Inspection on 03/11/05 for Joybrook

This inspection was carried out on 3rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Joybrook 15/01/08

Joybrook 23/08/06

Joybrook 14/02/06

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 Ms Rehema Russell Unannounced Inspection 3rd November 2005 10:30 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 DS0000022738.V257788.R01.S.doc Version 5.0 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. DS0000022738.V257788.R01.S.doc Version 5.0 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 Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places DS0000022738.V257788.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st March 2005 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. All communal areas are on the ground floor. There is a lift. The Manager has been at the home for over 12 years and there is a stable staff group. DS0000022738.V257788.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during the late morning and afternoon of 3rd November. The inspector toured the premises, spoke with the manager, deputy manager, two care assistants, several service users briefly, sampled the lunch and looked at documentation and records. 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. DS0000022738.V257788.R01.S.doc Version 5.0 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 DS0000022738.V257788.R01.S.doc Version 5.0 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): 2 and 6 Each service user has a written contract/statement of terms and conditions. Prospective service users and their carers have an opportunity to visit and assess the suitability of the home prior to admission. The home does not accept service users solely for intermediate care. EVIDENCE: All service users have signed contracts on file. Previous reports have raised the issue of whether the contract is a licence or tenancy agreement, and therefore what specific rights service users may have. The manager has conferred with other registered homes in the area and they are gathering more information before an informed decision can be made. It is recommended that the home continues to seek to clarify the situation. It may be that the Commissioning authorities would have a useful view on the question. The manager always visits a prospective service user in their home/hospital/accommodation to assess them prior to admission and the service user is always offered the opportunity to visit the home. This usually takes the form of a visit during the day to see the home and their prospective DS0000022738.V257788.R01.S.doc Version 5.0 Page 8 room, meet staff and other service users and have lunch. The prospective service user is welcome to have an overnight stay also if they so desire. The home does not admit service users solely for intermediate care and so Standard 6 is not applicable to the home. DS0000022738.V257788.R01.S.doc Version 5.0 Page 9 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 and 9 Service users’ health and personal care needs are set out in an individual plan of care. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Four care plans were seen. They were thorough and drawn up with the involvement of the service user. Staff maintain daily records of individual service user’s health/activities/moods and each month this information is used to undertake an assessment of need/review. Any needs arising are then added to the care plan. Care plans components covered a variety of needs and issues, including activities, independence, privacy, medication, mobility, continence, personal care and mental health. Care plan files also contained risk assessments and comments from both the service user and key worker. A member of staff spoken with was fully aware of the care plan relating to the service user for whom they were the key worker. They also said that the manager was very responsive if a key worker felt something should be added to or altered in a care plan. DS0000022738.V257788.R01.S.doc Version 5.0 Page 10 No service users are currently able to self-medicate. The storage, recording and administration of medication was checked and found to be in very good order, including the two tablet-count spot checks undertaken. The manager and acting deputy manager undertake monthly checks of all medication received. DS0000022738.V257788.R01.S.doc Version 5.0 Page 11 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): Service users are supported to satisfy their social, cultural, religious and recreational interests, although there is not currently a weekly activities programme. Service users are given a nutritious and balanced diet in pleasant surroundings. EVIDENCE: The home provides activities such as parties, newspapers, mobile library, games and reminiscence. Six service users attend a Friendly Club once a week at which they participate in shopping and day trips, bowling and tea dances. The home does not currently have a daily activities programme, although one care worker does an exercise class on Mondays, but the manager is currently undertaking 2 courses in activities for elderly people and has advertised for an activities organiser. Evidence was seen of service users being encouraged and supported to continue previous hobbies or interests and the new service user from a visible minority ethnic background is currently seeking membership of a suitable cultural organisation. A group of service users attend Church every 3rd Sunday of the month, one service user is taken to Church regularly by his family and two service users have received regular communion in the past. At the time of the inspection the menus were being re-written to include the forthcoming seasonal changes and the minority ethnic foods being provided for the new service user. Lunch was sampled and was found to be well presented, DS0000022738.V257788.R01.S.doc Version 5.0 Page 12 nutritious and tasty. Staff take a detailed audit after each meal to determine whether serviced users enjoyed the meal by asking for their comments and recording these. These comments then inform the menus devised. Service users spoken with said that they enjoyed the food provided at the home. DS0000022738.V257788.R01.S.doc Version 5.0 Page 13 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): 18 Service users are protected from abuse. EVIDENCE: The manager has obtained and read protection of vulnerable adults policies and trained all staff. The home’s elder abuse policy is very thorough but needs to incorporate the adult protection policy of the local borough, which the manager undertook to do. Observation of an incident during the inspection evidenced that staff understand verbal aggression and deal with it appropriately. Staff spoken with were fully aware of the different types of abuse that may take place towards service users and were aware of how any suspicions must be handled and reported. DS0000022738.V257788.R01.S.doc Version 5.0 Page 14 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, 22 and 26 Service users live in a safe, comfortable environment and have access to safe and homely indoor and outdoor communal facilities. The home is clean, pleasant and hygienic. EVIDENCE: The home is comfortable and homely and there is an on-going programme of maintenance. At the time of the inspection three areas of the home had been refurbished. A new, large and well equipped utility area had been built on the ground floor; a large decking area had been built from the house to the back garden giving a very pleasant area for service users to sit in during better weather; and one ground floor bedroom had been refurbished to a high standard, complete with en-suite toilet and washbasin. There are plans to continue to refurbish the home, to reduce the number of shared bedrooms and to upgrade the facilities. There are three communal areas in the home, excluding the garden and decking. These are all situated on the ground floor and are connected to each DS0000022738.V257788.R01.S.doc Version 5.0 Page 15 other. The first two are lounge areas that consist of one very long room that is divided off into two areas. The kitchen leads off from the first lounge area and the office and a wing of 4 bedrooms leads off from the second lounge area. Double doors at the end of the second lounge area, which can be left open, lead into the dining room area from which there is access to the garden. The new en-suite bedroom occupies an area which also leads off from the dining room. The remainder of the bedrooms (6) are on the first floor, which are accessed by stairs or by lift. On the day of the inspection, the carpet on the first floor hallway was frayed in some places and in need of renewal. The manager said that this would be done before the end of the financial year. ln regard to aids and adaptations there is a chair lift available for bathing and two service users have wheelchairs supplied by the occupational therapist. There was a requirement made following the previous inspection report that an individual occupational therapy assessment is undertaken for each service user needing to use any adaptation or equipment in the home. The manager had contacted the local borough and all service users have been put on the waiting list for an occupational therapist assessment. The kitchen was found to be very well organised, well equipped and thoroughly clean and hygienic. There are monthly maintenance sheets, weekly schedules of cleaning and defrosting and there was evidence that all food is ordered fresh on a weekly basis. Even though the home had not had a cleaner for two months prior to the inspection, the home was clean and hygienic throughout because the care workers had covered the work arising due to the vacancy. They are to be commended for this. The manager was in the process of shortlisting applications for the cleaner position at the time of the inspection. DS0000022738.V257788.R01.S.doc Version 5.0 Page 16 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 and 29 Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times and are protected by the home’s recruitment policy and practices. EVIDENCE: Rotas were seen and evidenced, along with observance on the day of inspection, that the home has at least 2 carers on duty for the early and late shifts and has 2 waking staff each night. In addition, the manager and acting deputy are at the home on each weekday. The acting deputy also works on Saturday mornings and the manager frequently pops into the home at weekends. There is a cook who works daily and a full time cleaner, although the latter position is currently vacant. The manager and acting deputy are both supernumery and they both undertake direct caring work, and so the home exceeds the care staff ratio requirement for a home of this size, both in regard to day and night staffing numbers. Three of the care workers at the home have NVQ Level 3 and four of the care workers were beginning NVQ Level 2 during the month of the inspection. Although the home has therefore not fully met the 2005 training target, it is making good progress. The previous inspection report required that the manager ensure that all new staff begin their induction programme on commencement of employment at the home. Since the previous inspection one new member of staff had joined DS0000022738.V257788.R01.S.doc Version 5.0 Page 17 the staff team, one week prior to this inspection. The inspector saw evidence that this staff member had started induction within 2 days of joining the home, due to be completed within the month, and that she had shadowed a more experienced staff member for her first two days of work. New staff members have a six month probationary period and have monthly probationary meetings during this time. The manager was fully aware of the checks that need to be carried out prior to employment commencing. A member of staff who had been at the home for one year confirmed that a full and proper recruitment procedure had been carried out when they had been employed, including all of the required checks, a signed contract and a probation period. This person’s file was seen and the full required documentation was present. DS0000022738.V257788.R01.S.doc Version 5.0 Page 18 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, 33 and 36 The home is run by a manager who is suitably experienced, qualified and committed to service users’ care. Service users benefit from the ethos, leadership and management approach of the home and the home is run in the best interests of service users. Staff are appropriately supervised. EVIDENCE: The Registered Manager has managed the home for more than 11 years. She has attained the Registered Manager’s Award and has completed threequarters of the NVQ Level 4 in Care. She has a good awareness of the needs and conditions associated with the home’s client group as well as a sensitive understanding of the needs, characteristics and behaviours of individual service users. The manager is a member of the Care Homes Association and uses this, plus contacts with other local registered homes, to keep up to date with developments and changes in the care field. DS0000022738.V257788.R01.S.doc Version 5.0 Page 19 Evidence from observation and from speaking with staff confirmed that the management style at the home is open, supportive and inclusive. Staff said that they feel part of a team, that the manager is approachable, very helpful, encourages comments and suggestions from staff, service users and visitors, and that the two monthly supervision given is always very useful. They said that they especially appreciated that they had time to sit and chat with service users. The manager operates an Employee of the Month scheme whereby service users and relatives/visitors nominate members of staff that they feel have been particularly helpful during the previous month, the winner receiving a Certificate which is displayed in the reception area, and a small cash payment. Staff were proud of the scheme and of winning the Certificate. The majority of care staff have been at the home for over 5 years, which is an indication of their satisfaction with working conditions and of stability and continuity of care at the home. In regard to quality assurance, the registered manager uses the Mulberry House self-assessment quality assurance tool to consistently assess all areas of the service provided at the home. In addition service users are asked to fill out a monthly satisfaction survey, copies of which were seen in the feedback file. There are service users meetings each month, and examples were seen of how comments/request raised at the meetings or via the satisfaction surveys had been acted upon by the home. The home does not currently publish the results of service users surveys but the manager undertook to do this annually and to prepare the first sheet/publication by the end of this financial year. DS0000022738.V257788.R01.S.doc Version 5.0 Page 20 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 2 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 2 X 2 X X X 3 STAFFING Standard No Score 27 4 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 2 X X 3 X x DS0000022738.V257788.R01.S.doc Version 5.0 Page 21 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 OP20 Regulation 23(2)(b) Requirement The Registered Person must renew the first floor hallway carpet to ensure safety for service users and staff. The registered manager must ensure that an individual occupational therapy assessment is undertaken for each service user needing to use any adaptation or equipment in the home. This is a previous requirement which has been progressed by the manager and is awaiting completion by the local authority. The Registered Person must ensure that a survey of service users views is published annually. Timescale for action 30/04/06 2 OP22 23(2)(n) 30/09/06 3 OP33 4(1)(c) Sch 1 10 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000022738.V257788.R01.S.doc Version 5.0 Page 22 No. 1 2 Refer to Standard OP2 OP18 Good Practice Recommendations The Registered Manager should seek to clarify whether the service user contract is a licence or tenancy agreement. The Registered Manager should incorporate the adult protection policy of the local borough into the home’s elder abuse policy. DS0000022738.V257788.R01.S.doc Version 5.0 Page 23 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. 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