Inspection on 26/04/05 for Just Homes

This inspection was carried out on 26th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Just Homes 25/02/08

Just Homes 26/06/06

Just Homes 20/09/05

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 26 April 2005 08:30am 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 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 Stationary 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. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Just Homes Address 3 Newhill Purley-on-Thames Reading Berkshire RG8 8AY 0118 962 4887 N/A N/A Mrs Pamela Mary Eales Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Susan Donovan Care Home 3 Category(ies) of Learning Disability (LD) - 2 registration, with number Learning Disability over 65 years of age of places (LD(E)) - 1 JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21/12/04 Brief Description of the Service: Just Homes 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 allservice users within a warm and caring atmosphere and in doing so will be sensitive to the service users 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). JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection on a week day morning over a period of four hours. A tour of the communal areas of the home and one bedroom, at the invitation of the service user was seen. A sample of service user, staff and health and safety records were examined. Time was spent with the three service users during the inspection including joining service users for the midday meal. Time was also spent with the three staff on duty, individually and as a group. Brief feedback was given to the shift leader at the end of the inspection and to the manager, by telephone some days later. At the last inspection three legal requirements were made. Two related to recording accurately on the duty roster staff on duty, management hours recorded on the duty roster and developing the home’s recruitment procedures. Two requirements have been complied with and the third requirement will be checked at the next inspection, as it was not possible to see staff personnel files. What the service does well: Care is provided flexibly around the needs of the three service users and the service enables service users to make individual choices about their preferences. Service users are treated with respect and dignity and their views and those of their relatives regularly sought, through reviews and key worker meetings. The service has good activity plans, and a professional and well motivated staff team which ensures good rapport between service users and the staff team. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 6 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. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 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 standard(s) 2,4 and 5 There is a detailed admissions procedure, which includes a full assessment of need and a programme of introduction to the home. Copies of contracts between the service provider and purchasing authority are on file. EVIDENCE: The three service users have lived together in the home for many years. One service user’s records were examined. Information regarding the initial assessment and background information was available on file and well documented. Care management, healthcare and social assessments are regularly reviewed and updated. Each service user has a copy of the home’s Service User Guide, which includes terms and conditions. This is in pictorial format. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 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 standard(s) 6,7 and 9 Service users have detailed service user plans and are involved as much as possible with decision making. Appropriate risk assessments are in place. EVIDENCE: Regular meetings take place to review service user plans and risk assessments. All risk assessments are currently being reviewed. Guidelines from healthcare professionals are up to date and reviewed on a regular basis Service users have a named key worker and regular key worker and service user meetings take place. Each service user has a Personal Planning Book in pictorial format, this included details of choices made about aspects of daily living. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 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 standard(s) 12,13,15,16 and 17 Service users enjoy a wide range of activities and leisure opportunities. Staff assist service users to maintain and develop appropriate relationships. Service users are assisted to make informed choices regarding aspects of daily living. A varied and well balanced diet is provided. EVIDENCE: All service users have a weekly activity report which is recorded daily. One service user now attends a Friendship Club held at a local church, the service user said that she enjoys meeting other people and had made several friends there. The manager is currently organising new activities including bowling and attendance at a local PHAB club. Service users make use of community facilities including the library. A family party was recently held for one service user. One service user has a pet rabbit, two birds and a kitten, staff assist the service user, as necessary to provide care to the animals. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 11 Daily records and service user reviews record that service users have regular contact with friends and family members. Service users are involved, as much as possible with food shopping and menu planning. Dietician advice has been obtained to develop varied and well balanced meals, taking into consideration service users specific dietary needs. One service user commented that “ all the staff here are good cooks”. Food stocks were plentiful with fresh vegetables, fruit and salad. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 12 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 standard(s) 18,19 and 20 Service users physical and personal care needs are well met . Medication is administered in a safe and appropriate manner. All staff who administer medication require medication training/ update. EVIDENCE: Service users physical and personal support needs are detailed in service user plans. Personal care given is recorded in daily records. Care is provided to a high standard. On the day of this visit, service users were well groomed and appropriately dressed. Service user records clearly evidence that regular healthcare checks take place. Medication administration records were well maintained with no obvious gaps in recordings. Staff on duty said that they had not received medication training. There are clear service user guidelines “ how I like to take my medication” and clear guidelines on the administration of PRN medication. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 13 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 standard(s) 22 and 23 The home has a clear complaints procedure and protects service users from abuse. Staff were unfamiliar with the procedures for the protection of vulnerable adults from abuse. All staff need to receive appropriate training. EVIDENCE: There is a clear complaints procedure and each service user has a copy of the complaints procedure in pictorial format. The last recorded complaint was October 2004. The home has a comments form for use by visitors to the home. Written comments from visiting relatives included that staff “are welcoming and pleasant” and “warm, welcoming and friendly” and that the care of service users was “excellent, staff are very patient and caring”. There is a procedure on the protection of vulnerable adults from abuse. This needs to be updated. Staff on duty confirmed that training was provided in 2001. The manager is to obtain a copy of the Multi-Agency Policy and Procedure for the Protection of Vulnerable Adults from Abuse. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 14 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 standard(s) 24,25,26,27 and 30 The home is comfortable, safe and meets the needs of the service users. EVIDENCE: The home is well maintained. Furniture is of a good standard and the home is in good decorative order. Service user bedrooms are appropriately furnished and personalised to reflect the service users interests. One bedroom has recently been redecorated and the service user said that she was able with staff assistance to choose the colour scheme and soft furnishings. Appropriate locks are fitted to bedroom doors. There is one bathroom and a separate toilet, fitted with appropriate aids to assist service users with safe bathing and independence. The home is clean, comfortable and free from unpleasant odours. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 15 Written comments from relatives included “cleanliness at the home is excellent” and a service users bedroom was described as “bright and comfortable”. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35 and 36 The service users benefit from a consistent staff team. The majority of staff have worked in the home for ten years plus. Staff are experienced and are able to meet the needs of the service users. The homes training and staff development programme needs updating. EVIDENCE: Staff on duty consisted of three support workers, all of whom were trained nurses. Staff were clear about their roles and responsibilities. It was evident that there is a good rapport between service users and staff on duty. At the last inspection a requirement was made that the home’s recruitment procedures are developed. This was not checked for compliance at this visit, as the shift leader did not have access to personnel records. One member of staff has been recruited since the last inspection. A staff training programme is displayed in the office, this needs updating as some staff names have been omitted and some staff have left. Training needs to be provided or updated in administration of medication, protection of vulnerable adults, basic food hygiene and fire safety. Several members of staff have completed NVQ training at levels II or III. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 17 Staff confirmed that they receive regular supervision from either the manager or deputy manager. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39and 42 This is a well managed home. Policies and procedures are in place. There are some shortfalls in relation to health and safety which could pose a risk to service users. EVIDENCE: The manager was registered with the CSCI in December 2004. She has a clear sense of direction and leadership and is supported by an experienced deputy manager. The manager is a registered nurse ( learning disability) and has recently completed the Registered Manager Award. The manager has developed care practices in the home and introduced staff supervision. There is a good rapport between the service users, relatives, staff and manager. Staff said that they felt well supported by the manager as well as the provider. A sample of health and safety and fire records were examined. The majority of service and maintenance records were up to date. Fire safety checks were up JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 19 to date with regular fire drills taking place. The home’s premises fire risk assessment was updated in November 2004. It was however, noted that a member of staff who works alone on night duty has not received fire safety training. This has previously been highlighted in inspection reports. Risk assessments need updating. COSHH records and safety data sheets need to be reviewed and update. All radiators are fitted with guards, thermostatic controls are fitted to all hot water outlets. It was noted that hot water temperatures are exceeding the recommended safe temperature of 43c. JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 20 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 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 JUST HOMES Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 21 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 20 Regulation 13(2) Requirement The manager must ensure that all staff receive training/updating in the administration of medication. The manager must ensure that all staff receive training in the protection of vulnerable adults. That the homes procedure is updated. The provider must develop the homes recruitment procedures (Not checked for compliance at this inspection). The manager must ensure that all staff receive training in the protection of vulnerable adults, basic food hygiene and fire safety. The manager must update the homes staff training programme. The manager must ensure that all risk assessments are updated and COSHH records are reviewed and updated. Timescale for action 26/06/05 2. 23 13(6) 26/06/05 3. 34 19 & Sch 2 12 21/01/05 4. 35 26/06/05 5. 6. 35 42 18 13 26/06/05 26/06/05 JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 22 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 Good Practice Recommendations JUST HOMES v214361 h52-h01 11212 justhomes v214361 250405 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading 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. 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