Inspection on 03/07/06 for Joseph House

This inspection was carried out on 3rd July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 24/01/06

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 Mrs Judith Huggins Unannounced Inspection 3rd July 2006 09:45 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.V302971.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. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 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 (35), Learning disability over registration, with number 65 years of age (35) of places Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of people accommodated must at no time exceed 35. Any person must, on admission, be at least 45 years of age. One person, named in the Commission’s records and less than 45 years of age, can be accommodated. 24th January 2006 Date of last inspection 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, it would not 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. Charges for living at the home vary from £328 to £628.89 per person per Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 5 week, according to dependency and facilities. There are additional charges for hairdressing, chiropody, newspapers and magazines, outings and personal spending. The manager says that the inspection report is accessible to residents or their representatives in the main reception hall. No comment cards were received from relatives or other visitors showing they are aware of this. The manager says that all prospective residents (or their representatives) are given a copy of the report. (One person could not confirm this in discussion.) Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was unannounced, and lasted about 7 hours. The inspector spoke to the manager, three members of staff and four residents. She also looked round part of the home and listened and looked at how staff cared for and spoke to people living at the home. Other information was taken from a sample of records, including care records for three people. Only two sets of written comments were received from residents, and none from their relatives which would have been helpful. Some feedback was received on behalf of visiting professionals. Other information was taken from the manager’s survey of quality. What the service does well: What has improved since the last inspection? The statement of purpose and service users guide are in simplified language and the complaints procedure has been included in this form. Two more staff have enrolled for level 2 National Vocational Qualifications (NVQ’s) in care meaning that the home is making good progress towards meeting the minimum standard. One of the management team sees staff more regularly to discuss whether they have any problems and are happy working at Joseph House. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 7 Some parts of the home have been redecorated and the manager says that she has bought new locks for bedroom doors (but they have not been fitted yet). Staff need to have regular meetings with a member of the management team, to talk about their work. The number of times this happens has improved a lot 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. Joseph House DS0000027295.V302971.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 Joseph House DS0000027295.V302971.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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs assessed and can be sure these will be addressed, before they move into the home. Standard 1 was inspected for compliance with previous requirements and deemed met. EVIDENCE: The assessment information for one person, and admissions process was checked for one person admitted in April. This shows that a good range of information was collected before the person moved into the home. The person themselves confirms that they visited before deciding to move in. The home does not admit people solely for rehabilitation. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 10 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 this service. The outcome would be good were privacy to be further enhanced, evidence of rigorous review improved and records of care delivered more accurately reflect that identified as necessary Medication is managed appropriately. EVIDENCE: There is good assessment information on file, particularly for one person recently admitted. Residents have goal-setting sheets and a staff member confirms that the keyworker helps set these with the resident, giving an account of the goals that was consistent with the records. One person admitted in April has no recorded goals yet, although the assessment is cross-referenced with care plans for activities of daily living. The manager says that sometimes staff find it difficult to help people identify goals, particularly where people have more complex needs and communication difficulties. (See comments regarding staff supervision.) Feedback from Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 11 visiting professionals is that staff can struggle to meet complex needs confirming the manager’s and inspector’s view. Interactions observed between staff and residents were appropriate, and two residents spoken to say that the staff are good and look after them well. Two anonymous comment cards confirm this. Staff from the community learning disabilities teams assist in reviewing some of the needs, although the home itself does not review these with the frequency set out in standards. (A file note shows that Person Centred Planning is not routinely available in Norfolk although for people with learning disabilities, government guidance in Valuing People says it should be.) One person’s plan says it will be reviewed annually. There is a need to make sure that all the “threads” in care plan documentation tie in together to improve evidence of a holistic approach to care. For example, review information for one person shows that continence difficulties are increased when drinks with caffeine are given. It says there will be another review in a month. The manager says that this aspect of care was included in the general review with the CLDT nurse but there is a lack of a clear record about this aspect of care and the information has not then been transferred to care plan sheets for either continence or eating and drinking. Feedback from visiting professionals indicates that although broad advice would be covered in care plans, some specialist and specific elements or advice is often overlooked. A requirement has been made regarding service users’ individual plans. Records show that residents are referred to other professionals including the doctor, dentist or optician and one person spoken to showed a good understanding of their health care needs. They confirmed that staff helped with appointments and offered reassurance. The manager and a staff member confirm that information is periodically transferred from the handover book into residents’ individual notes and as a result these may not be completely up to date. This is reflected for example by one person’s notes showing a dental appointment in December last year with a check up needed in another six months. The record does not show this has happened. Another has a care plan showing that exercises need to be encouraged three times daily, but records of care delivered do not clearly show that staff do this. (A useful goal in this case would be to improve gait and maintain mobility.) A recommendation has been made. Staff spoken to show that they understand residents’ needs. Feedback from a visiting professional is that some staff are knowledgeable, and experienced and more able to take on board information, although others lack recognition of people’s needs. The handover record shows that staff can access up to date Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 12 information about changes following days off or holidays, and so would be able to keep up to date. Medication storage and reported practice raised no concerns. Medication is supplied weekly from the pharmacy in “cassettes” prepared by the pharmacist. Other medication is dated when it is opened to ensure it remains safe and effective in use. There are sample signatures for those staff authorised to give medication, and medication training is provided. One staff prepares medication for administration and supervises the trolley, while another gives the medication and ensures it is taken, in the presence of the first person. In order to ensure the process remains fully accountable and to underpin safe practice, policy guidance needs to set this out clearly. A recommendation has been made. There is screening provided in shared rooms. However, privacy is compromised by glazed panels in bedroom doors, not all of which are screened sufficiently. At inspection the manager undertook to address this. A requirement has been made. The requirement made at the last inspection, for locks to be fitted to bedroom doors and keys provided subject to risk assessment and choice is still within time limits. The manager says the locks have now been obtained and are to be fitted within the timescale specified in the report. The existing “star” locks are not appropriate, need to be removed when proper locks are fitted, and are open to abuse. The requirement made is repeated pending completion. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 13 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 this service. Residents have access to a range of social and recreational opportunities, and a good diet. The way the home communicates available choices to residents could be improved as a matter of practice. Improving supporting records could further enhance evidence for this range of outcomes. EVIDENCE: Residents confirm that they have regular activities. One enjoys bingo and was making “pom-poms” as prizes. Residents were heard being asked by staff if they wished to join in activities. A programme of activities supplied with the pre-inspection questionnaire shows that activities sessions are arranged for men and women (for example a “gentlemen’s morning” and “ladies’ pampering session” as well as for large and small groups. Aromatherapy is listed and there is evidence in quality assurance monitoring that a dance and movement therapist and reflexologist also provide sessions for residents. There is a dedicated activities coordinator on duty during weekday day times. Residents confirm that they have visitors, and one said they were helped to keep in contact with friends by staff - who help with letter writing. There is a payphone available. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 14 During the fieldwork visit, one person was taken to visit family. Other residents went on the journey and spent the duration of the visit in Cromer. One person returning from the trip said they had a lovely time, with shandy, ice cream and sausage and chips. A trip was also arranged to the local Pettit’s animal centre. One person says that they have been taken to the local village. There are photographs of a recent boat trip which a group of residents clearly enjoyed. During “case tracking” the need for one person to have a full programme of activities was identified and set down in records. There was no indication of what this was or what the person did on a regular basis. The manager says the activities coordinator keeps separate records of people’s participation in sessions. These were not available during the inspection as the person concerned was escorting the outings on offer. See comments made under previous section and associated recommendation. The notes of one meeting with residents show that advocacy via “People First” is supported (see also quality assurance standards) and the manager says that 6 or 7 people attend sessions. The home is showing good practice in encouraging residents to do this. Residents can bring their own possessions into the home, and one was moving in belongings during the afternoon of the fieldwork visit. However, one person was heard becoming anxious having left their handbag in the lounge because she felt the staff member was going to take her out without it. The staff member was heard repeating that the person did not need it despite the resident’s increasing agitation. A second staff member retrieved the bag and prevented the situation escalating further. Care is needed that incidents are not unnecessarily provoked. Feedback from visiting professionals is that the home does not uphold well researched key concepts to help give residents valued lifestyles. Care plans could be adjusted to reflect how these are covered. A recommendation has been made. There is a choice of meals, based on menu records seen and discussion with the cook and manager. Residents say the food at the home is good. Speech and language therapists have been involved (based on records) where residents have difficulty swallowing. One file checked shows the involvement of the dietician and people’s weights are checked. The main meal of the day is at lunchtime, and there were choices of a roast dinner or salads. In response to the previous report, the manager said that residents were to be given the chance of seeing the menu in pictorial form. This would represent a welcome improvement in empowering residents and increasing the range of communication methods used, but has yet to be put in place. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 15 There was a heatwave at the time of the visit to the home. Copies of government guidance were available and the manager had made sure that there were jugs of drink and beakers at several points throughout the home in communal areas. Staff were heard to offer drinks frequently. This is good practice and of particular importance during such high temperatures. Joseph House DS0000027295.V302971.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 good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be sure their concerns will be taken seriously and acted on. Residents are protected from abuse, within the elements of standard 18. However, see also staffing standards. EVIDENCE: The complaints procedure is provided with some symbols and simple language. Observation of communication and apparent cognitive abilities means that some people would need additional explanation. One person recently admitted could not remember receiving any information. There are declarations in care plan files for residents to sign that they have received the information although this is not consistently completed. A recommendation has been made. The manager’s evaluation of relatives’ surveys recognised that not all of those responding knew what the complaints procedure was, and records show intended action to address this shortfall. Staff recognise their responsibilities to report any incidents or conduct that concerns them and have received training in adult protection, as has the manager. The manager has responded positively and appropriately to previous referrals under the Norfolk Protocol for the Protection of Vulnerable Adults. Joseph House DS0000027295.V302971.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, 21 (in part) and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been some expenditure on refurbishment, but the size and age of the home means that considerable attention is needed to maintenance and redecoration as well as routine checks. Water temperatures remain variable as at the last inspection. Areas of the home that were seen are clean, and there were no offensive odours in areas visited. EVIDENCE: The pre-inspection questionnaire shows that some refurbishment has taken place, and generally the newer rooms are in good condition based on the sample seen. As at the last inspection, there remain concerns about the overall maintenance of the older part of the home. Concerns include: • Damaged to wall covering caused by water penetration Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 18 • • • • • • • • • • • Privacy bolts to WC and bathing facilities that do not allow for opening from the outside in an emergency A dropped and unsteady area of flooring to the corner of one bathroom A fire extinguisher being used to prop up loose panelling on the corner of a staircase Some stained carpets Plant matter growing from the gutter Damaged seal to a shower Corroded seats to some shower facilities which may need refurbishment or replacement to ensure they are safe and can be kept clean properly Paintwork that is chipped Tiles that are damaged As at the last inspection, the hot water to one bath tap measured 39.6oC, which is just over blood heat and 3 oC cooler than suggested levels meaning bathwater may feel uncomfortably cool to residents One washbasin delivered hot water at 46 oC The inspector acknowledges that the size of the home means that some work needs to be prioritised due to risk and expenditure and so requirement regarding a schedule for repair of the above items, and any others logged as requiring maintenance, and also for routine maintenance programmes has been made, rather than for individual issues. Specific advice will be needed from the fire officer, in relation to fitting and use of locks to one shared room on the first floor, as this is currently a designated fire escape. A requirement has been made. The inspector acknowledges that there may be preferences for individuals and that some will use “comforters” but some of the items in the display cabinet of the large lounge are not “age appropriate” (teddies and soft toys). A recommendation has been made. The grounds of the home provide space for residents to sit and enjoy their surroundings, and part of the gravel area to the front of the home has been provided with sturdy picnic tables and parasols. Overall, areas of the home that were seen were clean. There is an infection control policy and the training file contains evidence that there has been training, and the home has received guidance and a review of practice. The person delivering the training is able to act as an “expert witness” based on letterhead information. Joseph House DS0000027295.V302971.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 poor. This judgement has been made using available evidence including a visit to this service. The overall judgement is arrived at because of the serious shortcomings in recruitment practices that are not sufficiently robust to ensure proper checks are made before employment in the interests of protecting vulnerable residents. Were this to be remedied and other standards maintained, the outcome would have been good. Residents are supported by adequate numbers of competent and trained staff. EVIDENCE: There is a recorded duty roster, showing the staff on shift, the hours they work, whether they are senior staff or not, and who is in charge of the shift. The manager and a senior care assistant responsibility for the day-to-day running of shifts is shared between senior staff. Staff spoken to feel there are enough of them on duty to meet the needs of residents and to spend time with them. The inspector activated one of the door alarms and staff responded promptly to this. Care staff are supplemented by a supervisor who can provide support to residents who need to attend health care appointments, and also by an activities coordinator. On the day of the fieldwork visit (unannounced) there Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 20 were sufficient staff on duty to take a group of residents (12) on an outing to Cromer. As at the last inspection the duty roster and manager confirm there are two staff on waking night duty in the main house. Mrs Joan Terry lives and sleeps in at the Annexe and can provide support to residents there or contact night staff if necessary. As at the last inspection, the manager needs to keep the adequacy of this arrangement under review, because of the increasing age and frailty of some of the residents. The staff list, and list of people with NVQ qualifications, shows that currently 30 of staff have NVQ qualifications to the level set out in the standard. The pre-inspection questionnaire showed that 3 staff are currently undertaking the training, but this was corrected to 2 at the fieldwork visit. These two staff members started the training in April (records seen and confirmed by one of the people concerned) meaning that the 50 ratio required will be achieved when they complete (providing no others leave). The manager says that 6 are on the waiting list. The requirement made at the last inspection was to provide a plan as to how the ratio of 50 of staff being qualified to this standard has been achieved. If existing staff remain and complete their training, as do those on the waiting list, the minimum standard will be exceeded. A good range of other training is provided based on the pre-inspection questionnaire, training records and discussion with staff and the manager. There are significant shortfalls in the evidence of appropriate checks before people start work. This includes for example, lack of evidence of checks against the register for the Protection of Vulnerable Adults (POVA) via PovaFirst before people start work, lack of dates of employment meaning that a full employment history cannot be demonstrated, lack of application form relevant to the job being done and lack of proof of identity including photograph. The manager was reminded that staff may only be employed in exceptional conditions without a full CRB being received, and then all other checks and a check against the Pova list via POVA First must have been obtained before the person starts work. A requirement has been made. In one case, although two written references had been obtained these were both from colleagues and not from the manager or proprietor of the former work place. The manager says she has taken a telephone reference from the manager of the home to supplement the other two but has made no record of the information. There is therefore no evidence that the conduct of the person concerned did not present concerns in any way to their previous employer. The manager says that staff do not deliver personal care unsupervised until the full disclosure is received. She is reminded that staff allocated to supervise Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 21 those newly recruited who are unchecked, must themselves have completed all checks and need to be named. One person recently recruited was spoken to and confirms that training opportunities have been provided. In addition, the person has come with evidence of induction from a previous work place. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 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, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The outcomes for the area will be good when supervision is given a more formal status and structured agenda. The manager is appropriately qualified to discharge her duties fully and insofar as the premises were checked, she generally upholds safety. Residents’ views are taken into account in the assessment of the quality of the service although there is scope for improving the range of areas looked at. Their financial interests are safeguarded. EVIDENCE: The manager has obtained her Registered Managers Award, and participates in other training from time to time, with the remainder of the staff group. Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 23 In two comment cards, residents say that they have meetings to discuss what is good and what can be improved. One person confirmed this in discussion, one had not been at the home very long and two could not remember. Records show that there was a meeting in January, and that the issue of questionnaires and the need to look at what people thought about the home was discussed, as was the opportunity for residents to join “People First”. It was agreed this would be reviewed in a month or so but as yet there are no records. The manager says that this is because they are currently being typed into more accessible language. There are results of surveys of residents and their relatives, and some action has been taken to address shortfalls (in the numbers of relatives who were not aware of the complaints procedure). There is also feedback from other professionals connected with the home (for example the dance and movement therapist, chiropodist and chiropractor). The manager says that only two residents wanted to complete comment cards for this fieldwork visit. Analysis of service quality is related to the range of questions the manager asks in comment cards and does not look at other potential indicators of service quality. The manager says she routinely allocates any personal allowances residents may wish to carry with them, on Monday afternoons. One resident confirms this and was provided with explanation that hairdressing bills had already been paid. Records were not checked on this occasion. The outcome of the standard was considered met at the last inspection. Supervision records show that the frequency has improved and would allow for a minimum of six sessions per year if sustained. The agenda is not yet as set out in standards. Discussion with the manager revealed other issues that could be appropriately addressed through supervision, including maintenance of keyworker files and goal setting with residents. Staff confirm that they receive supervision, although this is generally informal and unless there are particular problems may only take 15 minutes. The manager says she had misunderstood that the minimum standard required informal rather than formal supervision. A requirement has been made. Where disciplinary, grievance or performance issues need to be addressed, the manager should make reference to guidance issued by the Arbitration, Conciliation and Advisory Service (ACAS). Full servicing and maintenance records were not checked. However, fire extinguishers were seen from stickers as serviced in June and fire tests take place. The environmental health officer responsible for health and safety at Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 24 work legislation has not raised concerns about the service with the Commission. A random check showed that electrical appliances had been tested. The manager has signed the pre-inspection questionnaire as providing accurate information and this records recent testing of the heating system, electrical wiring, hoists and the lift. Training records show that staff have received training in fire safety. Joseph House DS0000027295.V302971.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 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 12, 15 Requirement The registered persons must ensure residents’ individual plans set out clearly in writing, how their needs in respect of health and welfare are to be met, and shall keep there under review with the frequency set out in standards. Timescale for action 31/08/06 2. OP10 3. 4. OP10 OP19 Residents or their representatives shall, unless impracticable be involved in these reviews. 12.4.a Outstanding requirement, but 31/08/06 within timescales The Registered Persons must 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. 12.2, 13.4 The registered persons must 31/08/06 & 13.6 remove “star” locks from bedroom doors. 23.4.b The registered persons must 31/07/06 and c seek advice from the fire officer regarding the fitting (or DS0000027295.V302971.R01.S.doc Version 5.2 Page 27 Joseph House 5. OP19 23(2) 6. OP21 13(4)(a) 7. OP29 19 8. OP29 19, Sch 2 9. OP29 19. Sch 2 10/ OP36 18(2) otherwise) of a lock to one first floor room providing access to the fire escape. 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 and submit a schedule showing how this is to be achieved by the due date. Outstanding requirement 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 complete the necessary checks before employing staff to work at the home, as set out in regulations and Department of Health Guidance. The registered persons must maintain statutory staffing records at all times as set out in Schedule 2 of regulations, amended in 2004. The registered persons must make arrangements for staff employed in emergency without full CRB checks, to be supervised by named staff members. The registered persons must ensure staff receive formal supervision to the agenda set out in standards. 31/08/06 31/08/06 31/07/06 31/07/06 31/07/06 31/08/06 Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 28 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 OP8 OP7 Good Practice Recommendations The registered persons should ensure that records of care delivered show that interventions considered necessary by other health professionals are acted upon and implemented. The registered persons should ensure that medication administration practices and accountabilities are clearly set out in the guidance for staff. The registered persons should, in updating care plans in line with requirements and good practice recommendations, ensure they take into account O’Brien’s five principles. The Registered Persons should make arrangements for other means of representation of menus (or other choices) such as in pictorial form, to increase the level of consultation and empowerment for those with cognitive or communication difficulties. The registered persons should record the form in which the complaints procedure is made available to residents, and where there are cognitive or communication difficulties, the methods that have been used to try and help residents to understand the information. The registered persons should develop more age appropriate displays for cabinets (or other locations) within communal areas. The registered persons should obtain relevant information about the management of disciplinary issues, poor performance and grievances from ACAS. 2. 3. OP9 OP12 to OP15 4. OP14 5. OP16 6. 7. OP19 OP36 Joseph House DS0000027295.V302971.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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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