Inspection on 23/08/06 for Joybrook

This inspection was carried out on 23rd August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Joybrook 15/01/08

Joybrook 14/02/06

Joybrook 03/11/05

Joybrook 21/03/05

Joybrook 21/12/04

Joybrook 18/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Joybrook 86 Braxted Park Streatham London SW16 3AU Lead Inspector Pam Cohen Unannounced Inspection 23rd August 2006 9 am 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 Joybrook DS0000022738.V309348.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. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Joybrook Address 86 Braxted Park Streatham London SW16 3AU 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) 0208-764-2028 0208-679 1138 JoyCare Home Services Limited Janet DeHaney Mrs Janet DeHaney Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14 February 2006 Brief Description of the Service: Joybrook is a 15-bedded private home for older people operated by a small family business, which includes the manager. It is situated on the corner of a pleasant residential road, within walking distance of a large common. It is a short bus ride from a local shopping centre which has rail and bus transport and full community facilities. The home has 11 single and 2 double bedrooms, some on the ground and some on the first floor accessed by a lift. All communal areas are on the ground floor. The Manager has been at the home for over 12 years and there is a stable staff group. On the day of inspection there was one vacancy. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the morning of the 23rd of August. The manager and administrator facilitated the inspection. The inspector was also able to check documentation including care plans, interview staff, talk to service users and a care manager undertaking a review at the home. The weekly fee at the time of inspection is between £395 and £525 What the service does well: 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. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 6 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 Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 7 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The proper process for admission to the home is not always followed which may mean that a service user’s needs may not be able to be met. EVIDENCE: The manager described the information which she would generally gather on a prospective service user, and the assessment that would be made by a member of the home’s staff. However, the file seen for a recent admission showed that full information on needs had not been gathered, and that they had not been assessed by a staff member, to see whether their needs could be met. The home does not offer intermediate care. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 8 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and other documentation are not sufficiently detailed to ensure that service users’ personal care and health care needs are met. Medication administration is generally good and there was every indication that service users feel that they are treated with dignity and respect. EVIDENCE: Care plans were seen for four service users. The home is working hard to draw up care plans which will cover all areas of a service user’s need. At the moment however there is not enough detail on how personal care should be delivered. In view of the number of service users who suffer from some degree of dementia there is also not enough information on how a service user’s dementia affects their activities of daily living and what action staff need to take. There should also be a life history for each service user so staff are able to relate to who they were as well as who they are now. One service user had been at the home for over a month and had no care plan. The manager described good relations with the GP who looks after all the service users in the home. She also described the good support offered to the home by the District Nurse who visits them. A chiropodist, dentist and optician Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 9 visit the home regularly. Although all this may point to service users’ health needs being well supported the home was not evidencing this. For example a service user was seen with a severe skin problem on her legs. The manager said that the GP and the District Nurse had been consulted and told the home what treatment was needed, however there was no documentation of this and so no way of auditing health care. At the moment no service user self-medicates and they should be given the opportunity to do so within a risk assessment framework, if they so wish. Recording of administration of medication was generally good. However the home must ensure that the quantities of medications obtained outside the pharmacist’s monthly deliveries are properly recorded on the MAR charts. Two staff in the home who were responsible for administering medication did not seem to be knowledgeable about what the medications were for and what side effects might arise, and this is something that needs to be remedied. Observation of staff interactions with service users, together with conversations with service users showed that they were happy and comfortable with staff and the way that staff looked after them. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 10 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): 12,13,14,15. Quality in this outcome area is good. This judgement has available evidence including a visit to this service Service users are encouraged to be as independent as provided with a good range of activities, inside and outside one and in groups. Food provision is good and is enjoyed by EVIDENCE: The home employs an activities co-ordinator who works 31 hours per week. All service users have a full assessment of their wishes and needs in terms of their social life, and the activities they enjoy; a varied and changing programme is then put in place. There are frequent outings and the staff have been making a particular effort to take service users out individually as well. The nephew of a man recently admitted, told the care manager how pleased he was that his uncle had already been out three times. On the day of inspection a service user was going out with a member of staff to choose his own birthday cake for a party that afternoon. Service user participation in activities is also well recorded. Visitors are welcomed at all times and links have been made with local churches and service users helped to visit them and to access the community and to be as independent as possible. Rooms were personalised to a considerable extent to enable service users to pursue a lifestyle they enjoyed. In order to further enhance service users’ control over their lives the home Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 11 been made using possible and are the home, one to service users. should ensure that an assessment of who deals with personal finances is made as part of the care planning process. Service users said that they enjoyed the food provided. The menu was varied and nutritious although on the day of inspection there was little fresh fruit or vegetables in evidence. Service users comments are recorded after each meal. The cook showed good knowledge of service users individual wishes and nutritional needs. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 12 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): 17,18,19. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints’ policy and procedures protects service users and their civil rights are also assured. The vulnerable adults’ policy and whistle blowing policy need some improvement. EVIDENCE: The home has a complaints policy which is provided to service users and their families. All complaints made are properly recorded and investigated. Service users are also helped to participate in the electoral process, using either postal votes or being taken to the polling station. The home has still not yet fully incorporated its vulnerable adults policy with the local authorities procedure. There is a whistle blowing procedure on file, but it is not clear in making staff aware of there responsibilities and rights and needs to be made more transparent and distributed to all staff. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Service users general benefit from a comfortable and well maintained home. Some furnishings are still needed in individual rooms and a service user’s wish for their own room must be respected. Hygiene is good but advice is needed for procedures when dealing with soiled linen. EVIDENCE: The home is comfortable, homely and well maintained with plentiful communal areas and appropriate bathing and toilet facilities. There is an accessible garden which has a raised bed where service users have grown tomatoes and other plants. Most service users have their own rooms which are well personalised but not all had an accessible bedside light and two comfortable chairs. One service user said her room was just right, not too posh, and that the home was always kept clean. There are two double rooms and it was clear from documentation that one service user in a double room does not wish to be sharing. Service users are supplied with keys to their rooms if they wish. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 14 The laundry room has been upgraded to conform to hygiene specifications and the home was clean throughout. However procedures for dealing with soiled linen did not adequately protect service users. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 15 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): 27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers and NVQ training mean good provision of care to service users. A training plan is needed to cover all areas of the staff workload. EVIDENCE: Staffing numbers are good with two care staff, a senior, activities organiser and manager or administrator on duty each day. The level of staff who hold an NVQ qualification is high with 12 out of 14 care staff holding or training for this award. Other training needed is not always being provided with gaps in basic health and safety training and no training plan to ensure that training necessary to the needs of the service users is supplied. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 16 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by a competent person and service users appreciate her efforts. Some augmentation of quality monitoring is needed and documentation of service users’ financial transactions needs to be rigorous to protect service users and staff. Some areas of health and safety provision need improvement in order to properly protect staff and service users. EVIDENCE: The manager has worked at the home for many years. She has completed her NVQ level 4 in management and is still in the process of completing the care component. She keeps herself updated on developments in the care home sector and the inspection showed that she is competent to run the home in the best interests of the service users, one of whom commented that it was like “home from home.” Supervision is provided to staff but the manager herself is not supported by supervision. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 17 The manager is auditing services and undertaking some quality monitoring by service user questionnaires. This needs to be augmented with surveys to other stakeholders and an annual report of the findings published. An annual development plan also needs to be undertaken. At the moment there is no monthly monitoring of the home by the responsible person, and a representative needs to be found to undertake this function. Records of transactions of service users monies were examined and found to be accurate but need to be better organised in an accounts book, and with signatories to all transactions. Many of the systems needed to ensure health and safety for service users and staff are in place. However staff do not all have up-to-date moving and handling training and service users do not have moving and handling assessments where needed. Fire drills need to be diarised to ensure that all staff have attended over a twelve-month period and all must attend fire training. Testing of water temperatures should be undertaken weekly and hoists and wheelchairs must be maintained and the maintenance documented. The cupboard containing substances hazardous to health should be labelled. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 18 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 X 2 2 X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 2 Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement The registered person must ensure that all service users are assessed before admission to ensure that their needs can be met. The registered person must ensure that a care plan is drawn immediately for the service user without one. The registered person must ensure that care plans cover all areas of service users’ needs. The registered person must ensure that there is evidence to show that service users’ health care needs are being met. The registered person must ensure that service users are able to take responsibility for their own medication if they wish and are able. The registered person must ensure that a clear record is kept of all medications received and that staff are knowledgeable about the medications they administer. The registered person must ensure that on admission service DS0000022738.V309348.R01.S.doc Timescale for action 31/10/06 2. OP7 15(1) 24/08/06 3. 4. OP7 OP8 15(1) 12(1)(a) (b) 12(2)(3) (4) 31/12/06 31/10/06 5. OP9 31/10/06 6. OP9 13(2) 17(1)(a) sch 3 (k) 31/10/06 7. OP14 12(2)(3) 31/10/06 Joybrook Version 5.2 Page 20 8. OP18 12(1)(a) 9. OP23 23 (2)(e) 10. OP24 16(2)(c) 11. OP26 13(3) 12. OP30 18(1)(a) (b)(c) 13. OP33 24(1)(a) (b)(2)(3) 14. OP33 26 15. OP35 17(2) sch4 (8)(9) (a,b) 13(4) 23(4) 16. OP38 users wishes and abilities to manage their own financial affairs are assessed The registered person must ensure that the vulnerable adults policy and whistle blowing policy are complete and accessible The registered person must ensure that the service user who wishes to have a single room is offered the next suitable room which becomes vacant. In the future only service users who make a positive choice to move into a double room should do so The registered person must ensure that all rooms have bedside lighting and two comfortable chairs. The registered person must ensure that professional advice is taken in order to ensure that soiled linen can be properly dealt with and sluiced if necessary. The registered person must ensure that there is a staff training and development plan which delivers all necessary training. The registered person must ensure that an annual report of quality monitoring is produced and that there is an annual development plan. The registered person must ensure that arrangements are made to find a person to undertake monthly monitoring functions The registered person must ensure that recording and signing of all transactions of service users’ monies is complete and accessible. The registered person must ensure that systems for fire drills and training, COSHH, monitoring of water temperatures and DS0000022738.V309348.R01.S.doc 31/10/06 31/12/06 31/12/06 31/10/06 30/11/06 31/03/07 30/11/06 31/10/06 31/10/06 Joybrook Version 5.2 Page 21 17. OP38 13(5) maintenance of equipment are in line with regulation The registered person must 31/10/06 ensure that all aspects of moving and handling of service users are in place. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP36 Good Practice Recommendations It is recommended that fresh fruit is available in sufficient quantities at all times It is recommended that the registered manager receive supervision to support her in her role. Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. Extracts may not be used or reproduced without the express permission of CSCI Joybrook DS0000022738.V309348.R01.S.doc Version 5.2 Page 23 - 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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