Inspection on 24/01/06 for Joseph House

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Joseph House 19/06/09

Joseph House 21/06/07

Joseph House 03/07/06

Joseph House 23/06/05

Joseph House 28/02/05

Joseph House 06/01/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOMES FOR OLDER PEOPLE Joseph House The Old Rectory Reedham Norwich Norfolk NR13 3TZ Lead Inspector David Welch Unannounced Inspection 24th January 2006 11:00 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 Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Joseph House Address The Old Rectory Reedham Norwich Norfolk NR13 3TZ 01493 700580 01493 700994 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) Joseph House (Reedham) Ltd Mrs Beverley Mary Terry Care Home 35 Category(ies) of Learning disability over 65 years of age (35) registration, with number of places Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Joseph House is a care home currently registered to provide personal care and accommodation to 35 elderly adults with learning disabilities. However, almost half of the people living here are under 65 years old and, with Mrs Terry’s cooperation, the Commission is looking at issuing a certificate of registration that more accurately describes the category of resident accommodated. The home is privately owned and has been run by the same proprietors for a considerable period of time. The service, located in the village of Reedham, approximately 20 miles from Norwich, is a large period house, which has been extended. There are also two other small units, one of which is presently undergoing some refurbishment. Mrs Terry’s intention is to encourage a ‘more able’ group to live there, supported by dedicated staff. The other small unit is a bungalow which 3 service users share with Mrs Joan Terry, one of the proprietors. When Mrs Joan Terry some time ago moved out of the main house to the ‘Lodge’ the three people presently living with her are said to have asked to move too. While the residents and Mrs Joan Terry each have their own private parts of the Lodge, they share the kitchen and conservatory. The Commission acknowledges that this arrangement was the preferred choice for the people currently living in the Bungalow. However, we would not consider it to be appropriate if, when a place becomes vacant, somebody else moved in there. The home has a total of 21 single bedrooms, most of which are en-suite, and 7 shared rooms, all of which have en-suite facilities. The main house has accommodation on the ground and first floors and has a shaft lift. Joseph House is on a no through road so has little passing traffic and stands in large grounds. There is off-road parking. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two planned inspections, both unannounced. In addition, two further visits have taken place to gather information following an anonymous complaint and an unannounced site visit was made to check water temperatures. This second inspection fulfilled the Commission’s responsibility to inspect the home on at least two occasions within a 12-month period. It was important that all of the National Minimum Standards considered to be ‘key’ to the quality of life of people living in the home were checked over the two inspection visits. There were 29 people on the home’s roll. This included one person who was in hospital for a mental health assessment. Three people were out shopping with staff in Great Yarmouth. There were 4 carers on shift, 3 Domestic Assistants and 2 caterers. A senior care assistant and the manager were also present. The intention was to speak with as many service users as possible and to interview staff on duty using a prepared list of questions that sought to evidence compliance with National Minimum Standards. Four staff agreed to be interviewed in private. The manager was also interviewed. It was also possible during the day to speak in private to the person responsible for catering in the home. While no service users were formally interviewed, many of them were spoken with as they relaxed in the lounges, had their meal and, later, took part in a ‘Bingo’ session. An agreement exists that the Commission will use the National Minimum Standards for Homes for Older People, but details provided by the manager during the inspection showed that almost half of the people living at Joseph House are under 65 years of age and 3 others have only just reached that age. With this in mind, it has been suggested to Mrs Terry that the home’s registration should be changed to reflect the resident group. She is agreeable to this and at the time of writing has written to us saying that a lower age limit of 45 years should be added as a condition to the Certificate of Registration as she said the home is not suitable for people younger than this. Arrangements to change the home’s certificate are, therefore, taking place on this basis. The Care Plans of four service users, largely picked at random, but including one person who had been most recently admitted, were looked at. During this inspection Mrs Terry discussed her plans to create a small, selfcontained unit in the Annex for what she described as ‘more able’ people. At Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 6 the time of the visit some refurbishment of this area was taking place. The unit will have facilities for a staff room. The Annex is currently within the home’s registration. What will require an application to vary the registration of the home is Mrs Terry’s additional proposal to have a small unit for people with dementia. This would be located in the long corridor where some communal space will be adapted so that the group can live together safely. The creation of a secure garden, where people can move freely around in safety, had already started. Mrs Terry said that she had begun to discuss the proposal with interested parties, who felt it was a good idea. When the application is made it will be considered against certain criteria: – • • • Whether the premises are suitable in terms of their simplicity of layout, signage, security etc, Whether Mrs Terry’s background, knowledge and experience is sufficient and Whether the staff have been trained, are committed to, and have an understanding of, the conditions affecting people with dementia. The home’s recently-appointed Regulation 26 visitor arrived for her inspection. Arrangements were made to send her a copy of the Commission’s Reg 26 report format. At the end of the inspection Mrs Terry was given verbal and written feedback on how the Commission saw the home in operation. What the service does well: What has improved since the last inspection? Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 7 The programme of radiator covering has been completed. A handover period of 15 minutes has been ‘built-in’ to the staff roster so this important aspect no longer relies on the obvious good will of staff going off duty and those coming on. Staff have been reminded about proper infection control procedures. Regulation 26 visits have been reintroduced on a regular basis. The Regulation 26 visitor has been provided with a report format that will cover all necessary aspects. The manager has completed her RMA, Registered Manager’s Award (Adults). Some work has been done on improving the Statement of Purpose and Service User Guide, but further modification is required. What they could do better: Eight requirements have been made that would improve the service in line with the National Minimum Standards and latest thinking. These include: • • • • • • • Further work on the Statement of Purpose and Service User Guide Fitting appropriate locks on bedroom doors Providing the Complaints Procedure in formats that everybody living here is likely to understand Carrying out some repairs and redecoration where necessary Encouraging more staff to do NVQ Ensuring more regular and timely individual supervision Ensuring that water supplied to all bathrooms and showers is regulated to a temperature of 43o C A number of good practice recommendations have been made that will add to the quality of life of the residents. These include: • • • • • • • Arranging a communication assessment for all residents Checking ‘befrienders’ to the same level as new staff Encouraging visitors to use the Visitor’s Lounge rather than bedrooms, especially where rooms are shared Formalising the system by which people make a choice at mealtimes Monitoring staffing levels, specially at night Making sure staff all have a job description (some will have lost or mislaid the original) Consider downloading the new CIS (Common Induction Standards) from the Skills for Care website and using them consistently for all new staff. Please contact the provider for advice of actions taken in response to this Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 9 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 Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 10 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): 1, 2, 3, 4, 5 and 6. It is pleasing to see that service users are safeguarded with a terms and conditions of residence document and their needs have been assessed. But, some people will be at a disadvantage because the Statement of Purpose does not yet include all the required information and the Service User Guide is not in a format that everybody is likely to understand. A communication assessment would ensure that staff could communicate in the most appropriate way with everybody living here. EVIDENCE: Mrs Terry kindly provided copies of the home’s Mission Statement, Statement of Purpose and Service User Guide to take away. It was agreed that these would be returned by post as soon as possible after the inspection. Later consideration of the documents showed that the Statement of Purpose was, simplistically, a list of the National Minimum Standards and the information required did not include in most respects that given in Schedule 1 of the Care Homes Regulations 2001. The easiest way to develop a Statement of Purpose is, simply, to use Schedule 1 as a guide and prompt. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 11 The Service User Guide, although produced in a large font, which is helpful, contained some of the information required under the National Minimum Standards, but must also include key elements of the terms and conditions of residence such as fees and ‘extras’ and service users’ views. Bearing in mind that the resident group is people with learning disabilities, some of whom might not have sufficiently good literacy skills, the document should not only be produced in written form. It should, also, be in a variety of formats such as pictorial, symbol, sign and possibly audio so that everybody coming to live in the home has a chance of understanding it. Four case files were looked at with a view to assessing whether National Minimum Standards were being met. Each person had a contract that was signed. This is good practice. Each had a needs-led assessment. Of the two people most recently admitted, one had made a preliminary visit and one had not. The staff interviewed said that many of the residents can write and that they ‘talk to most people, although signalling is also used’. Staff also ‘write things down’. Two staff said that they have formed what they described as ‘an advocacy group’. By this they meant a Resident’s Group. It has a Chair and Committee. Minutes are taken. Mrs Terry confirmed that the home did not cater for people on an Intermediate Care package. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 12 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, 10 and 11. The recent pharmaceutical inspection found that, in general, residents’ health care needs were being well met, with satisfactory outside consultancy, where necessary. Service users’ privacy could be improved in one important respect. EVIDENCE: The staff all knew where to find the residents’ Care Plans. They were constructed such that carers were given the information necessary to assist people with care that was needed at times that were to their liking. The staff interviewed acted as ‘keyworkers’ to residents. They described this as doing something particular with, and for, some residents that they did not do with others. This might include writing letters, reading, playing games and accompanying on appointments. At the time of the inspection, no service user was suffering from a pressure ulcer, although the home did have equipment such as special mattresses and cushions in case this happened. Staff said that they were aware of the people at risk of developing pressure ulcers as a result of their lack of mobility, Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 13 perhaps, and they looked out for any reddened areas when they assisted people with personal care. Mrs Terry said that staff remind some people about using the toilet. She contacts the Continence Nurse through the East Learning Disability Team. About 6 or 7 people used pads. During the afternoon the medication was given out. The procedures were satisfactory. Nobody was at the time of the inspection prescribed ‘controlled medication’. Mrs Terry said that the home had 5 shared bedrooms. Screens were available to provide some privacy. Medical attention was given in the Treatment Room. Twenty of the bedrooms had some form of en-suite facilities. The name by which people preferred to be called was recorded on Care Plans. This is good practice. Where bedroom doors had a lock, this tended to be a ‘Star lock’. Mrs Terry said that residents are offered a key, but this was not recorded. Star locks are not appropriate for people living in a care home. They must be able to lock their door when they leave the room, if they wish and, when they return, ensure their privacy by using a deadlock system on the inside, i.e. one that does not require the key to be used in case they leave it in the lock or mislay it. Staff must be able to enter in an emergency, say if the person collapses behind the door or staff fear for their health. Mrs Terry used the minister at Cantley Church as a bereavement counsellor for residents and staff. The wishes that residents might have for after they are dead are discussed appropriately with them, sometimes using a storyline. Sometimes relatives are used to find out resident wishes. These are recorded on Care Plans. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 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. In general, the National Minimum Standards have been met. Three good practice recommendations have been made. These would further enhance the quality of life of the people living here and in one case provide added protection for them. EVIDENCE: There was a long list of activities displayed on the house notice board. Staff described a great number of activities and options available to people living in the home. On the day of the inspection three people were out with staff shopping in Great Yarmouth. A bingo session was observed, at which most of the residents were present. This was a very convivial affair, with a deal of banter between residents and staff. The ‘compere’ handled things in a very sensitive way taking into account the different needs of the people playing the game. He was inclusive in his manner and used praise and encouragement particularly well. As members of staff came in at different times there was usually a friendly exchange between him or her and the residents. It was a very cheery occasion and one clearly enjoyed by those taking part. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 15 Mrs Terry said she would like the local minister to come in once a month and conduct a service. Mrs Terry said that visitors could be seen in private, either in the Visitors Lounge or service users’ bedrooms. It will not always be appropriate for the bedroom to be used, especially as some people share. Mrs Terry said that she was currently advertising for ‘befrienders’ for the service users. She was aware that all the checks that apply to the recruitment of staff also apply to any volunteer who has access to vulnerable people in or outside the home. She confirmed that one person had an independent advocate arranged through the Community Learning Disability Nurse. The staff explained what choices residents had in their day-to-day lives. This included, they said, what they want to eat. To this end, the person in charge of catering agreed to be interviewed. Staff said that there were usually a couple of choices and a salad option. While the home clearly was satisfied that the system for consulting with residents worked well, it was difficult to see exactly how residents were involved in making a daily choice of meals. Nobody on the care side or catering staff seemed to be able to say precisely how this consultation was carried out. The staff knew who had a special diet. This included a soft diet and dishes suitable for people with diabetes. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 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, 17 and 18. The home showed that it acted in a proper way when a recent complaint was made. Training in the Protection of Vulnerable Adults has given staff the necessary background knowledge. The service users could be encouraged to take up all their rights as citizens, which might serve to embed them further into the local community. EVIDENCE: The bound Complaints Log was seen, but there were no entries. Staff said, when asked what they would advise somebody to do if they had a complaint about the care at the home, that there was a complaints form or they could speak to the two staff who manage the ‘advocacy meetings’. Other carers said that they would steer complainants towards senior care staff or management. If complaints were made to them, they said, they would pass them on to senior colleagues. The home’s Complaints Procedure is not in a format that everybody is likely to understand. It must be provided in alternative formats. Despite encouraging service users in the written information about the home that they will be assisted to exercise their rights as citizens to vote, Mrs Terry said that nobody had done so at the last election. Mrs Terry said that she remains the ‘appointee’ in respect of the benefit allowances for 10 residents. This figure is dwindling over time. She would like Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 17 the placing authority to take over this considerable responsibility. Personal allowances are paid to residents on a weekly basis in cash. Some residents wish to keep cash in the home’s safe for easy access, say to finance outings. Mrs Terry said that if there was a build up of cash in an account she sent the balance to Norfolk County Council for credit to the account of the person concerned. Some accounts were looked at and found to be in order. All four staff interviewed said that they had completed Protection of Vulnerable Adults (POVA) training, although one person said that this had not been done recently. Staff understood that they must not accept gifts from residents or be named beneficiaries in wills. None of the care staff act financially for service users. An anonymous complaint last year led to an investigation that involved police, social services, visiting nurses and inspectors from the Commission, including a pharmaceutical inspector who was a trained nurse. Mrs Terry was found to have acted appropriately and while she was asked to make a retrospective referral to Social Services in respect of a carer who had acted in an unprofessional way towards colleagues, the complaints were not upheld in any substantial sense. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 18 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, 21, 25 and 26. Generally, good efforts have been made to make sure people are safe, but there are some areas of the home that would benefit from repair and redecoration. Some remedial work is needed on the hot water system to ensure that while people are not at risk, their hot water is at a comfortable temperature. EVIDENCE: All four staff interviewed found it hard to say which areas of the home they found more pleasant than others. One person said she felt the lounges were ‘bright and open. Another person said she liked the garden in the summer when barbecues were arranged. Staff felt that the Shower Room at the bottom of the long corridor could ‘be improved as the floor gets very wet’. This is the area equipped with knee-high screens to prevent staff getting wet when assisting residents in the shower. Another carer said that the en-suites could be bigger so that residents could be helped more easily. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 19 In truth, some parts of the house are beginning to look ‘tired’, with some damaged areas, especially where wheel chairs are used. On the day of the unannounced inspection, additional handrails were being fitted in the long corridor. In parts, where measures had been taken to provide level access by ramping the original steps, the slope was quite steep. The programme of covering radiators to prevent residents from being burned had been completed. Mrs Terry intends to use one of the bedrooms in the Annex, currently occupied by a service user, as a staff room. This room has two quite steep steps and is not suitable for use by service users, so her decision to use the room only for staff is to be welcomed. Following the unannounced inspection that took place last year a requirement was made that staff were reminded only to leave soiled clothing in the proper places to promote good infection control. Interestingly, when later the Regulation 26 visitor made an unannounced visit, she also found that staff were not managing this aspect of care well. The matter was again discussed with Mrs Terry at this inspection and she said that staff had reminded, but she had also arranged some infection control training for staff. The four staff interviewed said that they had done infection control training. There were no unpleasant odours noticeable in any of the communal areas. During a second unannounced site visit on Friday 3rd February 2006 the temperature of the water supplied to the home’s four bathrooms and showers was checked. A wash hand basin was also checked. Between 13.45 and 14.00hrs the hot water supplied was not at a dangerous temperature, being, in two washing areas about 46oC – about 3oC above the level felt to be safe by the Department of Health. In the other two bathrooms the water was about 39oC – just above blood heat, with the potential that bathwater would very soon feel quite cool. Mrs Terry said she would arrange for the necessary adjustments to be made as soon as possible. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 20 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. There is good training for staff. In a home for vulnerable people such as this, the physical layout is not easy and although staffing levels seem OK at the moment, the manager has been asked to monitor them, especially at night. EVIDENCE: In line with a recommendation made last time, a handover period of 15 minutes had been built in to the staff roster. This is good practice. There appeared to be sufficient staff on duty at the time of the unannounced inspection. Two staff felt that the numbers on duty were adequate, although they did say that they would like ‘some more time with residents’. The other staff said that they would like there to be more carers on shift. The re-assessment of one person, away in hospital at the time of the visit, had released staff, they said, to attend to others. Staff paid tribute to the manager who, they said, ‘was all for the residents’. Two carers perform waking night duties. In addition, Mrs Joan Terry sleeps in the Lodge and can contact night staff if necessary. One person said that she had completed her NVQ level 3. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 21 The staff confirmed that they had done moving and handling training. The recruitment was checked of the four people who had come to work at the home since February 2005. In fact, all four were workers recruited from Eastern Europe, in 3 cases through an agency. Three were care staff and one person worked in the home as a Domestic Assistant. All four had Home Office work permits and two had CRB checks on file. All four had written references and photo identification. Staff confirmed that they had access to the General Social Care Council Code of Practice, but some were unsure whether they had a job description. Training was checked with the four staff interviewed and included, apart from that mentioned above, medication, challenging behaviour, fire safety and dementia. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 22 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, 32, 35 and 36 There is good focus on service users. The regular staff meetings have the potential for a sharing of ideas and an openness of approach. More regular individual supervision of staff will provide staff with more confidence in what they are doing and the necessary personal support. EVIDENCE: Mrs Terry completed her Registered Manager’s Award (Adults) and had attended additional training in the last 12 months. She said that further dementia training was planned for February 2006. Staff confirmed that there were full staff meetings every month. They said that they did have individual supervision, but not every 8 weeks or so in line with National Minimum Standards. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 23 Staff said that they do not act financially for residents beyond sometimes handling small amounts of cash, say when people are accompanied on outings or to the pub. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 X 2 X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 2 X X Are there any outstanding requirements from the last inspection? Yes. Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4(1)(c) Requirement Timescale for action 30/04/06 2. OP1 5(1) 3. OP10 12(4)(a) 4. OP16 22(2) The Registered Persons must ensure that the Statement of Purpose includes all the information required under Schedule 1 of the Care Homes Regulations 2001. In an Action Plan sent to the Commission and received on 10th March 2006, Mrs Terry said that the Statement of Purpose was to be amended. The Registered Persons must 30/04/06 ensure that the Service User Guide is provided in a format that everybody living in the home is likely to understand. Following receipt of the draft report, Mrs Terry said that the Service User Guide had been commissioned in an Easy Read format. The Registered Persons must 31/08/06 ensure that appropriate locks are fitted to all bedroom doors and service users are given the choice of whether they want to hold a key. The decision to do so must be recorded in their individual Care Plan. The Registered Persons must 30/04/06 provide the Complaints Procedure in a format that everybody living in the home is likely to understand. Following DS0000027295.V280623.R01.S.doc Version 5.1 Joseph House Page 26 5. OP19 23(2) 6. OP21 13(4)(a) 7. OP28 18((c)(i) 8. OP36 18(2) receipt of the draft report, Mrs Terry said that the Service User Guide had been commissioned in an Easy Read format The Registered Persons must ensure that all parts of the house are well maintained, i.e. damage is repaired and areas that require it are redecorated. Following receipt of the draft report, Mrs Terry confirmed that all maintenance items will be logged and items prioritised by risk assessment. The Registered Persons must ensure that hot water supplied to the baths and showers is at a temperature close to 43oC. The Registered Persons must provide the Commission with a plan for ensuring that at least 50 of care staff are trained to NVQ level 2 as soon as practicable. Following receipt of the draft report, Mrs Terry said that a plan would be sent to the Commission. The Registered Persons must ensure that staff receive individual supervision at least 6 times a year. Following receipt of the draft report, Mrs Terry said that a format was already in use and a copy would be sent to the Commission. 30/06/06 03/02/06 30/04/06 28/02/06 Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 27 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 YA4 Good Practice Recommendations The Registered Persons should make arrangements for all service users to have an assessment of their communication needs to ensure that staff are communicating with them in the most appropriate way. Following receipt of the draft report, Mrs Terry said that referrals had been made to the Community Learning Disability Team. The Registered Persons should ensure that any person engaged to act as a ‘befriender’ to service users is subject to the same checking and vetting as for new staff. Following receipt of the draft report, Mrs Terry said that this had been added to the operational policy. The Registered Persons should encourage visitors to use the Visitors Lounge rather than bedrooms. This is especially important in the case of shared accommodation. The Registered Persons should formalise the system by which service users make choices about what they want to eat on a daily basis. Following receipt of the draft report, Mrs Terry said that menu choice is already in operation, but residents will be given the chance of seeing the menu is pictorial form. The Registered Persons should monitor staffing levels, especially at night, and report her findings to the Commission. The Registered Persons should provide all staff with another copy of their job description to ensure that they have one that is up to date. Following receipt of the draft report, Mrs Terry said that all staff were now in receipt of a job description. The Registered Persons may wish to consult the Skills for Care website and download, where applicable, the new Common Induction Standards (CIS) for use in care homes for adults. Following receipt of the draft report, Mrs Terry said that she had looked at the website mentioned above. 2. OP13 3. 4. OP13 OP14 5. 6. OP27 OP29 7. OP30 Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispin’s Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk Joseph House DS0000027295.V280623.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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