Inspection on 25/09/06 for Jobs Close

This inspection was carried out on 25th September 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 but made no statutory requirements on the home.

Other inspections for this house

Jobs Close 24/09/08

Jobs Close 27/02/06

Jobs Close 28/11/05

Jobs Close 18/03/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Jobs Close Lodge Road Knowle Solihull West Midlands B93 0HF Lead Inspector Brenda O’Neill Key Unannounced Inspection 25th September 2006 09:10 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 Jobs Close DS0000060958.V306004.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 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. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jobs Close Address Lodge Road Knowle Solihull West Midlands B93 0HF 01564 773499 01564 774333 care@jobsclose.org.uk 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) Job’s Close Residential Home for the Elderly Mrs Leonore Patricia Park Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That one named person who is diagnosed as having dementia at the time of admission can be accommodated and cared for in this home from October 20th 2006 to October 30th 2006. 27th February 2006. Date of last inspection Brief Description of the Service: Jobs Close, which was established on the 1st July 1957, is an extended and adapted Edwardian House built in 1904. The Home, which is adjacent to and overlooks a park, has very attractive gardens with ample car parking facilities. The Home provides permanent placements for up to 33 frail older people over the age of 65 whose care needs can be met within a residential setting. Additionally one room is designated for respite/short stay placements. The Service Users receive accommodation, full board, 24-hour care and supervision and personal care as required. Of the 34 single bedrooms, 33 have en-suite facilities. Daily routine is organised on a group living basis although the Home is flexible in meeting individual needs and preferences. Communal facilities include two large lounges, one of which is used as a library, a separate sun lounge and dining room with an activities room that is also used for dining. There is a hairdressing salon and two smaller lounges in the annex building. There are 2 passenger lifts and a stair lift. The fees at the home are £375.00 per week for permanent residents and £445.00 per week for respite or short stay placements. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this key unannounced inspection over one day in September 2006. During the course of the inspection a tour of the premises was carried out, the inspectors had lunch with the residents, four resident and three staff files were sampled as well as other care and health and safety documentation. The inspectors spoke with the manager, deputy, cook and nine residents. Prior to the inspection a completed pre inspection questionnaire had been returned to the inspector. This included a variety of written information about the home. What the service does well: The home provided residents with a good standard of accommodation in a very pleasant location. Residents at the home were very satisfied with the service they were receiving and their relation ships with staff. Comments received included: ‘It’s excellent really.’ ‘They’ve been very kind.’ ‘Staff are wonderful. Great consideration for old people.’ ‘Lovely location and lovely staff.’ ‘Staff are good.’ Prospective residents were able to visit the home to assess the facilities and if necessary have a further visit to ensure they were happy. There was good documented evidence that the health care needs of the residents were being met. All residents had a separate sheet for recording professional visits and the reasons for the visits and the outcomes were detailed. There were no rigid rules or routines in the home and residents were able to spend their time as they chose. There were a variety of activities on offer if the residents wished to take part. The home had close links with the local schools and churches. There were no restrictions on visitors to the home and they were seen to come and go throughout the course of the inspection. Many of the residents were very independent in relation to their personal care and staff helped them maintain this as long as possible. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 6 Residents spoken with were generally satisfied with the catering arrangements and there was evidence that they were consulted about meals at residents meetings. Residents commented that they would have no issues raising any concerns with the manager or the deputy manager of the home and were confident they would be addressed. There was also documented evidence to support this. Good staffing levels were being maintained and many of the staff had worked at the home for a considerable amount of time which was good for the continuity of care of the residents. The health and safety of residents and staff were generally well managed and the home were quick to act on any requirements made in relation to health and safety. What has improved since the last inspection? What they could do better: The manager needed to ensure the pre admission assessment was further developed to include the residents’ social needs and their dietary preferences to ensure all prospective residents’ needs were known prior to admission. The manager needed to ensure that residents’ care plans were written up as soon as possible after admission so that staff knew how to meet the residents’ needs. Care plans also needed to include any short term needs. Manual handling risk assessments needed to include the action to be taken by staff in the event of a fall to ensure the correct handling methods were used. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 7 To ensure the medication system was entirely safe the balances of any medication held at the end of the month needed to be carried forward to the next medication record. The manager needed to ensure that staff received induction training in line with the specifications laid down by skills for care to ensure they were equipped with all the necessary skills and knowledge to care for the residents. The quality monitoring systems needed to be further developed to ensure there was an annual development plan for the home based on a systematic cycle of planning, action and review reflecting the aims and outcomes for the residents. To ensure the safety of the residents the stair lift needed to be serviced and there needed to be evidence on site that the fire extinguishers had been serviced. 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. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 8 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 Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 9 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 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The pre admission assessment procedure needed to be further developed to ensure all the needs of the residents were known to staff prior to admission. Prospective residents were able to visit the home to assess the facilities available. EVIDENCE: The files for two residents recently admitted to the home were sampled. The files included evidence that a pre admission assessment was carried out by staff at the home. The assessments were quite comprehensive and covered all the physical needs of the residents, for example, mobility, personal care needs and sensory impairments however there was no evidence of the residents needs in relation to social interests, hobbies religious and cultural needs. It was also noted that the assessment did cover eating but this did not indicate what the residents’ dietary preferences were. One of the pre admission assessments was not dated this was an outstanding requirement from the last inspection. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 10 The daily records for residents evidenced that prospective residents were able to visit the home prior to admission and there was comprehensive documentation of how the day had gone. In one case it was evident that as the individual was unsettled a further pre admission was offered. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 11 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, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care planning process in the home was comprehensive but all care plans needed to accurately reflect both the long and short term needs of the residents. The health care needs of the residents were met and the medication system was safe. Residents were treated with respect and their right to privacy upheld. EVIDENCE: The care files for four residents were sampled. Three files included a life history and an assessment of strengths and abilities and details of what was to be maintained and what was to be developed. One of the resident’s life histories only had information about childhood years the other sections stated ‘no recollection of this’ but there was no evidence to suggest that the relatives had been asked to help with this. Another resident had not had the strengths and abilities assessment fully completed. Where a specific need had been identified there was a care plan detailing how the need was to be met by staff. One individual did not have a care plan and had been living at the home for four months. This was ample time to draw up a care plan. The way the care plans were structured was to assist carers in seeing the resident as a whole Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 12 person however it was noted that in some areas they were contradictory. For example, one of the assessments stated ‘expresses a need by communicating in ways that disturb others’ and ‘expresses a need by mistaking other people’s belongings for their own’ the care plan stated the opposite to this. It is very important that any assessment of the residents’ needs is accurately reflected in the care plans so that staff are able to meet the needs of the residents. Short term needs, for example, health concerns were not being included in the care plans. The care planning process was very lengthy and it was strongly recommended that a summary of residents’ needs was included at the front of the care plan to assist staff in the provision of care. Some of the care plans were being reviewed on a monthly basis others were not. All four files sampled included a variety of risk assessments including, moving and handling, tissue viability and nutritional risk assessments. The manual handling risk assessments needed to include details of the actions to be taken by staff in the event of a fall. Staff were also completing a risk assessment check list for personal risks that covered a variety of areas and risks were categorised as low medium or high. Generally where a risk had been identified on the documentation there was a corresponding risk reduction plan however for one of the residents a risk had been identified as medium in relation to their walking but there was no corresponding risk reduction plan. There was good documented evidence that the health care needs of the residents were being met. All residents had a separate sheet for recording professional visits and the reasons for the visits and the outcomes were detailed. The visits recorded could be cross referenced to the daily records where health care issues had been raised. There was evidence of regular visits from chiropodists, opticians and district nurses as well as more specialist referrals to physiotherapists. Residents spoken with were satisfied that their health care needs were met. Medication was being administered via a 28 day monitored dosage system which was well managed. Copies of prescriptions were being kept and all medication was being acknowledged when received into the home. There was an audit trail for the majority of the medication however it was noted that for PRN (as and when necessary) medication any balances held at the end of the month were not being carried forward to the next MAR (medication administration chart) therefore these were not auditable. Six of the residents were self medicating and risk assessments had been undertaken for these individuals. The amounts of medication given to the residents varied depending on the outcome of the risk assessment. Monthly checks were being undertaken for residents who self administered their medication to ensure they were taking what was prescribed. There were some homely remedies being kept and the records for the administration of these were appropriate. The homely remedies policy for the home had not been reviewed since 2004 and it was strongly recommended that this was reviewed to ensure it was still accurate. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 13 There was nothing observed during the course of the inspection to indicate that the privacy and dignity of the residents was not being respected. Residents were able to spend time in their rooms without being disturbed if they wished. All the bedrooms were lockable with keys available for the residents and all rooms had a lockable facility for personal effects. The majority of the residents had their own telephones in their rooms and there was also a pay phone available for their use in a private area of the home. There were several areas in the home where residents could meet with their relatives in private if they wished. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There were no rigid rules or routines in the home and there were activities available for the residents to take part in if they wished. Residents were generally satisfied with the catering arrangements at the home. EVIDENCE: There were no rigid rules or routines in the home. Residents were seen to spend time sitting in the lounges chatting, spending time quietly in their rooms, meeting with visitors, going out for a walk and taking part in organised activities. The home employed an activities coordinator and there was a programme of daily activities. During the course of the inspection residents were taking part in an art group, which they appeared to very much enjoy, and a quiz. Other activities included crosswords, keep fit, word games and bible reading. The inspectors were informed by the residents that they also had visiting entertainers and that they had recently been out to the theatre. The home also had close links with the local schools and churches. Several of the residents at the home were able to go out independently and went out for walks and to the local shops as well as further a field. Other residents were taken out by families or staff and there were organised trips by the Friends Committee. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 15 There were no restrictions on visitors to the home and they were seen to come and go throughout the course of the inspection. Residents were able to make choices, for example, how to spend their days, what to eat and wear. Many of the residents were very independent in relation to their personal care and staff helped them maintain this as long as possible. All residents were able to personalise their rooms to their choosing and personal effects were observed in the bedrooms seen. The menus were varied and nutritious and offered residents choices at all meals. The inspectors joined the residents for lunch and the meal was well cooked and presented and choices were evident. Residents spoken with were generally satisfied with the catering arrangements and there was evidence that they were consulted about meals at residents meetings. Some issues had been raised by residents about the time of the mid day meal and this had been raised at a previous inspection. To try and resolve the issue residents had completed a questionnaire, which included this topic, and the outcome of these was to be discussed with the residents at the next meeting. Another issue that had been raised was that residents should have a choice of where they sit for meals. It appeared from the daily records seen that where this had been raised by residents it had been addressed appropriately and an alternative place identified. Records of the foods being served to residents were being kept but these did not include breakfast. These records need to be further developed to include breakfast. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents spoken with were satisfied that any issued they raised would be dealt with appropriately. The home had appropriate procedures in place for the protection of the residents but these needed some revision to ensure that residents were protected satisfactorily. EVIDENCE: There was an appropriate complaints procedure on display on display in the home and residents received a copy of this. There was evidence in daily records that where residents raised concerns, for example, things going missing that these were addressed promptly and appropriately. Residents commented that they would have no issues raising any concerns with the manager or the deputy manager of the home and were confident they would be addressed. It was recommended that a log was kept of any minor concerns raised and how they were addressed as evidence that staff do listen to the residents and respond appropriately. The home had not had any complaints raised with them since the last inspection and none had been lodged with CSCI. There was an extensive adult protection procedure that had been amended since the last inspection however it still did not make it clear that the home do not investigate allegations without consultation with Social care and Health and the CSCI. There was also a copy of the relevant multi agency guidelines for adult protection on site. The majority of staff had received training in adult protection issues. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 17 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): 19, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provided residents with a safe and very comfortable environment in which to live. EVIDENCE: There had been no changes to the layout of the home since the last inspection which was safe, accessible and well maintained. There was ample communal space at the home with large and small lounges and a conservatory. The lounges were well furnished and decorated and very homely with numerous pictures, ornaments and books around. Most of the communal areas overlooked the very pleasant gardens to the rear of the home. It was noted that the hoist was being stored in the lounge but when this was raised as an issue alternative storage was found. The home also had a hairdressing room but this was also used by the staff for ironing and housed a very large press. The room also had quite a large step up into it which could be difficult for some residents to negotiate. The inspector had received Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 18 information on the pre inspection questionnaire that a different room had been designated as the ‘future hairdressing room’ which will overcome the difficulties. Some of the carpets in the corridors were looking well worn however these were being replaced on an ongoing basis. There were two communal bathrooms at the home that were equipped with parker baths and were large enough for staff to offer assistance where required. Many of the rooms had en-suite showers, which were floor level, and all but one had an en-suite toilet. There were communal toilets also available throughout the home. The home was accessible and had some aids and adaptations including two shaft lifts, one stair lift, free standing hoist, grab rails in toilets and bathrooms and parker baths. The manager stated that the home had no handrails along corridors and this was evident during the tour of the building these should be installed wherever possible to ensure residents who need some support do not have to rely on staff for this. The emergency call system had been replaced since the last inspection and all calls now have to be cancelled at the point they were made and all emergency call systems were accessible to the residents. During the tour of the home the bedrooms were sampled. These varied in size and all but one had en-suite facilities and this was empty at the time of the inspection and due to be refurbished to include an en-suite toilet and wash hand basin. All bedrooms were of single occupancy and varied in size. All were equipped with a good standard of furnishings and fittings and adequately decorated. The linen and curtains in use in the bedrooms were of very good quality. Residents spoken with were very happy with their rooms and all personalised to the occupants choosing. The heating, lighting and ventilation appeared to meet the needs of the residents. All radiators easily accessible to the residents had been guarded and window openings were restricted where necessary. The home was clean and odour free at the time of the inspection. The laundry was appropriately located and equipped. Both the sinks in the laundry were badly stained and in need of replacement. Since the last inspection the main kitchen had been completely refurbished and was clean and tidy with all the appropriate checks in place. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Appropriate staffing levels were being maintained by a stable staff team. Induction training needed to be further developed to ensure staff were equipped with the necessary skills and knowledge to care for the residents. Recruitment procedures were robust and protected the residents. EVIDENCE: Several of the staff had worked at the home for a considerable amount of time which was very good for the continuity of care of the residents. Rotas and discussions with the manager evidenced that there were four care staff plus a senior during the morning shift and four staff during the afternoon. Night staffing levels had been increased from two to three since the last inspection to ensure the residents’ needs could be met during the night. In addition to this there were also catering, domestic, laundry and maintenance staff. The rotas for the home needed to clearly evidence the hours worked by all staff and include the manager’s hours. Residents spoken with were very positive about the staff at the home many of them describing them as ‘lovely’ and ‘very kind’. The files for three staff recently appointed to the home were sampled. All included a completed application form, two written references, POVA first or CRB checks and a medical questionnaire. It was strongly recommended that the application be further developed as it did not allow much room for prospective employees to detail their previous employment. It was noted that for one employee there was no evidence that they were eligible to work in this Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 20 country. Also as the person had only been resident in this country for a short period of time it was strongly recommended that some proof of good conduct was sought from the previous country of residence. The training records for the three new employees were sampled. There was only evidence on two of these of any induction training and this was all completed in one day. One of those sampled was for a domestic assistant and may have been adequate but it was not adequate for care staff who are having to assist with personal care, know all the needs of the residents and how to meet them and so on. Induction training must be inline with the specifications laid down by Skills for Care and completed within twelve weeks of staff commencing their employment. Over 50 of staff were qualified to NVQ level 2 or the equivalent as is required. There appeared to be a lot of ongoing training for staff including fire, health and safety, infection control, manual handling and vulnerable adults however this was difficult to track. The training folder indicated on the uppermost sheet that several staff had not received all their mandatory training but then later in the folder it appeared they had. The manager must ensure there is a system in place to enable all training to be easily audited. This was also a requirement at the last inspection. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 21 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, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager ensured the smooth running of the home in a competent manner. The health and safety of residents and staff was well managed. The systems in place for the monitoring the quality of the service offered in the home needed to be further improved and an annual development plan produced. EVIDENCE: The manager of the home had several years experience of caring for elderly people and the running of a residential home. She was appropriately qualified and updated her training regularly. Since the last inspection she had been registered by the CSCI as the registered manager of the home. Throughout the course of the inspection she demonstrated a good knowledge of the residents in her care. Relationships between the manager, staff and residents appeared to be good. Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 22 The inspectors also met briefly with the responsible individual for the home. He was undertaking the required monthly visits and providing a report for the Commission. There were some systems in place for monitoring the quality of the service offered in the home including, audits on care plans, medication, the general environment and so on. Residents had recently completed a questionnaire about such things as catering and food, personal care and support, daily living, the premises and management. The results of the survey had been collated and were to e followed up in the next residents’ meeting. The manager was also intending to set up a residents’ committee. The quality systems needed to be further developed to ensure there was an annual development plan for the home based on a systematic cycle of planning, action and review reflecting the aims and outcomes for the residents. Some of the residents continued to manage their own finances others were assisted by their families. The manager held money for only three of the residents. The records for these were sampled. The records were generally adequate, residents were signing for receipt of their money where possible, there were receipts available for any expenditure made on behalf of residents and two staff signatures. One of the records evidenced that a small amount of money had not been accounted for and the manager had no explanation for this but was going to pursue this with senior staff. The health and safety of the staff and residents was generally well managed. Staff appeared to receive training in safe working practices. There was protective clothing available for staff when necessary and a system in place for the disposal of clinical waste. There was evidence on site of the regular servicing of equipment, with the exception of the fire extinguishers, however this was forwarded to CSCI prior to the publication of the report therefore the requirement has been removed. The water system had been checked for the prevention of legionella. The home were having difficulties getting the stair lift serviced evidence that they were pursuing this was seen by the inspectors however this needed to be done as soon as possible as it was three months overdue and it was used. Accident and incident reporting were seen to be appropriate. Jobs Close DS0000060958.V306004.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 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 Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 24 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 2 X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Jobs Close DS0000060958.V306004.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1)(a) Requirement The home must ensure that all pre admission assessments are dated. (Previous time scale of 30/03/06 not met.) Preadmission assessments must include all the areas detailed in 3.3 of the National Minimum Standards. 2. OP7 15(1) Care plans must be written up as soon as possible after admission to enable staff to know how the residents’ needs are to be met. Care plans must accurately reflect any needs assessments. Any short term needs of the residents must be reflected in the care plans. Care plans must be reviewed on a monthly basis. 3 OP7 13(5) Manual handling risk assessments must detail the action to be taken by staff in the event of a fall. DS0000060958.V306004.R01.S.doc Timescale for action 31/10/06 30/11/06 30/11/06 Jobs Close Version 5.2 Page 26 4. OP8 13(4)(b) 5. OP9 13(2) 6. 7. OP15 OP18 17(2) schedule 4(13) 13(6) Where a risk has been identified for any resident there must be a plan in place detailing how this is to be minimised. The balances of any medication held in the home at the end of the month must be carried forward to the next MAR chart. Records of food being served must be further developed to include breakfast. The adult protection procedure must be revised to ensure that an investigation does not take place without the sanction of the lead authority (Social Care and Health) (Previous time scale of 31/03/06 not met.) Wherever possible handrails must be fitted along the corridors. The badly stained sinks in the laundry must be replaced. Staff rotas must clearly detail the hours worked by all staff and include the manager’s hours. 30/11/06 14/10/06 30/11/06 31/10/06 8. 9. 10. OP22 OP26 OP27 23(2)(n) 13(3) 17(2) schedule 4(7) 19 31/12/06 31/12/06 01/11/06 11. OP29 12. OP30 18(c)(i)24 The registered person must 01/11/06 ensure that staff are eligible to work in this country prior to their employment. The home must ensure that 01/11/06 evidence of the staff team training is available in an auditable form. (Previous time scale of 30/04/06) The registered manager must ensure that all care staff receive induction training in line with the specifications laid down by Skills for Care and completed within twelve weeks of employment. The Home must establish and maintain a system for reviewing and improving the quality of care provided by the Home. The DS0000060958.V306004.R01.S.doc 13. OP30 18(1)(a) 30/11/06 14. OP33 24 31/12/06 Jobs Close Version 5.2 Page 27 system must include consultation with Service users and their representatives. (Previous time scale of 28/02/06 partially met.) 14. OP35 17(2) schedule 4(9)(b) 23(2)(c) The manager must establish where the personal allowance that was unaccounted for on resident’s records has gone. The stair lift must be serviced as soon as possible and evidence forwarded to the CSCI. Evidence that this had been completed on 11/10/06 was forwarded to the CSCI. 31/10/06 15. OP38 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. Refer to Standard OP7 Good Practice Recommendations It is recommended that a full summary of actions required to deliver care to residents is more prominent in resident’s records to assist staff. It is recommended that where residents are unable to contribute fully to their life history that their relatives are asked to contribute. It is strongly recommended that the homely remedies policy is reviewed to ensure it is still accurate. It was recommended that a log was kept of any minor concerns raised and how they were addressed as evidence that staff do listen to the residents and respond appropriately. It is strongly recommended that where a prospective employee has only been resident in this country for a short period of time that some proof of conduct is sought from the previous country of residence. It is strongly recommended that the staff application form is further developed to ensure applicants have sufficient space to enter all their previous employment. DS0000060958.V306004.R01.S.doc Version 5.2 Page 28 2. 3. 4. OP7 OP9 OP16 5. OP29 6. OP29 Jobs Close Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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