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Inspection on 24/05/06 for Jubilee House Jonquil Close

Also see our care home review for Jubilee House Jonquil Close for more information

This inspection was carried out on 24th May 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The organisation including the staff team continues to embrace and deliver on the National Minimum Standards for Young Adults. The inspection main finding is that 20 of the 27 standards assessed (74%) meet the National Minimum Standards; 4 of these Standards have been exceeded. Information gathered from staff members, records and observation of care practices confirm the core values as well understood by the staff team. The staff members appear to have a thorough knowledge of service users and their individual needs. The service offered is of a good standard and it is able to meet the social and health needs of people with complex needs and a range of dependency. Evidence shows that the health and personal care needs are being identified and addressed satisfactorily. Given the severe learning disabilities of the service users accommodated, it was not possible to gain any accurate information about their views and experience regarding the quality of services they receive. They however appeared to be very happy and relax amidst their peers and in the company of staff members. Staff members are conversant with the home`s procedures on Adult Protection and information gained suggests that staff`s response to any issue relating to the protection of a resident, would be dealt with quickly and appropriately. Significant incidents are notified to various authorities including the Commission. The protection systems including staff recruitment are adequately robust to ensure the safety of service users.The building and all areas viewed were found to be fresh and clean. The accommodation is homely, comfortable and furnished to a high standard. Service users are encouraged to make it their home through inclusion in the decision-making process, as appropriate. Health and safety matters are being attended to. Staffing arrangements remain satisfactory; staff training continues to be given a high priority. The inspection indicates that the service is well run, with highly motivated and well - trained staff who related well to the service users.

What has improved since the last inspection?

The home has acquired a mini-bus suitable for wheelchair users. Staff spoken with said that they are now able to access a greater level and variety of outside activities for the service users. A significant development is the Organisation`s plan to refurbish the kitchen; this would on completion, no doubt, complement the high standards in the rest of the premises. Mandatory training for the staff team including Adult Protection has further reinforced the protection of vulnerable adults from harm.

What the care home could do better:

There are 5 requirements (including 2 outstanding from report dated 11.01.06) and 2 recommendations arising from this report; these need addressing. The service user`s guide requires updating and a copy must then be provided to the Commission, each service user and their relatives as appropriate. The care plans must reflect how identified needs would be met, timescales for implementation and the review dates. In terms of health and safety, the worn out kitchen worktops must be replaced (an outstanding requirement). The recruitment files for staff requires some attention. A quality monitoring system for seeking the views of service users and significant others is required (an outstanding requirement). It would be good practice to obtain the signature of the relative or Social Worker as appropriate, in the tenancy agreement. NVQ assessment should be given a higher profile, in order to meet the stated standard. Also, the Manager should demonstrate more clearly that the service user and their relatives are being informed about their rights to confidentiality and access to records retained about them.

CARE HOME ADULTS 18-65 Jubilee House Jonquil Close 29 Jonquil Close Panshanger Welwyn Garden City Herts AL7 3HX Lead Inspector Mr Neil Fernando Key Unannounced Inspection 24th May 2006 10:30 Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee House Jonquil Close Address 29 Jonquil Close Panshanger Welwyn Garden City Herts AL7 3HX 01707 391113 01707 394022 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) Jubilee House Care Trust Limited Michael John O`Connell Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 Brief Description of the Service: Jubilee House, Jonquil Close, is a 6-bedded purpose-built bungalow for high dependency service users. Services are offered to younger adults with a learning disability, and those with an additional physical disability. The home is situated in a residential area of Welwyn Garden City and the town centre, with its wide range of facilities, is about a mile away. The property is leased through a housing association. There is ample car parking for the home and a minibus is provided for the service users to facilitate outings. The weekly placement fee for each service user is £ 1198: 23. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection for the inspection year 2006/7. The last inspection (Unannounced) was undertaken on 11.01.06. Jubilee House, Jonquil Close is one of a number of Care homes managed by Jubilee House Care Trust Limited in the Hertfordshire area. It is registered to accommodate up to 6 younger adults with a learning disability, of both genders, who may have an associated physical disability. On the day of the visit, there were 6 people in residence. Service users arrived home from day services and were observed to be very content. This unannounced inspection took place during the latter part of May 2006. During this visit, all service users and 7 staff members including the Registered Manager were spoken to, in order to seek their views regarding the quality of life for residents at Jubilee House, Jonquil Close. A number of records were examined and a tour of the premises was also undertaken. What the service does well: The organisation including the staff team continues to embrace and deliver on the National Minimum Standards for Young Adults. The inspection main finding is that 20 of the 27 standards assessed (74 ) meet the National Minimum Standards; 4 of these Standards have been exceeded. Information gathered from staff members, records and observation of care practices confirm the core values as well understood by the staff team. The staff members appear to have a thorough knowledge of service users and their individual needs. The service offered is of a good standard and it is able to meet the social and health needs of people with complex needs and a range of dependency. Evidence shows that the health and personal care needs are being identified and addressed satisfactorily. Given the severe learning disabilities of the service users accommodated, it was not possible to gain any accurate information about their views and experience regarding the quality of services they receive. They however appeared to be very happy and relax amidst their peers and in the company of staff members. Staff members are conversant with the home’s procedures on Adult Protection and information gained suggests that staff’s response to any issue relating to the protection of a resident, would be dealt with quickly and appropriately. Significant incidents are notified to various authorities including the Commission. The protection systems including staff recruitment are adequately robust to ensure the safety of service users. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 6 The building and all areas viewed were found to be fresh and clean. The accommodation is homely, comfortable and furnished to a high standard. Service users are encouraged to make it their home through inclusion in the decision-making process, as appropriate. Health and safety matters are being attended to. Staffing arrangements remain satisfactory; staff training continues to be given a high priority. The inspection indicates that the service is well run, with highly motivated and well - trained staff who related well to the service users. 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. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. The staff team including the Manager understand and appreciate the need to support the service user and their family to make an informed decision regarding the suitability of the home. The service user’s guide requires updating to suit the people the home accommodates; also, the signature of the next of kin/Social Worker should be reflected in the tenancy agreement. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be adequate. EVIDENCE: A service user’s guide is available but considering the severe learning disabilities of the current service users, the content and format require significant amendments, in order to suit the needs of the people the home accommodates. The Manager is aware of the above issues and the need for remedial action. Once the guide is updated, a copy must be provided to the Commission, each service user as appropriate and their relatives. Records show that all of the current service users were accommodated a significant number of years ago (last admission to the home – 5 years back), prior to the National Minimum Standards becoming operational. In spite of this staff members including the Registered Manager are clear that any prospective service user and their family will be fully supported by the care staff team, in order to enable them decide if the home is suitable to meet their needs. Also, every opportunity would be given for the prospective service user, their relatives and significant others to visit the home and assess for themselves the Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 9 services offered and the suitability of the home. A minimum ‘settling in’ trial period of residence would then be offered, followed by a placement review with the service user, Social Worker, their relative and other professionals if required. Personal files examined for all 6 residents contain licence agreements that set out the terms and conditions of staying in the home. It is clearly inappropriate for any of the current service users to sign the agreement; with this in mind, it is recommended that the signature of the relative or Social Worker should be obtained. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. The care planning process involves the service user and their relatives; this ensures that their wishes and preferences are taken into account. The care plan however requires improving in order to adequately reflect how the identified needs would be addressed, timescales and the review dates. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Information gathered demonstrates that the service user’s care plan is drawn up from a range of assessment of needs including Social Worker’s reports, input from family representatives, staff’s on going assessment and contributions from any other professional as appropriate. Care plans for the 6 service users were examined. These provide a core of information covering personal care, medical health, mobility, eating and drinking, communications, activities and leisure, behaviour, cultural and spiritual elements. The care plans however do not reflect how identified needs/requirements would be met, timescales for implementation and the review dates. “Residents’ meetings” are held monthly however, staff members mainly learn about individual wishes, feelings and preferences through daily observations of Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 11 body language, facial expression and other behavioural indicators. The home is linked to an external advocacy group and referrals are made as appropriate. This demonstrates the home’s commitment to expanding the service users’ influence over their lives. Each service user has an individual risk assessment and management as appropriate, which covers various areas including mobility, manual handling and daily activities on and off the premises. All risk assessments are formulated with service users’ safety and welfare in mind and are not restrictive as such. The quality of records maintained is very good. The home has procedures for responding to absences without authority. Staff members demonstrated an excellent understanding of their responsibilities to respond promptly to unexplained absences. There have been no service users missing from the home during the previous twelve months. Evidence gathered suggests that staff respect information given by service users in confidence. Records regarding the residents are compiled and stored in accordance with the Organisation’s written procedures and the Data Protection Act 1998, and in their best interests. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 and 17. The service users appeared to be well supported to enjoy a full and meaningful life. An excellent level and variety of social and recreational activities is being facilitated; this appears to assist in the development and promote the welfare of service users. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Progress records demonstrate that the service users have good access to the local community resources. Information available also suggests that the staff team and residents have worked very hard at building positive relationships with neighbours. The location of the home in Welwyn Garden City allows easy access to community facilities and shops. The town centre is only about a mile away and offers a wide range of facilities including shopping and recreational activities. All six care plans and the monthly activities programme were examined; these provide details of the identified social and recreational activities enjoyed by the service user. Staff duty rotas is organised in such a manner to ensure staff availability to facilitate planned activities for the residents. Good evidence is Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 13 available to demonstrate that leisure interests take into account religious and cultural needs as well as individual preference and the pattern followed in the resident’s previous home. The home has acquired a mini-bus suitable for wheelchair users. Staff spoken with said that they are now able to access a greater level and variety of outside activities for the service users. Information available demonstrates that excellent assistance is available from staff members, in order to facilitate/access activities for the residents. In the main, the level and variety of social and recreational activities offered appeared to be very good. Information gained indicates that promoting the rights of the service user is central to the philosophy of this establishment. Residents’ rights are upheld through policies and procedures and on going staff training and supervision. Service users appeared to be very happy with the food that was presented to them. Menus list examined is well balanced and varied. A cooked meal is normally available in the evening, as all of the current service users attend a Day Centre on weekdays. Residents have access to hot drinks and snacks as required. Dietary requirements of each person according to cultural, religious observations and particular needs are catered for. Specialist dietary advice can be accessed as required. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. All personal and health care support is well maintained; hence ensuring that individual needs, choices and preferences are met at all times. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Care plans seen detailed individual personal and healthcare needs. For example, records seen referred to a service user’s health, mobility and medication issues, with information on the level of support required. In more general terms, staff provide appropriate support/guidance to service users regarding health matters, personal hygiene, suitable presentation and dress and so on. All 7 staff members including the Manager interacted with residents in a friendly and helpful manner. Staff members spoken to demonstrated good knowledge of individual needs and evidently were able to address them sensitively and appropriately. Service users were physically well presented and dressed in clean and appropriate clothes. Considering that 2 of the service users are wheelchair dependent and all have severe learning disabilities, they are all dependent on staff assistance to meet their physical and emotional health needs. Evidence indicates that they receive adequate and appropriate support to address their physical and emotional health needs. Staff are aware that any restriction on personal Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 15 freedom must be fully justified on therapeutic grounds and agreed on a multidisciplinary basis with other care/health professionals and relatives, and these would be documented in individual care plans. All service users are registered with a GP; other professionals, residents have access to include Optician, Dietician, Dentist, Podiatrist, Community Nurses and other specialist professionals. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Service users or (more likely) their relatives and significant others are adequately empowered to make a complaint. Systems in operation including adult protection and notification of significant incidents to appropriate authorities, should offer adequate protection to a resident. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Information regarding how to make a complaint is included in the service user’s guide and the home’s statement of purpose. Staff members interviewed including the Registered Manager reported that the procedures on complaints are available and accessible to all staff members, relatives and professionals as appropriate. Members of staff demonstrated a good understanding of the need to investigate and record all complaints, including remedial action taken, if any. Information gathered suggests that staff routinely inform residents about the complaint procedures. Given the severe learning disabilities of the residents accommodated at the time of the visit, it was not appropriate to seek their views, in order to gain any accurate information regarding this subject. They however appeared to be very happy and relax amidst their peers and in the company of staff members. Complaints record examined indicates that there has been one minor complaint made by a parent since the last inspection on 11 January 2006. Overall, information available suggests that the management of complaints is satisfactory. A copy of the Hertfordshire inter-agency adult protection procedures is available and accessible to the staff team. Staff members spoken to confirmed Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 17 that they are familiar with the procedures. Staff members have received training on Adult Protection; an element on this subject is also covered in the induction programme for all new staff members and those people undertaking the NVQ assessment. There were no adult protection matters pending at the time of the inspection; there have not been any staff members referred to the POVA and POCA Registers. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The premises provide a safe, comfortable and homely environment suitable for the needs of service users. The standard of cleanliness was high. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: The building is spacious and airy, with single bedrooms; the communal lounge/diner is very spacious. There is also an impressive sensory room, equipped with numerous devices to provide a very attractive facility for sensory stimulation, relaxation and leisure. All bedrooms seen are painted different colours chosen by the residents and are thoroughly personalised to reflect the tastes and interests of the occupants, with gadgets, pictures and hobby materials. Furniture and fittings in all areas viewed are of a domestic type and of good quality. Specialist equipment is provided such as tailor made wheelchairs, assisted bathing facilities and hoists. However, as indicated in the last inspection report dated 11.01.06 the kitchen is showing signs of age. The laminate on the kitchen worktops is worn out in places, creating a potential bacteria trap that represents a food hygiene risk. The Manager reported that the plan is to refurbish the kitchen. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 19 A high standard of cleanliness was evident throughout those areas viewed. There were no mal-odours present. The laundry facility is suitable and adequate for the residents accommodated. There are infection control policies and procedures in place. The arrangements for the storage and collection of domestic and clinical waste remain satisfactory. There were no health hazards noted. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 36. The day and night staffing arrangements meet the needs of the current service users. Staff recruitment process is robust, but some attention is needed to fully meet the requirement of Schedules 2 and 4.6 of the Regulations. NVQ assessment for care staff should be given a higher profile. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Staff duty roster for a period of one month was scrutinised and discussion with staff members including the Registered Manager indicates that staffing levels are adequate to meet the needs of service users. Information gathered indicates that staff members have adequate experience and skills to enable them deliver a good service to the resident group. The home has not yet achieved the 50 NVQ Level 2 for its staff. 3 care staff (33.3 ) have completed their assessment and another member is currently undertaking the same course. NVQ assessment should be given a higher profile, in order to meet the stated standard. Evidence demonstrates that teamwork and communications in the unit are good and staff members felt well supported by senior colleagues, with shift handovers, regular team meetings and annual appraisals. The Registered Manager was said to be approachable, helpful and very constructive. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 21 The home follows the Organisation’s procedures for the recruitment and selection of staff members. The recruitment files for 6 staff members including the latest recruit were scrutinised and these were found to be in order, except for a current photograph and CRB check certificate not being available in 4 of the 6 cases. The Manager said that the CRB check certificates are stored at the Head Office, although some written confirmation was available to show that these checks had been completed. It is however positive to note that all members of staff spoken to reported that they have had their CRB checks completed. Information available indicates that staff members are being offered formal supervision within the stated frequency. All staff members interviewed expressed a good deal of satisfaction regarding the quality of supervision they received. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 40, 41 and 42. The Registered Manager has the appropriate qualifications, knowledge and experience to manage this establishment. The home is well run, with a committed staff team and an open and inclusive atmosphere. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: The relationship between the service users and the staff is positive and interactions observed are conducive to commendable standard. The ethos and management approach of the home creates an open, positive and inclusive atmosphere, and staff spoken to felt well supported. There is a clear commitment to equal opportunities within the home. The home has a range of policies and procedural guidelines, which are being implemented to good effect. Staff are requested to read and sign risk assessments and policies and procedures. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 23 Statutory records viewed were found to be maintained and stored in accordance with legislation. The Manager should however demonstrate more clearly how the service user and their relatives are being informed about these issues and their rights of access to records retained about them. Staff members receive ongoing training that ensures safe working practice. Disinfectant and cleaning materials are stored in locked cupboards and care is taken by staff members to ensure that service users are not exposed to any hazard. Mandatory training has been facilitated and risk assessments for each service user are in place. Fire equipment and the fire alarm system including smoke detectors and emergency lighting are serviced within the required frequency; fire drills and weekly tests of break-glass points are carried out as required. Hot water temperature is tested regularly and portable electrical appliances are checked, tagged and a record maintained. Overall, health and safety matters appeared to be attended to. Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 x 3 x 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 x 30 4 STAFFING Standard No Score 31 x 32 2 33 3 34 2 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 4 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 4 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x 4 X X 3 2 3 3 Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 5 Requirement A service user’s guide that is suitable to the needs of people the home accommodates must be available; An updated copy must then be provided to the Commission, each service user as appropriate and their relatives. Care plans must reflect how identified needs/requirements would be met, timescales for implementation and the review dates. The worn out kitchen worktops must be replaced to maintain good hygiene and prevent infection. (Outstanding requirement arising from report dated 11.01.06). Staff’s recruitment files must include all documents as detailed in Schedules 2 and 4.6 of The Care Homes Regulations 2001. The home must ensure that there is an effective quality monitoring system based on DS0000062294.V296306.R01.S.doc Timescale for action 31/08/06 2 YA6 15 24/08/06 3 YA24 13 & 16 31/08/06 4 YA34 17 (2) & 19 (1) (b) (i) 24/07/06 5 YA39 24 24/08/06 Jubilee House Jonquil Close Version 5.2 Page 26 seeking the views of the service users, their representatives and other stakeholders, for the purpose of reviewing and improving the quality of care provided at the home. (Outstanding requirement arising from report dated 11.01.06). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA5 Good Practice Recommendations Considering the severe learning disabilities of the service user, the tenancy agreement should reflect the signature of the relative or Social Worker, as appropriate. NVQ assessment should be given a higher profile, in order to meet the stated standard. A system should be instituted, in order to demonstrate more clearly that the service user and their relatives are being informed about their rights to confidentiality and access to records retained about them. 2 3 YA32 YA41 YA10 Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Jubilee House Jonquil Close DS0000062294.V296306.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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