Inspection on 25/07/07 for Juniper House

This inspection was carried out on 25th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Juniper House 16/09/08

Juniper House 06/03/07

Juniper House 19/01/06

Juniper House 14/07/05

Juniper House 11/02/05

Juniper House 20/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Juniper House 159 Strathmore Avenue Luton LU1 3QR Lead Inspector Ansuya Chudasama Unannounced Inspection 25th July 2007 02:30 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 Juniper House DS0000015013.V346538.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. Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Juniper House Address 159 Strathmore Avenue Luton LU1 3QR 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) 01582 419923 albute.3@ntlworld.com Mrs Audrey Greer Mrs Audrey Greer Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: Juniper House is a small home for three service users with learning disabilities. The home was owned and managed by Mrs Audrey Greer. A small staff team are employed and work closely with service users. The home is situated in a residential of Luton, close to shops and other amenities. The building is a detached house with four single bedrooms. The ground floor has a lounge, dining room and the kitchen with washing machine. An enclosed garden with a patio was accessed from the kitchen. The home charges between £600 and £700 per week for the care, depending on the individual needs of the service user. Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited the home without telling any one that she was going to visit on Tuesday the 24th of July 2007. The people living in the home were having their lunch in the garden and enjoying themselves. One of the people living in the home told the inspector that they did not go to the day centre today. This was because they had their hair cut at the hairdressers and they were getting ready to go on holiday to Wales on Saturday. The inspector spoke to the manager and another member of staff who was on duty. She talked to the people using the service, and asked staff about those people’s needs. She also looked at the care plans, medical records and daily notes for one of the people. This is called case tracking. She watched a member of staff and one of the people living in the home prepare the evening meal. She also looked around the house. At the time of the inspection there were three people living in the home. The home did not have any vacancies. The registered manager had completed the annual quality assurance assessment document that was sent by the CSCI and the information from this record has been used in this inspection report. The inspector would like to thank the manager, staff, and the people living in the home for their time in helping with this inspection. This inspection report should be read alongside the National Minimum Standards for Younger Adults (18-65). What the service does well: The people living in the home are provided with a homely environment. They go on holidays, and day trips. They choose where they want to go with help from the staff. They choose their meals for the weekly menu. They also like living at the home and they like their bedrooms. One person living in the home had a birthday a few days ago and told the inspector “I went for a meal and I chose Chinese food and went to the pictures” which the person enjoyed very much. It was also said that the “staff help us” and “I like them”. The staff on duty was seen treating the people living in the home with respect and talking to them in a positive manner. The staff stated that they enjoyed working at the home and liked the people living in the home. The manager was said to be very supportive to staff. She had meetings with the staff to Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 6 make sure that they were doing things that they should be doing in the right way. The people living in the home have their health care needs looked after very well by staff. When staff give out medication they do it in a safe way. Staff receive training to help them meet the needs of the people living in the home. 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. The summary of this inspection report can be made available in other formats on request. Juniper House DS0000015013.V346538.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 Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users are able to visit the home and have the information needed to help them make an informed choice about moving into the home EVIDENCE: The home had a statement of purpose and a service user guide. Some of the information on staffing needed to be updated because some of the staff were no longer working at the home. All the people using the service had contracts and these were in picture format. Information on fees charged by the home was recorded in their files. Evidence showed that a new person using the service that was admitted to the home had a needs assessment undertaken by the home. The manager stated that an advocate was also involved in the process and a visit to the home was also undertaken. The manager had also visited the potential service user in their own placement to gather information and to discuss information about Juniper house. The manager stated that she Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 9 would not admit any person to the home unless she and the staff felt that they would be able to meet their needs. It was also emphasised that they would not admit any one to the home unless they were able to get on well with the other people living in home. Evidence showed that the three people in the home were observed to be getting on well together. Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home had care plans for the people using the service but these needed reviewing to ensure that the staff had the information needed to meet the needs of the people living in the home. EVIDENCE: All the people living in the home had care plans. The care plan of one of the people that was case tracked had not been reviewed since an advocate who was representing this person did this. This was because the person was not able to understand the information due to their disability. The manager stated Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 11 that she was going to complete new care plans for all the people living in the home when she returned from the resident’s holiday. All the people living in the home had annual reviews by their funding authorities. Review’s carried out by the day centre was also discussed at these meetings and copies of these were seen in the file of the person that was case tracked. The manager stated that all the reviews commented that since the service users came to live at the home, their behaviours had improved. The manager stated that one of the people living in the home had a person centred planning (PCP) folder. The day centre and the home completed this. It was stated that because the PCP file belonged to the person using the service, they were given the choice to keep the file where they wanted to. This person had decided to keep the file at the day centre. The manager stated that she would ask the person that the file belonged to if they could keep a copy of this file in the home. The manager stated that the home would involve the day centre when they start to do a PCP folder for the new person admitted to the home. The manager stated that one of the people living in the home attended a private day care facility. She was going to ask the manager from the centre to help undertake this persons PCP folder. The manager stated that she and another member of staff were going to attend the person centred planning training on the 7th of September 2007 to get a better understanding of this planning. The manager stated that they listen to the views of the people living in the home by staff having a one to one with them. They also had monthly service users meetings, and yearly reviews by the funding authority and day centres to discuss their views and discuss their goals. The staff also sat with the people using the service at meal times to listen to them about what they had to say about every day needs. It was stated that due to their requests, the home had made many positive changes. For example the people had takeaways of their choice once a month, and they went out with staff on a one to one basis when celebrating their birthday. The home had risk assessments for the people living in the home. The risk assessments inspected for the person that was case tracked showed that these had not been reviewed. The manager confirmed that these had not been updated due to having to work shifts. This was because a member of staff left and the manager had to work on the rota. It was stated that she has not been able to employ a suitable staff to care for the people living in the home. The manager and staff on duty had very good understanding of the risks and needs of the person that was being case tracked and of other people living in the home. The individual files of the people living in the home were kept locked in the office. Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people using the service are offered a variety of educational activities to develop their personal and independent living skills. EVIDENCE: On the day of the inspection the people living in the home were having lunch in the garden and enjoying themselves. The inspector was informed that they had all been to the hairdressers to have their hair cut. This was because they were going on holiday on Saturday. Observation and discussion with the people showed that they were all very exited about the holiday. Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 13 Two of the people living in the home attended day care five days a week. This also included going to college three times a week for one of the people living in the home, and they enjoyed this. One person living in the home attended day care two days a week. The other days were spent on a one to one basis with staff on improving the person’s independent living skills. This included doing their laundry, cleaning their room and making their bed and helping with lunch. Another day was spent going out in the community to places that the person enjoyed with staff. The people living in the home helped out with hovering, and laying and clearing the dining table after having their meal. They also helped with meal preparation and this was observed on the day of the inspection. The home had meetings with the people living in the home once a month. It was said that the staff asked them if they liked the food, discussed fire safety, and talked about holidays. For example the people living in the home asked for certain meals and the out come was that they now have a takeaway once a month of their favourite food. All the people living in the home celebrated their birthdays by doing what they wanted. For example one person told the inspector that they went to the pictures and had her favourite meal for their birthday and enjoyed this. The people using the service went out for picnics, day trips, holidays, shopping and ate out. They also went to the cinema, discos, pubs, and had a video nights in the home. One person’s file checked had a diabetes management plan and this had information on “eating for diabetes guidelines”. The staff spoken to stated that there were two people living in the home who were diabetics and she understood their needs. The people living in the home chose the meals and liked the food. Only one person living in the home had a family who visited once a week and they had tea with the person at the home. The home welcomed friends and families of the people living in the home. A member of staff, who retired, also visits one of the people living in the home and takes them out on special occasions. The manager has been trying to get an advocate for the people using the service. Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Systems were in place to ensure the people using the service had good personal and healthcare support to meet their needs. EVIDENCE: The manager stated that the people living in the home choose their own cloths and the staff would never buy any thing without the person being with them. Personal care was stated to be given in the person’s own room and having staff of the same gender. The person living in the home that was case tracked had an individual care plan on how to manage the person’s diabetes. The district nurse had completed this plan. All the staff had the training on diabetic awareness. The Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 15 manager had completed the medical plan and had started the behaviour management care plan. The community outreach Officer had provided the home with behaviour management guidelines for the person living in the home. The guidelines needed to be reviewed as these were completed in October 2002. The manager stated that some one from Twinwoods Resource Centre was coming to the home on the 10th of August to undertake training on managing behaviour and autism. The manager was going to ask this specialist person to review the behaviour guidelines. The medication records inspected for the person living in the home were kept satisfactorly. Appointments were recorded well. Some of these included, going to the dentist, opticians, chiropodist, and the audiology department. Appointments to the GP for monitoring the person’s diabetes were also recorded well. Regular blood tests and specialist appointments at the hospital were also recorded. Weight charts were being completed properly. The home also kept a chart for when the people bruised themselves. It was stated that this was monitored by the GP and social services were also involved with this monitoring. The home had Health Action Plans (HAP) for the people using the service. HAPs are a fundamental part of the Governments ‘Valuing People’ document and considered best practice for people with a learning disability The two people living in the home had procedures sent to them by the funding authority to tell them what to in the event of death or illness occurring for these people. The manager was going to ask the family of the new person for information on dealing with illness and death. Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The staff in the home understands the procedures for protecting the people who use the service to ensure that they are kept safe. EVIDENCE: The home had a complaints policy. The manager stated that she was going to make this in a format that was easy for the people living in the home to understand. However it was stated that this was discussed with the people living in the home at their meetings and at meal times. It was stated that two of the people were able to verbally tell staff or the manager or the day centre if they were not happy. The manager stated that the actions and words used by the other person living in the home would tell if the person was not happy. The home has not received any complaints. Two new staff had not been on a training course on protecting of vulnerable adults. The rest of the staff had this training. The manager stated a member of staff who had recently attended this course had fed back to the team at their team meetings and gave them up to date information on this issue. It Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 17 was also stated that all the staff read the policies and procedures on protection of vulnerable adults when they start work at the home. The new staff on duty was spoken to regarding their understanding about protecting vulnerable adults. They had covered this in their induction and NVQ level 2 training. The member of staff was able to give examples of behaviours and words that one of the people living in the home used when they were not happy, and when they were happy. It was also stated that the staff would inform the manager if they though any of the people living in the home were being abused in any way. The manager also had very good understanding of the needs and behaviours displayed by the people living in the home. She also had good understanding of the procedures to follow if any one made an allegation of abuse. The file case tracked for the person living in the home had information on how their money was being managed. It was also stated that when the person had their an annual review, the funding authority also monitored the person’s finances to make sure that their money was being managed appropriately by the home. The money and records checked were correct for this person. Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people using the service live in an environment that is homely and meets their needs. EVIDENCE: The house was clean and tidy on the day of the inspection. The home is well decorated, and each person living in the home has been able to help with choosing the colour schemes both in their own room and in communal areas. Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 19 The manager stated that one of the people living in the home some times had accidents and this stained the carpet. The manager said that she was going to replace the carpet in the room with a suitable replacement that met the needs of the person. The manager said that she needed to discuss this with the person the room belonged to get their consent and get them involved. The person the room belonged to stated that they wanted to change the colour of their room. The manager agreed to help with this. The toilet and bathroom had a new door. The manager confirmed that the bathroom was being re modernised, as this was needed. It was also stated that in the future she was going to change the dining room into another bedroom with en-suite facilities. The main lounge would therefore become a dinning room with lounge. Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people living in the home are protected by the homes recruitment procedures and staff have good understanding of their needs to ensure their individual needs are met. EVIDENCE: The manager stated that when any staff attended any training courses, they feed back to the team at their staff meetings. The last meeting was held on the 7th June 2007. The staff meetings were held every two months but the manager also spoke to the staff on a day to day basis and she was available for advice as and when required by staff. Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 21 All the staff except for the new staff who started recently had not completed the Mental Capacity Act training. These staff were to undertake this training later on in the year. The new staff at present had completed the induction part of Learning Disability Award Frame work accredited training (LDAF). The staff were waiting for confirmation to state that they had passed the course so they could continue to complete the foundation module. The staff training records showed that they had all completed the fire, food hygiene, manual handling, first aid, diabetic awareness and medication training. Some of the staff were doing the health and safety training through the distance learning route. One staff was doing the infection control training and another staff was doing the safe handling of medication through distance learning. The staff were also having training provided by Twinwoods Resource Centre on managing behaviour and autism in August 2007. 50 of the staff in the home had achieved NVQ level 2 and some were doing NVQ level 3. The manager and another member of staff were going to attend the person centred planning training on the 7th of September 2007. The home had low rates of turn over and sick leave and did not use agency staff. The staff team also reflected the cultural and gender composition of the people living in the home. The home had a member of staff leave after they had completed all their training with the home. The manager worked these hours. It was stated that once the manager appointed a new senior carer to the home, the manager was going work less hours. This was so she could have more time to work on her managerial side of her job. The manager stated that finding the right staff to work with the people living in the home was proving to be difficult. However she was going to advertise in the local paper for a senior position. The manager stated that she supervised all the staff and a list of the names of the staff with dates of supervision was displayed on the wall. The supervision notes were kept in a blue folder and locked in a cabinet. The staff on duty confirmed that she was getting supervision every two months and the manager was available to talk to staff out of work time. The staff also enjoyed working at the home and with the people living in the home. The staff recruitment files inspected all had CRB checks, two references, copies of their passport, birth certificate, and driving licence. Other information stated in the standard was also available in the staff files. Juniper House DS0000015013.V346538.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager has good understanding of the areas that need improving to protect and meet the needs of the people living in the home. EVIDENCE: The manager has many years experience of managing the home. She has the qualification in NVQ level 4 in management and care. The manager has a good understanding of the areas in which the home needs to improve. This was also discussed in the AQAA document completed by the manager. The manager Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 23 stated that due to being short of staff, and having to cover the shifts on the rota, she had found it difficult to make the improvements on the managerial side of the task. It was stated that once the manager appointed a new senior carer to the home, she was going to work less hours. This was so she could have more time to work on reviewing all the care plans and risk assessments. The AQAA completed by the manager also confirmed that the home needed to review the care plans and risk assessments on a six monthly basis. The manager stated that finding the right staff to work with the people living in the home was proving to be difficult. However she was going to advertise in the local paper for a senior position. The manager stated that she and the staff were very motivated and very committed to meeting the needs of the people living in the home. They also had a very good understanding of their needs and this was observed on the day of the inspection. The staff spoken to stated that the manager was very supportive and she was available for advice when needed. The home had written assessments on hazardous substances (COSHH) file. There were risk assessments for fire, kitchen, bedrooms, upstairs and down stairs hallway, the electrical cupboard, food and drink, administration of medication, garden steps, lounge, bathroom, use of kitchen equipment, transport, and smoke detector testing. However the risk assessments had not been reviewed since October 2005. The manager stated that she would review these when she returned from the service users holiday. The manager stated that she checked the smoke detectors every week. The home had a fire emergency plan. The manager stated that she had not carried out a service users survey this year. However it was stated that staff had service users meetings every month and their suggestions were always put into practice. It was also stated that the staff sat with the people living in the home at meal times and listened to them about what they would like to do and things that they would like to change in the home. The service users views about the home were also asked at their annual reviews. The manager stated that she would carry out a service user questionnaire in the home. Juniper House DS0000015013.V346538.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 3 2 3 3 3 4 3 5 3 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 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 X Juniper House DS0000015013.V346538.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 YA6 Regulation 15(1) Requirement Individual care plans must be available and reviewed to ensure all staff are aware of how to meet service users needs. The timescale of 30/06/07 was not met Risk assessments must be completed to ensure the safety of service users both inside and outside the home. The timescale of 30/06/07 was not met Timescale for action 30/10/07 2. YA9 13(4)(b) 30/10/07 Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 26 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 3 4 Refer to Standard YA22 YA1 YA27 YA39 Good Practice Recommendations Provide the complaints procedure in a format that the people living in the home can understand Up date the statement of purpose Modernise the bathroom and toilet Undertake a Service User questionnaire to get their views of how the home is meeting their needs Juniper House DS0000015013.V346538.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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