Inspection on 08/11/06 for Jonathan House

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jonathan House 19/03/06

Jonathan House 15/09/05

Jonathan House 18/03/05

Jonathan House 16/10/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Jonathan House 19 Bayswater Avenue Westbury Park Bristol BS6 7NU Lead Inspector Sarah Webb Unannounced Inspection 8 , 10 & 15 November 2006 09:30 th th th Jonathan House DS0000026539.V319028.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 Jonathan House DS0000026539.V319028.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. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jonathan House Address 19 Bayswater Avenue Westbury Park Bristol BS6 7NU 0117 9736361 0117 9736361 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) Freeways Trust Ltd Helen Rachel Brownell Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 8 persons, aged 18 - 64 years, requiring personal care. 19th March 2006 Date of last inspection Brief Description of the Service: Jonathan House is operated by Freeways Trust Limited and is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to eight persons aged between 18 and 64 years, who have a learning disability. The home aims to support individuals within a community setting to lead as independent a lifestyle as they wish. Jonathan House is a mature three storey terraced house that is situated in a residential area in the North of Bristol that blends in well with the immediate environment. There are eight single bedrooms over three floors and the stairs are the sole means of access to each floor. This home would not be suitable to individuals with mobility issues as the lounge is on the first floor. It is close to local amenities including shops, a cinema, local bus routes, a church and a large common land, the Downs, which is used for a variety of recreational purposes. The current range of fees are from £483.89 to £611.54. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection with the focus on reviewing the progress of the requirements and recommendations from the unannounced visit in March 2006 and in assessing the key standards of the National Minimum Standards. The home has demonstrated compliance in meeting the requirements and recommendations from the previous inspection. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at Jonathan House and the provider has sent monthly appraisals of the service. The inspection was conducted over 9 hours. The inspector had an opportunity to meet with seven of the eight residents, two members of staff, the assistant manager and the manager. Residents gave their views of the home saying it was the ‘best’ home to live in and that they are supported well by the staff. Staff identified that the home has good communication and management systems in place. Eight completed comment cards/questionnaires were received from both families and residents on the service provided by Jonathon House. These were positive in their feedback of the service provided. The inspection process included viewing care records and other relevant documents required of a care home and a tour of the home. What the service does well: Residents are supported through individualised care planning and are involved in making decisions about the way they want their service to be delivered. The home is proactive in meeting individual’s needs and if their needs change this is followed through appropriate channels. Residents are supported in their chosen lifestyle promoting independence and community participation. There is an open atmosphere within the home and individuals can be confident that they will be listened to. Residents are involved in all aspects of the running of the home and an open culture of communication is promoted. They stated that the manager and the staff team were good at listening and supporting them in their chosen goals. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 6 The home seeks advice from other professionals in order to provide a quality service complimenting the skills of the staff team. 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. The summary of this inspection report can be made available in other formats on request. Jonathan House DS0000026539.V319028.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 Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have sufficient information to enable them to make a choice on whether to move to the home. Prospective residents needs are assessed prior to moving to the home in order that the home can make a decision as to whether their needs can be met. EVIDENCE: A reviewed statement of purpose was in place providing comprehensive information. Through observation and discussion with staff it was identified that the ethos of the home is reflected in the vision statement and service values. The service user guide contains appropriate information for both new and prospective residents in an accessible format. Residents surveys received indicated that individuals had a choice when deciding to move to the home and that they had received a guide. The majority of residents’ files had both original assessment and care plan in place by the placing authority and also assessment carried out by the home. Records evidenced that individuals’ care is reviewed regularly with the relevant Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 9 placing authorities. A review took place during the inspection and the resident said “it went well”, and that they were pleased with the outcome. The manager also keeps both the funding authorities and the Commission well informed of any changes to individuals needs and progress through written reports. Jonathan House DS0000026539.V319028.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are empowered in the planning of their care through processes in place in setting personal goals. Residents are supported in making decisions about their lifestyles and also in taking calculated risks in order that they pursue an independent life. EVIDENCE: The home operates a key working system whereby each resident has a named member of staff who plays a key role in co-ordinating the services they receive. Care files examined included personnel details, financial details, and monthly meetings with key worker incorporating monitoring of individuals healthcare. Pen profiles in place recorded clear guidelines informing staff of residents preferences. For example, statements indicated that some people may want a ‘lie in’ on certain days identifying that staff must respect this choice. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 11 Keyworker packs in place include individualised care planning approaches such as ‘Listen to Me’ booklets, and ‘Paths’ that identify choice in recording service users support needs and goals. Additional support plans were also in place designed to inform staff of how to support individuals. Discussion with residents and observation of records indicated that monthly meetings are held with their keyworker to review individual care plans. Annual reviews also take place where all aspects of individuals’ lifestyles are discussed. These were comprehensive records and provided clear detailed information about any progress made with their aims for the future year. Records demonstrated that individuals are fully involved with this process along with significant people in their lives. All records were up to date and in order. Comment cards received from all 8 families stated that they are kept informed of important matters affecting their relative. Through discussion with residents and observation of records it was evident that they are encouraged to make differing decisions about their lifestyle including choice of food to attending various activities and in the routines of the home. Individuals said that they were ‘supported in making decisions’ by staff and that processes such as house meetings were a good forum to discuss issues. Risk assessments observed were comprehensive and had all been reviewed and up to date. These detailed perceived risks, factors contributing to risks and strategies to reduce risk and included conclusions, recommendations, and outcomes with strategies reviewed monthly. Risk assessments covered differing areas such as using public transport, accessing the community, bathing and showering, using various household appliances, and using cleaning products. Records indicated that residents are involved in risk assessments and sign appropriate documentation to evidence their involvement and agreement. Jonathan House DS0000026539.V319028.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to lead full and active lifestyles and are supported by staff to access leisure opportunities in the community. Individuals’ rights are respected and they are encouraged to take responsibility in their daily lives. Residents’ benefit from contact with their families and friends. Residents are offered a healthy diet and have input into menu planning and food preparation. EVIDENCE: Residents spoken with discussed the differing activities they attended included work placements, day services, and college courses. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 13 One person said that the home is in a good location for bus services; that they were able to get to their work placement at a main shopping venue easily. They were pleased that they had a free bus pass in getting around. Another person said they worked at a placement within the organisation. All residents also access the local community for shopping trips, and attend various leisure activities including attending both football and rugby matches regularly. One person said they were looking forward to going to a main horseracing event for the weekend with staff. Another person said they go to church regularly, and have opportunities for going on day trips. Documentation identified that an individual has 1:1 support in accessing the community and that bus training is an ongoing part of individuals’ life skills programme to aid independence. The home supports individuals in making choices about holidays. Two residents spoken with said that they had been on holiday to Center Parcs this year and that a cruise had been booked for next year for 5 residents while 3 others were accessing an alternative holiday. Although the home now has employed a cleaner, residents carry out specific household tasks such as responsibility for their laundry and the cleaning of their rooms. An individual was keen to show the tasks they carried out around the house. It was evident that individuals are supported with maintaining friendships and contact with families. Records indicated that some people have overnight stays with their families. Discussion with individuals also identified that they have friendships both within the organisation and through their differing daily activities. Comment cards received from all 8 families stated that they are welcomed to the home at any time and can visit their relative in private. All residents are on the electoral register; the manager said it was individuals’ choice as to whether they wished to vote or not. However at a previous election some residents had used their vote. An individual confirmed that they have their own bedroom door key. Observation of residents indicated that they have opportunities for being independent in preparing snacks and refreshments. Everyone has a turn in preparing an evening meal with support from staff. Menus are decided together and a record is kept of meals offered. Although staff record any alternatives offered in daily running notes, a recommendation is made for all alternative food offered to be recorded together with the main option in order to monitor specific diets and regular changes. Jonathan House DS0000026539.V319028.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead healthy lifestyles with their healthcare and personal needs being monitored well. The home operates a robust medication system ensuring the safety of the service users. EVIDENCE: Examination of residents’ healthcare records evidenced that individuals’ physical and mental healthcare needs were being met through regular reviews of medication and support from appropriate professionals. There was also documentation indicating both guidance and training is offered to staff through specific healthcare professionals and agencies. There was evidence that the Community Learning Disability Team including the consultant psychiatrist was supporting the home, staff and the individuals and that referrals are made to specialist services such as psychology and art therapy. This is seen as good practice and demonstrated a multi-disciplinary approach to the care of the individuals. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 15 Completed Health Action plans include medication profile, support with personal needs and records of visit to doctor, consultant, dentist, chiropody, and optician. The organisation has a policy and procedure for the administration of medication, including a homely remedies policy. These outline the protocols for the administration, recording, ordering, disposal and self-medication processes. It was evident through the observation of records that the home has appropriate systems in place for the safe administration of medication. Staff sign to agree that they have read and understood individuals medication profiles and are informed of changes to medication through the handover file. Medication is administered through blister packs that the local pharmacy delivers weekly. Care files included an assessment of the ability to self medicate. There were also risk assessments for 2 people who self medicate with a lockable storage provided in their bedrooms for this purpose. A recommendation is made for the home to hold documentation stating that residents have consented to medication being administered. Staff are trained in the administration of medication through the organisation’s induction processes. The home has procedures in place for monitoring staff competency in the administration of medication; new staff initially shadow those deemed competent and are then observed through the medication process. Staff also complete a questionnaire as part of the competency measures. There are appropriate procedures for the medication to be sent to day services and when residents take social leave. Jonathan House DS0000026539.V319028.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from robust systems for complaints and protection and can be confident that they will be listened to and that they will be protected from abuse. EVIDENCE: The Freeways organisation has a formal complaints procedure; residents have been given an accessible copy of the procedure explaining how people can complain; this also includes appropriate contacts and timescales to respond to any complaint. Questionnaires received from residents also evidenced that they are aware of the complaints procedure. Discussion with residents indicated that they knew who they could go to if they had a concern or a complaint. Two individuals spoken with said they would go to their keyworker or the manager. The complaints/concerns log identified that the home takes any issue raised seriously and if necessary will follow the correct protocol. Records evidenced that there have been 4 concerns and 3 complaints logged. These have been dealt with appropriately with a record kept of both action taken and the outcome. Residents said they talk about their views at house meetings; the manager said feedback is also sought at reviews from both residents and their families. Comment cards received from all 8 families stated that they are aware of the homes complaints procedure and that none have had to make a complaint. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 17 The organisation has a policy on the protection of vulnerable adults. Staff have been given a copy of Department of Healths and Local Authority’s No Secrets guidance and all staff are trained in abuse awareness within their induction period; this is an essential part of the induction process and as part of the Learning Disability Award Framework. The manager is also a trainer in the protection of vulnerable adults and updates staff regularly. It was evident that this is an area that the home treats seriously with robust procedures in place. Through discussion with the manager and observation of relevant documentation it was also evidenced that the home follows appropriate procedures involving a multidisciplinary approach in dealing with sensitive issues of protection. Staffing files identified that all staff had been through the process of a police check with the Criminal Records Bureau prior to working at the home. Individuals care files contained comprehensive reactive strategies in place indicating triggers and indicators that behaviour is imminent. Staff spoken with said there is detailed information to inform the staff team as a whole what action to take and to ensure there is a consistency in supporting individuals with their differing behaviours. Records also indicated that the home involves appropriate professionals in supporting both staff and residents. The organisation operates safe financial systems for the administration of residents’ finances. This is followed by the home with specific controls in place that are adhered to. Observation of individual financial risk assessments, including assessment of understanding of money and financial management, contribute to the outcome of the risk assessment. Records indicated that staff also attend financial training regarding the organisation’s financial policies and procedures. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a clean, homely and comfortable environment. However, the home needs to improve in the safety of residents by carrying out risk assessments regarding access to hot radiators and in ensuring staff are able to access locked bedrooms in the case of an emergency. EVIDENCE: Jonathan House is in keeping with the local neighbourhood and is close to local amenities including shops, a church, and a cinema and is a short walk from the “Downs” a large common. There are good transport facilities to access both the City of Bristol and surrounding areas. The manager said the home has a maintenance programme with planned redecoration and refurbishment. All of the bedrooms have been decorated since the last inspection with two bedrooms having had carpets replaced. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 19 Discussion with residents identified that they are consulted regarding the decoration of their rooms; all were suitably and individually furnished with personal possessions on display. A requirement has been met from the last inspection to remove an unwanted chair from a bedroom. A resident had consented to their room being visited, but it was not possible to gain access by the homes master key. Therefore a requirement is made for the home to make proper provision for the care and supervision of residents by ensuring staff are able to access locked bedrooms in the case of an emergency. During visits to individuals’ bedrooms it was noted that three of the rooms had radiators that were hot to touch; this raised concerns that individuals could burn themselves. The home needs to ensure the heat levels are monitored regularly and a requirement is made to carry out risk assessments in relation to access to hot radiators; that if there is a risk of injury to any resident or staff then radiators should be covered in order to safeguard individuals health and safety. The ground floor bathroom has been refurbished with a new bathroom suite whilst the first floor bathroom has been decorated. A broken shower head was repaired during this visit. Communal areas were homely and comfortably furnished. The lounge doubles up as the sleep in facility for staff. The manager stated that this does not hinder residents who wish to stay up late; there is also a television available in the dining area where there is comfortable seating. A broken curtain rail was replaced in the lounge during this visit. The manager has instigated an investigation into a garden wall that has cracks running through the brickwork. Surveyors have inspected the wall and the home is awaiting a response from Bristol City Council regarding action to be taken. Currently the home is vigilant in informing both residents and visitors to the home regarding this. The home was clean and free from odour. A requirement has been met for the home to be ‘deep cleaned’ on a regular basis. The manager stated that both staff and the residents are responsible for the cleaning of the home and residents bedrooms are deep cleaned monthly. The home also now has a cleaner for 1 day a week; this is a resident from another home within the organisation and the work is classed as a work placement. The manager meets with the individual, monitoring their work and training them in specific areas. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from clarity of staff roles and responsibilities. Residents are supported by competent staff in order to meet their assessed care needs. There is a good rolling programme of training available to the staff team. EVIDENCE: Discussion with staff indicated that they have a good understanding of their roles and responsibilities. They stated that staff team communicates well and that issues are discussed openly. Staff files identified that there is a robust recruitment practice followed. All staff has undergone the process of completing application form, 2 references followed up by the home, and undergone an induction period. A newer staff member explained their induction process and that the manager keeps a signed record of each area covered. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 21 An induction checklist is also in place for bank staff covering areas such as fire, accident reporting, and systems in place for staff handover. A recommendation is made for this information to be dated. Staff training records identified all staff are up to date with statutory training and have had access to other training courses such as mental health, loss and bereavement, risk assessment, and autism. A newer staff member said the organisation is good at offering training courses. A team of five staff excluding the manager supports residents. The assistant manager has completed a National Vocational Qualification at level 3 and is in the process of completing Level 4. Two staff have completed a National Vocational Qualification at level 3 whilst another staff member has obtained a qualification at level 2. It is also planned for a further two staff to start at level 3. This will mean that all staff have either a qualification or are in the process of obtaining one. This is good practice. All residents spoken with said the staff team was good and made comments such as “ excellent staff”, and “they help us and support us in making the right decisions”. Comment cards received from all 8 families stated that in their opinion there are sufficient numbers of staff on duty. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, &42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well run home with effective systems in place. Residents know that their views are listened to and contribute to the development of the home. The home practices effective record keeping in order to safeguard the rights and interests of the residents. The home has measures in place to monitor the health and safety of staff and residents. EVIDENCE: Ms Brownell has been the manager Jonathan House since December 2005. However she is due to leave the home at the end of this year. The Commission Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 23 has been informed that another experienced manager within the organisation is to take over her role. Ms Brownell has worked for Freeways Trust for a number of years. Ms Brownell has completed both National Vocational Qualification level 4 in care and the Registered Managers Award. Both staff and residents spoken with were positive in their comments regarding Ms Brownell and said they will miss her when she leaves. It was evident through comments made that the home follows a policy of ‘ openness’. Residents confidently stated that they thought the home was good with staff supporting them with their needs. The organisation has recently produced a quality assurance tool. A residents’ questionnaire has been operated in the home. Areas covered included everyday routines, where people live, health, rights and choices. Information has also been collated from surveys from families. The manger said this is to be passed onto senior managers within Freeways in order to inform the business plan and future planning for areas of improvement. The manager also said that residents are to be informed of the outcome of the findings. The home also seeks the views of residents through a series of meetings including those at review, key worker and house meetings. Although the outcome from these questionnaires and surveys was good with indication that both residents and families are happy with the service, staff felt it would be more beneficial to the organisation as a whole if residents were supported through an external advocacy service in completing the questionnaires rather than through house support. The manager explained that her performance is also monitored through appraisal, including through a checklist linked to the National Minimum Standards. Examination of the fire log indicated that all staff have been received annual fire training and have been involved in fire drills. A fire risk assessment had been carried out and fire maintenance records indicated that fire equipment is inspected on a regular basis by both staff and contactors. Records were held securely and found to be current and up to date. Residents had signed records where relevant. There was a current certificate of insurance displayed in the home. From discussions with staff and staff training records it was evident that there is a rolling programme of health and safety training including manual handling, fire, food hygiene and first aid. The home has comprehensive procedures for the Control of substances hazardous to health. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 24 Accident and incident recording evidenced that the home follows the organisation’s policy and procedure effectively. The Commission receives regular and comprehensive reports regarding all aspects of the home through Regulation 26 visits. The home has also had a recent financial audit that identified all appropriate procedures were in place and up to date. Senior management carry out monthly house audits covering all aspects of health and safety, including fire procedures and training, and environmental issues. Comment cards received from all 8 families stated that they are satisfied with the overall care provided by the home. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 25 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 3 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 4 23 4 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 4 3 x 3 3 3 Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 26 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 YA25 Regulation 13(4)(a) Requirement Carrying out risk assessments in relation to access to hot radiators; that if there is a risk of injury to any resident or staff then radiators should be covered in order to safeguard individuals health and safety. Timescale for action 31/12/06 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. 3. Refer to Standard YA17 YA35 YA10 Good Practice Recommendations Keep a record of alternative foods offered on ongoing menu sheets. Date bank staff induction checklist Obtain service users consent for medication to be administered. Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jonathan House DS0000026539.V319028.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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