Inspection on 07/06/07 for Menorah House

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Menorah House 21/03/06

Menorah House 10/08/05

Menorah House 15/03/05

Menorah House 14/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Menorah House 331-337 Anlaby Road Hull East Yorkshire HU3 2SA Lead Inspector Janet Lamb Key Unannounced Inspection 7th June 2007 09:00 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 DS0000000855.V342502.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000000855.V342502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Menorah House Address 331-337 Anlaby Road Hull East Yorkshire HU3 2SA 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) 01482 328227 01482 211349 hjcc.menorah@revlis278.karoo.co.uk Hull Jewish Community Care Margaret Johnson (unregistered) Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places DS0000000855.V342502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st March 2006 Brief Description of the Service: Hull Jewish Community Care a registered charity own Menorah House. The home is registered to provide accommodation and personal care for up to 25 service users of either gender, over the age of 65, some of whom may have dementia. The cost of living in the home is currently £367.50 per week. The home is situated off Anlaby Road about a mile from the city centre. There is an attractive garden and a car park to the rear of the house and residents may access bus routes immediately outside the home into the city centre or to the outskirts of the city. Residents’ private accommodation consists of very spacious 21 single and two double rooms, all with en-suite facilities and a sitting area. There are two passenger lifts to the first floor and an additional chairlift to support service users up a short flight of stairs leading off the first floor where the layout of the home is split-level. Communal areas consist of two lounges and a large dining room. There is also a function room, where special events are held for the residents in the home and sometimes the local community. DS0000000855.V342502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of Menorah House has taken place over a period of time and involved sending a request for information to the home in February 2007 concerning service users and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in early March 2007 and questionnaires were then issued to all service users and their relatives and GPs. They were also sent to other health care professionals with an interest in their care, to social service departments commissioning their care and to the staff working in the home. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 7th June 2007 to test these suggestions, and to interview service users, staff, visitors and the home Manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with three bedrooms/flats. A total of four service users and two staff were interviewed and the manager and two members of the board of Hull Jewish Community Care provided information or were spoken to during the site visit. All of the information collected was checked against that obtained through questionnaires and details already known because of previous information gathering and contact with the home. What the service does well: Service users are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication extremely well and staff are highly trained in medication administration. Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. DS0000000855.V342502.R01.S.doc Version 5.2 Page 6 They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. Service users enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. Service users are confident their complaints will be listened to and acted upon. Service users are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. Service users experience a safe, clean and well-maintained environment. A more than sufficient number of care staff work in the home on each shift to meet the needs of service users. The manager runs the service in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? What they could do better: The service could offer a wider variety of activities for service users to take up and perhaps provide more one-to-ones for pastimes or going out, so that service users have more to do that they like. Staff could make sure everyone is informed of activities and happenings in the home, well in advance of and just before the events, so that everyone has the chance to take part. DS0000000855.V342502.R01.S.doc Version 5.2 Page 7 The service could make sure it maintains its provision of ‘safe’ staff by providing up-to-date training on safeguarding adults’ procedures, and by reviewing the security checks of staff with the Criminal Records Bureau. For those staff with checks that are more than three years old it is recommended they be re-done, so that service users are confident ‘safe’ staff are providing their care. 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. DS0000000855.V342502.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000000855.V342502.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their individual and diverse needs well assessed so they are confident needs will be met. EVIDENCE: Discussion with four service users about their placement at Menorah House, and viewing two of their files, with permission, reveals all service users are assessed fully by the placing authority before admission. They are then assessed in the home for individual needs and wishes and according to risk on pressure care and falls. From all of this information staff determine an action plan to deliver the care needed. DS0000000855.V342502.R01.S.doc Version 5.2 Page 10 Usually the home obtains a copy of the local authority assessment and keeps this in a filing cabinet in the office, but not together with service users’ care plan files. Assessments from the local authorities are usually held with other contractual documents. All documents sampled for the two service users having given permission to view them, did not contain the local authority assessment form. Therefore another service user’s documents held was used to show copies of assessments are obtained and held in the home. Discussion with management provided an explanation of why the two service users chosen for sampling had no such document. The explanation was acceptable. Service users sign all documents where possible or their relatives do. Service users could not fully remember having had assessments done, but all are well aware of their care plans. One said, “Oh yes you can look in my files, I’ve nothing to hide, but you had better ask first. They may not let you.” Another said, “I don’t think I had an assessment done, because I came in with my wife, some years ago.” DS0000000855.V342502.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service receive good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so they are confident their overall quality of life is good. EVIDENCE: Service users, staff and management spoken to, documents seen in files and information obtained from the random inspection completed by Helen Jackson, the Commission’s Pharmacy Inspector, and new information provided from the manager, reveal improvements have been made in this section. All service users have a care plan, which is generated from the information obtained during assessment and from information provided by relatives. DS0000000855.V342502.R01.S.doc Version 5.2 Page 12 Individual and diverse needs in respect of religion, social activities and physical impairment in particular, are recorded to ensure service users have their individual needs met, and according to their preferences. Action plans and risk assessments are also written in the care plans, though these have only recently been properly introduced. Care plans are reviewed monthly in the home, and annually with the council and other stakeholders, and all dates are maintained and copies of council reviews are held. Service users or their relatives sign care plans. Some comments taken from service users’ questionnaires include, “The staff are very good by getting the doctor if one is unwell at any time,” and “The care staff are really nice. I only have to ask for anything and they get it for me or help me. I don’t know what I would do if I wasn’t hers as I am so well looked after.” Discussion with the staff team and scrutiny of the home’s assessments and care plans show that while service users needs are assessed and some new ‘interventions’ have been added to show how needs will be met, the assessments and care plans need developing a little further to ensure all areas listed in 3.3 are considered – oral health, mental state and cognition, and carer and family involvement. Where needs are well recorded they show that service users with particular diverse needs have the equipment they require, such as loop system on the television, hearing aids, walking frames and wheelchairs, reclining lounge chairs etc. Some service users also have specialist clothing, dressings, shoes and cushions or mattresses for their comfort. At the moment staff find care plans a useful tool for checking on care needed and for recording the actual assistance given. Within the care plans health care needs are also recorded and met, and records of GP, nurse and other health care professionals are maintained. Medication administration systems were not inspected so soon after the pharmacy inspection on the 17th May, but the requirements and recommendations made then, were discussed. The manager and staff felt the pharmacy inspection was extremely helpful and they have implemented almost all of the requests made, except for the setting up of service users’ photographs. These are to be completed shortly. In view of the work already done to meet requests and the integrity of the manager displayed on the day of the key inspection, it is felt the final request shall be met shortly and therefore the standard on medication is now satisfactorily met. Service users spoken to are satisfied their medication is handled for them. One said, “My medication is done by the girls, everything is fine.” Service users spoken to acknowledge that they are afforded privacy and dignity with personal care, spending time in their room, seeing visitors if requested, etc. They have no concerns over the way their personal care needs DS0000000855.V342502.R01.S.doc Version 5.2 Page 13 are met. Observation of staff interaction with service users though was not entirely satisfactory. The cook and two care staff walked into service users’ rooms on three occasions without knocking. This was passed onto senior staff for them to discuss in staff meetings. One service user did not know they could have a lock on their door. DS0000000855.V342502.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users enjoy flexible routines, good contact with relatives and friends, good opportunities to be self-determining, and highly satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Service users, staff and management spoken to and some documents seen reveal service users lead fulfilling lifestyles of their choosing and preference. There are routines within the home around rising and having meals etc. but individuals can disregarded them if they wish. Service users said they come and go as they please, decide when to rise or go to bed and that they enjoy some level of exercise where possible. Some service users have kettles and tea making facilities in their rooms/flats and make drinks independently. DS0000000855.V342502.R01.S.doc Version 5.2 Page 15 Some service users observe their faith on a daily basis and all maintain fairly private, individual lives. The home is primarily for service users of the Jewish faith and provides kosher meals and Jewish rituals, but does also care for people of other denominations. Staff work well to meet the needs of all service users with differing religions in the home. Care plans record preferences and there are individual records of activities undertaken. Posters advertise activities and ‘word of mouth’ reminds service users when something is about to happen, but not all service users feel fully included on these occasions. Staff need to make sure everyone is given the same opportunity to attend meetings and pastimes. Service users state on their returned questionnaires that they would like to be offered a different activity to the usual bingo and quiz. Some do go on organised outings or out for impromptu walks with staff, but within the home there is little variety. Television, music and newspapers are taken up every day and visitors play an important role. There were many visitors to the home on the day of the Commission’s visit and some service users were observed watching television. Service users said they handle their own finances, wherever possible, or family members do. Some service users have a small amount of money held in safekeeping for which individual records are kept, showing amount in/out, the balance and the signature of the service user. These documents were not viewed. Service users said they are quite satisfied with these arrangements and are pleased they no longer have the responsibilities of budgeting, and cooking or cleaning even. All people having a ‘stake’ or interest in the home made comments that the food provision is very good. The cook/chef compiles menus after consulting service users about their likes and preferences, and changes these according to seasons, medical diets and healthy eating. Each morning s/he asks each service user what they would like from the menu for the two main meals of the day, records this and prepares it accordingly. All food is prepared according to the requirements of kosher practices and for those service users that are nonJewish it has little impact, except for perhaps missing out on certain meat products. Jewish service users are confident their meals are prepared according to their religion. No one made any adverse comment about meals or food preparation. The kitchen is always maintained in a very clean condition and according to kosher practices, equipment is replaced as requested and foodstuff is purchased to suit menus, religions and tastes. DS0000000855.V342502.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so service users are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: Service users, staff and management spoken to, information in questionnaires and records viewed reveal service users have good opportunities to make their concerns or complaints known before they become major issues and have good systems in place for their protection. There are complaint and protection policies and procedures in place, staff have signed to say they understand them, and have had training in handling complaints and in safeguarding adults. However the training in safeguarding adults was done approximately two and four years ago by the two staff interviewed and now needs updating. There are some more recently employed staff that have done the training a shorter time ago, but it would benefit the home to ensure all staff have up-to-date safeguarding adults DS0000000855.V342502.R01.S.doc Version 5.2 Page 17 training in line with the new safeguarding adults’ protocols. No staff questionnaires were returned to the Commission therefore only the staff interviewed could give an indication of the levels of understanding of procedures. Staff are competent in passing on information to the required bodies and know the procedures to be followed. There is a good ethos amongst the staff group and lead by the manager, that shows they are open to suggestions for improvement, consider complaints to be a means of helping the service move forward with improvements, and that service users views should be listened to. Two service user questionnaires state they do not feel the staff listen to them and act on what they say, but both imply this is because staff are always busy and in a hurry. Records of complaints and allegations made are held but only the complaint record has entries, there having been no allegations or incidents for some time. These have been dealt with appropriately and quickly. One service user said, “I always speak to the manager Maggie but care staff usually sort anything out too. I have no complaints.” The new manager in post from February 2007 has begun to introduce improved systems for the recording of incidents in the home that may be safeguarding adults’ issues. She is devising a separate incident document to record happenings on, because the home’s current accident book shows insufficient information to be able to make an informed decision about the nature of the accident. One relative questionnaire states, “A very thoughtful group of people work in Menorah House. Respect is shown to my parents’ different needs. Their physical/medical conditions are taken care of exceptionally well.” DS0000000855.V342502.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have a well-maintained, safe, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: Communal areas of the home were viewed, but service users permission to see their flats was only obtained from the three that were interviewed and so only three flats were seen. These are satisfactorily furnished and decorated and are very personalised. All flats apparently have en-suite toilets and some have kitchenettes, but those service users wishing to have tea-making facilities are provided with them. DS0000000855.V342502.R01.S.doc Version 5.2 Page 19 The house is suitable for its stated purpose of providing care and accommodation to older people. Handrails are provided in en-suites according to individual need, there are two passenger lifts to the upper floor and a stair lift to some odd rooms that are a few steps up higher than the upper floor. The garden to the rear has a ramp and rails for access to those with poorer mobility or that use wheelchairs. Maintenance of the house internally and externally is very good. Service users spoken to are satisfied with the cleanliness of the home, their flats and the opportunities they have to mix with different people in the lounge and dining room. There is a maintenance man employed in the home 12 hours a week, who keeps on top of minor repairs and redecoration. Service users have access to the rear of the property where there is patio space with garden furniture for those service users and staff that smoke. There is a secure car park to the rear accessed from a communal road and via electrically operated gates. Relatives and professional visitors to the home use the front entrance, which is also secure and double locked because of locks to the main door and the porch door. The last Fire Prevention Officer visit to the home was undertaken in January 2007 and the last Environmental Health Officer visit was undertaken in May 2006. The home currently complies with requirements of both organisations although work is ongoing to upgrade the fire doors as required on the fire report. The house is well maintained, and is kept clean and comfortable. The laundry is away from the kitchen and has separate access. It meets the Water Supply (Water Fittings) Regulations 1999 and provides sluicing and hand washing facilities. There are two laundry assistants employed for a total of 36 hours a week. Staff have infection control policies to follow, have access to strategically placed disinfecting hand gel, and have done infection control training. Both standards in this section are met. DS0000000855.V342502.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users are cared for by well-recruited, well-trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy an excellent service of care. EVIDENCE: Two staff were interviewed and their permission was obtained to view their recruitment and selection, their training and their supervision files. Discussion with the manager, viewing of rosters over a three-week period and using information from the home to determine the Residential Staffing Forum figures shows the home is sufficiently staffed in terms of staffing hours provided per week. Forum figures require 415.32 hours for 0 high, 9 medium and 13 low dependency service users, and the general environment, layout of the home causing some difficulty in providing care. The home provides 607, 592 and 615 hours over the three-week roster, and therefore standard 27 is being very well met. Discussion with staff and the management and information taken from the inspection questionnaire reveals there are now only 7 from 17 care workers DS0000000855.V342502.R01.S.doc Version 5.2 Page 21 with the required qualification, giving 41½ with the award. Efforts need to increase to encourage staff to undertake the award or equivalent in order to meet the requirement of standard 28, that of 50 with the award. There is a recruitment and selection policy and procedure for the management to follow and discussion with staff and viewing of files reveal these to be satisfactorily followed. Requirements under regulation 19, schedule 2 are being met. Staff files contain details of their application for the job, security check, employment contract, job description and so on. The two files viewed have security checks that were completed in 2002 and therefore it is recommended they be redone and updated. The files also had references missing, but the manager explained that because the two staff have worked in the home since 1997 and 1995, many of their documents have been archived. References for another staff member were therefore verified as being available in her recruitment file. All staff undertake induction training in line with Skills For Care and do mandatory training in fire safety, moving and handling, etc. Not all staff training undertaken was checked and therefore the manager is requested to ensure she audits individual staff training to determine any gaps and any incidents where up-dates are needed. DS0000000855.V342502.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service. Their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with the manager and staff, and viewing of documentation, safety records and certificates reveals, service users and staff benefit from a safe and well-run home. DS0000000855.V342502.R01.S.doc Version 5.2 Page 23 The manager has the NVQ level 4 Registered Manager’s Award. She has 9 years experience as a Registered Manager in other homes and constantly strives to improve her own knowledge and understanding of the care business for the benefit of improved services to service users. It is the intention of Hull Jewish Community Care to submit an application for her to become the Registered Manager for the home, within the next month. There have been no changes to the systems for quality assuring the service provided in the home since the last inspection. These were not assessed on this inspection, but the manager explained the home usually carries out service user, relative and staff surveys, which she as the new manager has not been party to yet. Service users have control of their own finances, where possible, and if unable then their relatives do. Some have a small amount of money held in safekeeping for which the home maintains a record of money in and out, with signatures and running balance. These were not seen on the site visit, but service users spoken to state their satisfaction with the arrangements. Outcomes are very good. The manager and staff maintain a safe environment for service users and staff by ensuring all equipment is regularly serviced and certificated if necessary, by following all relevant legislation in respect of health and safety responsibilities, and by maintaining appropriate records of safety checks, etc. Areas sampled to determine whether or not standard 38 is met are, fire safety, passenger lift and hoist maintenance, water temperature and legionella testing and safety in the use of cleaning substances. Weekly fire safety and equipment checks are carried out and recorded and monthly emergency lighting checks are done and recorded. The home carries out fire drills as necessary and one was completed on 28/03/07, but there is another soon to be held. Staff names of those present are recorded and the head chef has completed a fire safety training instructors course. Seventeen staff completed fire safety training on 29/05/07 and the home’s fire risk assessment document was reviewed on the 25/05/07. Extinguishers were last maintained in August 2006. Pickering’s Lifts last maintained the home’s passenger lift early this month, June 2007, and the lifting hoists were last serviced by Arjo Mecanaids only yesterday, 06/06/07. Certificates have not yet been received, but maintenance reports are available. A hot water storage legionella test was carried out 16/04/06 and the result was negative. DS0000000855.V342502.R01.S.doc Version 5.2 Page 24 All materials used in the home for cleaning etc. are kept locked safely away, have appropriate safety instructions and dilutions and are used in conjunction with the necessary safety guidelines under Control of Substances Hazardous to Health Regulations 1988. Safety instructions are maintained in a file in the office. Staff have completed training in the awareness and use of dangerous substances, on 05/06/07. DS0000000855.V342502.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 4 DS0000000855.V342502.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action DS0000000855.V342502.R01.S.doc Version 5.2 Page 27 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 OP3 OP7 2. OP12 Good Practice Recommendations The manager should make sure all items listed in standard 3.3 are fully assessed for each individual so that the care plan reflects needs to be met and service users know their needs are met. The manager should make sure activities are varied and reflect service users’ preferences and that all service users are fully informed of pastimes and events, so they know what and when entertainment or activity is on offer. All staff should be given up-dated training in safeguarding adults’ procedures and practice, so that service users know they are well protected from harm or abuse. The manager should make sure all staff are encouraged to undertake the recommended training qualifications (NVQ or equivalent) and achieve 50 of the care staff with the award, so that service users know they are being cared for by competent staff. The manager should make sure all staff are security checked with the CRB in accordance with their recommended frequency, so that service users are confident they are being cared for by ‘safe’ staff. 3. 4. OP18 OP28 5. OP29 DS0000000855.V342502.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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