 6. 7. YA20 YA20 YA20 YA23 13(2) 13(2) 13(2) 13(6) 15/08/06 15/08/06 15/08/06 31/08/06 8. 9. YA23 YA24 13(6) 23(2)(d) 30/09/06 30/09/06 Page 25 Jewish Care Version 5.2 10. 11. YA35 YA37 18(1)(a) 8,9,10 must be replaced. • The communal areas in the home must be redecorated. • The smoking room must be re-decorated. • The loose and missing tiles on the ground floor toilet must be replaced. The manager must ensure that all induction records are available for inspection. A permanent manager must be recruited and registered with the Commission for Social Care Inspection. 15/08/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA18 Good Practice Recommendations Service users should be involved in designing of the Statement of Purpose and Service Users Guide. The home should start planning in how to meet the needs of residents in the future. Jewish Care DS0000017467.V305223.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. 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