Inspection on 20/09/05 for Just Homes

This inspection was carried out on 20th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. 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.

Other inspections for this house

Just Homes 25/02/08

Just Homes 26/06/06

Just Homes 26/04/05

Just Homes 21/12/04

Just Homes 31/07/04

Just Homes 06/02/04

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

CARE HOME ADULTS 18-65 Just Homes 3 Newhill Purley On Thames Reading Berkshire RG8 8AY Lead Inspector Marie Carvell Unannounced Inspection 20 th September 2005 12:40 DS0000011212.V249258.R01.S.doc Version 5.0 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 DS0000011212.V249258.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 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. DS0000011212.V249258.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Just Homes Address 3 Newhill Purley On Thames Reading Berkshire RG8 8AY 0118 962 4887 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) Mrs Pamela Mary Eales Mrs Susan Donovan Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places DS0000011212.V249258.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: Just Home’s Purley aims to provide its service users with a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance. Carers will strive to preserve and maintain the dignity, individuality and privacy of all service users within a warm and caring atmosphere and in doing so will be sensitive to the service user’s ever changing needs. Such needs may be medical/therapeutic (for physical and mental welfare), cultural, psychological, spiritual, emotional and social and the service users are encouraged to participate in the development of their individualised service user plans in which the involvement of family and friends may be appropriate and greatly valued. (Extract from the Statement of Purpose). DS0000011212.V249258.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by the lead inspector for the home, from 12.40pm until 3.40pm. Time was spent with the deputy manager, staff on duty and the three service users. A tour of the communal areas of the home and two bedrooms, at the invitation of the service users were seen. A sample of records required to be kept in the home were examined. At the last inspection in April 2005, six requirements were made, these related to staff training in the administration of medication, protection of vulnerable adults from abuse, basic food hygiene, and fire training, the development of staff recruitment procedures, updating the staff training programme and the updating of all risk assessments and COSHH records. Two requirements have been complied with. Feedback was given to the deputy manager at the end of the inspection. What the service does well: What has improved since the last inspection? The home’s recruitment procedures have been developed. DS0000011212.V249258.R01.S.doc Version 5.0 Page 6 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. DS0000011212.V249258.R01.S.doc Version 5.0 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 DS0000011212.V249258.R01.S.doc Version 5.0 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): Standards inspected at previous visit. EVIDENCE: DS0000011212.V249258.R01.S.doc Version 5.0 Page 9 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): Standards inspected at previous visit. EVIDENCE: DS0000011212.V249258.R01.S.doc Version 5.0 Page 10 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 and 17 Service users enjoy a range of activities and leisure opportunities. A varied and well balanced diet is provided to service users. EVIDENCE: At the time of this visit two service users were preparing to attend the Tuesday Club and Church Club. The third service user stayed at home as she was feeling unwell. Two service users had been out shopping with staff support. Service users are involved as much as possible with menu planning, shopping and preparation of meals. Menus are planned taking into consideration service users food preferences and dietary needs. Mealtimes are flexible to meet service user needs. One service user able to express an opinion said that she enjoyed the food provided. Food stocks were plentiful. DS0000011212.V249258.R01.S.doc Version 5.0 Page 11 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): Standards inspected at previous visit. EVIDENCE: DS0000011212.V249258.R01.S.doc Version 5.0 Page 12 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 The home has a clear complaints procedure. Staff need to receive appropriate training in the protection of vulnerable adults from abuse. This was a requirement made at the last inspection. EVIDENCE: The home has a clear complaints procedure and each service user has a copy of the complaints procedure in pictorial format. Staff on duty were clear about the complaints procedure in the home. The last recorded complaint was in October 2004. The deputy manager was advised to correct some factual inaccuracies in the complaints procedure. At the last inspection the manager was advised to obtain a copy of the MultiAgency procedures on the protection of vulnerable adults from abuse. It was not evident that this been obtained. From a sample of staff training records it was not evident that staff have received appropriate training in the protection of vulnerable adult from abuse. DS0000011212.V249258.R01.S.doc Version 5.0 Page 13 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): 30 The home is comfortable, safe and meets the needs of the service users. EVIDENCE: The home is clean, homely and free from odours. DS0000011212.V249258.R01.S.doc Version 5.0 Page 14 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): 33, 34 and 35 Staff recruitment procedures have been developed. The service users benefit from a consistent staff team. The home’s training and development programme needs updating. This was a requirement made at the last inspection. EVIDENCE: Staff recruitment procedures have been developed and now meet the national minimum standards and regulation. Staff on duty consisted of the deputy manager, a senior support worker and a support worker working from 7.15am until 2.45 pm. At 2.15pm an additional two support workers came on duty to work until 9.45pm. One awake support worker was rostered to work from 9.30pm until 7.30am the following morning. The majority of staff have worked at the home for ten years plus. There is sufficient staff rostered on shifts to meet the needs of service users. The staff training programme was not available for examination by the inspector. The deputy manager advised the inspector that all staff have recently been provided with training in medication administration however. This was not evidenced. From examination of a sample of staff training files it was not evidenced that staff have received training in the protection of vulnerable adults from abuse, basic food hygiene or fire safety training. DS0000011212.V249258.R01.S.doc Version 5.0 Page 15 DS0000011212.V249258.R01.S.doc Version 5.0 Page 16 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): 42 There are some shortfalls in relation to health and safety, which could pose a risk to service users and staff. This was a requirement made at the last inspection. EVIDENCE: A sample of records relating to the recording of hot water temperatures, fridge and freezer temperatures, fire drills and fire detection systems were up to date. It was noted that the hot water temperatures in the bathroom are frequently recorded as being in excess of the recommended safe hot water temperature of 43c. The night support worker referred to in the last inspection report has now received fire safety training. Risk assessments need to be updated. COSHH records and safety data sheets need to be reviewed and updated. The deputy manager requested an additional six weeks to complete this requirement. This was agreed. DS0000011212.V249258.R01.S.doc Version 5.0 Page 17 DS0000011212.V249258.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000011212.V249258.R01.S.doc Version 5.0 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 YA23 Regulation 13(6) Requirement The manager must ensure that all staff receive training in the protection of vulnerable adults from abuse and a copy of the Multi-Agency procedures obtained. The manager must ensure that all staff receive training in basic food hygiene and fire safety procedures. The manager must update the home’s staff training programme and send a copy to the CSCI The manager must ensure that all risk assessments are updated and all COSHH records are reviewed and updated. That the manager ensures that the hot water temperatures are maintained at the recommended safe temperatures at all times. This was discussed with the deputy manager at the time of inspection. Timescale for action 20/11/05 2 YA35 12 20/11/05 3 4 YA35 YA42 18 13 20/11/05 20/11/05 5 YA42 13 21/10/05 DS0000011212.V249258.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000011212.V249258.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000011212.V249258.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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