CARE HOME ADULTS 18-65
Rela Goldhill Lodge Wolfson Court Limes Avenue London NW11 9TJ Lead Inspector
Anthony Lewis Key Unannounced Inspection 10 and 11th April 2006 09:00
th Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 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 Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 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. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Rela Goldhill Lodge Address Wolfson Court Limes Avenue London NW11 9TJ 020 8905 5229 020 8455 8250 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) Jewish Care Mr Steven Mark Wax Care Home 21 Category(ies) of Physical disability (0), Sensory impairment (0) registration, with number of places Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Limited to 21 adults with a physical disability including visual impairment. Two specified service users who are over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as either of the specified service users vacates the home. 24th October 2005 Date of last inspection Brief Description of the Service: Rela Goldhill Lodge is owned and managed by Jewish Care, who are the largest providers of health and social care services for the Jewish community in the United Kingdom. The home is registered to provide residential accommodation and care for a maximum of twenty-one young Jewish adults with physical and sensory impairment. The home provides for respite and short-term care. The staff also provide respite care for people living in their own flats, opposite the home. Staff are available on a twenty-four hour basis. The home is situated in a residential part of Golders Green, near to Golders Green and Brent Cross underground stations, local shops, and bus routes and Brent Cross Shopping Centre, all of which are a short distance from the home. The home is purpose built as part of the Wolfson Court, which was opened in 1992. The home occupies all of the first and part of the second floors. The rest of the building provides warden supported accommodation for elderly people. The home is wheelchair accessible throughout. There are twenty-one single bedrooms, each with en-suite shower and toilet facilities. The home also provides support with all aspects of personal care and daily living. There is also support for residents to enable them to be part of the local community and to develop and maintain work, education, leisure and social activities. The home adheres to the customs of the Jewish religion, taking into account religious holidays and festivals. The fees for residents living in the home range from £389.57 - £1,063.98 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over two day on Monday 10th April 2006 at 9am and was completed at 3.20pm and on Tuesday 11th April at 1.20pm and was completed at 5.20pm. The registered manager was available throughout both inspections and was very helpful and accommodating. To gather evidence for this inspection, twelve residents were spoken to, nine formally and three informally. Six staff were spoken to, four formally and two informally. One relative and two volunteers were informally spoken to. Evidence was also gathered for this inspection from viewing ten residents’ files and seven staff files. The home’s fire, health and safety files and records as well as various other documents, files and certificates were also viewed. An extensive internal and external tour of the home was conducted with the registered manager. What the service does well:
A dedicated staff team, most of whom have worked in the home for many years, have a good understanding of the needs of the residents. They have a good working relationship with each other and ensure that they work as a team to best meet the residents’ health, personal, social and spiritual needs. Residents are assertive and independent. The majority of them have close links with their family, many of whom visit the home regularly. The residents are active within their local and the wider community and the staff team encourage and support the residents to engage in their spiritual beliefs. Although many of the residents are wheelchair bound or have varying degrees of mobility difficulties, they still enjoy a good degree of autonomy and flexibility. They are supported to engage in various activities and interests inside and outside the home. Residents, family members and other visitors are confident with the care provided by the staff team and provide a good insight into the quality of care and professionalism of the staff. The staff ensure that the home is run in accordance with Jewish beliefs and customs and that residents are supported to engage in their religious festivals, if they so wish. The home has a diverse mixture of staff of both genders that are from various cultures and religions. They all have a good understanding of the Jewish religion through comprehensive inductions and working together as a team. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
At this inspection, three requirements have been made. One is restated from the previous inspection and two are new requirements. It is felt that the dedication and close professional relationship of the staff team will ensure that the three requirements will be met within the given timescales. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. To ensure that residents are not put at risk, staff must ensure that the correct procedures are followed when administering medication. All maintenance issues must be dealt with as soon as they are identified to ensure the safety of residents, staff and visitors. To ensure that all staff are being sufficiently supported, they must receive regular formal supervision. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 7 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. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 8 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 Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 9 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): 2 and 5 Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. The staff are carrying out comprehensive risk assessment with residents’ input to ensure their safety. Staff are also ensuring that contracts are agreed between the home and each resident and that residents have their own copy for reference. EVIDENCE: On the day of the inspection, the home’s care manager had an appointment at a hospital to carry out an assessment for a potential resident to the home. The assessment process was discussed at length with the care manager, who has worked in the home and for Jewish Care for many years. Her knowledge and understanding of the care needs of residents is vast. Information for the assessment process was seen and included a reassessment form that is completed once the resident has settled into the home. The care manager stated that the assessments forms part of residents’ care planning. The assessment/care plans of twelve residents were seen and all contained information relating to their care needs such as: their personal details, health, culture, religion and family and friends details. Contained in all residents’ file was a copy of their terms and conditions between the home and the resident. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Comprehensive assessments and care planning ensures that the present and changing needs of the residents can be continually met by the staff team. Residents are confident that they will be supported, other than by staff if they so wish, to make decisions about their care needs and that they will be supported to take informed risks. EVIDENCE: The registered manager stated that care plans are generated from each resident’s individual assessment and from discussing, with the resident and or their family, all elements of their care needs. The home has developed a more comprehensive care planning format, which they have recently begun to use to record the needs of individual residents. A resident was spoken to about her involvement in compiling her care plan she said, “My keyworker always sits with me and I tell her what I like and don’t like, she’s very good.” At the previous inspection a requirement was made that the changing needs of a specific resident must be reviewed. The registered manager stated that a
Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 11 review was carried out in October 2005 and from that review the resident is being supported to be more independent. The residents’ care plan contained up to date information about his present and changing needs, recorded as a result from his review. The resident was spoken to and he said, “I was happy with the review and I’m even more independent now and doing a lot for myself.” The resident went on to discuss his hopes and aspirations saying, “I’ve got lots of friends and I can stick up for myself.” Residents have a considerable amount of independence and autonomy within the home and their local community. According to their care plans and from speaking to a number of residents, they are able to make informed choices with regards to all aspects of their care. Throughout the day, it became apparent that the majority of residents are quite assertive and ready to voice their opinions, choices and feelings. One resident said that her keyworker regularly discusses her choices with her. The resident went on to say, “I enjoy going to my day centre.” She leaned over and whispered, “I really enjoy it there and the food’s good.” An advocate was spoken to at length. She said that she has been the independent carer and advocate for one resident in the home for many years. She also said that she attends reviews and other meetings regarding the resident and will speak up for the resident when required. She went on to say about the resident, “ She has progressed dramatically since living here.” Each resident has a “client risk assessment”, which details identified risks. The individual assessments are comprehensive in that they contain information on the resident’s abilities and their various activities. In addition, there is also information on the harm that might be incurred by carrying out a specific activity and likelihood of the resident being harmed. A risk rating score is given and where necessary control measures are put in place to manage the risk. A resident was spoken to about his social life. He said. “I go all over the place, I go to bars, clubs, restaurants and I’ve got a wide circle of friends.” There was information in the resident’s file regarding potential risks and how they would be managed. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Residents are confident that staff will encourage and support them to take part in appropriate leisure pursuits and various activities and be a part of their local community. Residents are also confident that links with their family and friends will be encouraged and maintained and that their rights and choices will be sought and respected. EVIDENCE: According to the activities co-ordinator, residents regularly participate in shopping trips, attending their day centre and some go greyhound racing. A resident said that she attends her day centre regularly and enjoys it there. One resident, who has had a part-time job for many years was discussing his work with the registered manager just before he left the home for work. The registered manager stated that all of the residents in the home are Jewish and are fully integrated within their community, which has a high Jewish population. The registered manager went on to say that residents access their local community shops, restaurants and a day centre.
Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 13 Throughout the day, residents were observed being encouraged and supported by staff and volunteers to access their local community. Residents were observed coming and going with support from staff and volunteers. Several residents were spoken to about the involvement of their family and friends. They all said that their family take an active part in the home and the care that is being provided to them. Individual care plans seen contained the resident’s next of kin details. A resident’s father, who has been seen and spoken to at previous inspections, was briefly spoken to. He said, “I come most days and stay as long as I can, the staff are always welcoming.” A resident said, “I’ve built up a close circle of friends over the past few years.” He went on to say, “They phone me and I go out with them.” Staff were indirectly observed and overheard supporting and interacting with residents in a professional and courteous manner at all times. Staff were seen to be patient and attentive to residents’ needs and responded promptly to requests. Staff were overheard using individual resident’s first name and observed knocking on bedroom doors prior to entering. Residents were observed moving about the home, especially communal areas without restrictions and were supported by staff whenever required. A residents said, “The staff are very helpful and when I want to be alone in my bedroom, they give me space.” He went on to say, “I enjoy listening to my radio alone.” At the previous inspection, a requirement was made that residents are consulted and that their views are taken into consideration when planning the menu. A detailed tour of the kitchen was conducted and the chef and kitchen staff spoken to at length about the food preparation and menu planning. The chef has a form, which is used to collate residents’ likes, dislikes and suggestions with regards to meals. Care plans also contained information on residents’ likes and dislikes, which was reflected on the four previous menus seen. The menu for the past four weeks was seen and contained a variety of dishes, with plenty of salads, vegetables, meats and desserts. At lunch, many of the residents were spoken to about the quality of food all were very positive and said that they enjoy the meals. One resident said, “The chef sometimes comes round and talks to us about the food.” Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Residents are confident that staff will support them and carry out their personal care according to their wishes and that their health care needs will be regularly monitored. However, residents are being put at risk due to staff not following the correct procedures when administering medication. EVIDENCE: Six residents were spoken to, two at length about the support that they receive regarding their personal care. One resident said that he is able to stay up late and watch television if he so wishes. He went on to say, “Staff always ask me if I’m ready for bed and are very supportive with my personal care.” He went on to say, “They never grumble.” Another resident said, “There’s one night staff who I like to help me get ready for bed, she’s really kind.” Care plans viewed all contained comprehensive information regarding the residents’ health care needs. There was also information in their files regarding health care appointments and the outcomes of the appointments. There was clearly recorded information on visits to or by the GP, chiropodist, dentist, physiotherapist and other health care professionals. Residents spoken to said that their health is regularly monitored and that they are always involved in any review of their health care.
Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 15 A requirement was made at the previous inspection that individual assessments are carried out on all residents who self-medicate and an agreement is signed between the resident and their GP. On looking through the files of the residents who self-medicate, there were signed agreements between the resident, their GP and the home. On looking at the Medication Administration Record (MAR) sheets for all of the residents, there were some gaps in the administration charts where the administration of medication was not been signed for or non administration coded as to the reason for the non administration. The gaps were found at various times of the day. A requirement is made that the registered persons must ensure that the administration of all medication is signed for on the (MAR) sheets and any non administration coded as to the reason why the medication was not administered. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. The staff team are ensuring that complaints are taken seriously and acted upon promptly to reassure residents. They are also ensuring that robust recruitment procedures are followed and all allegations are investigated thoroughly. EVIDENCE: The home has Jewish Care’s complaints policy and procedures, which contains clear information on how to make a complaint. In addition, the home has a complaints file, where all complaints are recorded appropriately with details of the complaint and the conclusion. Residents spoken to said that they are aware of the complaints procedure. One resident said, “If I’ve got a complaint to make, I’ll talk to a member of staff.” Another resident said, I’ve made a few complaints in the past and they’ve always been resolved quickly.” The home has the London Borough of Barnet’s Multi-Agency Adult Protection Policy and Procedure. They also have Jewish Care’s “Vulnerable Adults” policy and procedure. A member of staff spoken to had a good understanding with regards to the protection of vulnerable adults and some of the types of abuse that can occur. To ensure that residents are protected as much as possible, the home is ensuring that all staff have the required documents as stated in the National Minimum Standards and a Criminal Records Bureau (CRB) check carried out prior to commencing working in the home. An allegation recently made by a resident has been reported to the correct individuals and agencies, including the Commission and a robust investigation has been carried out. The staff have also ensured that the resident has received sufficient support.
Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. Residents live in a clean and tidy home and have the necessary adaptations to ensure their independents and dignity is respected. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. However, the staff are not ensuring that maintenance issues are dealt with swiftly to ensure their safety and the safety of the residents and visitors. Quality in this outcome area is poor. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: At the previous inspection a requirement was made that parts of the home that were damaged due to damp be repaired and re-decorated. Whilst touring the home, there was no damp and the damage has been made good. In the kitchen, an electrical socket was dangling precariously and almost touching the floor and posed a risk from water or other spillages. A requirement is made that the registered persons must ensure that the socket dangling in the kitchen is made safe. All of the residents have some form of physical or mobility difficulty. In light of this, Jewish Care has ensured that environmental adaptations are in place and that all areas of the home are wheelchair accessible. There are two lifts to all floors, and residents have been provided with wheelchairs, walking frames,
Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 18 hoists and assisted baths. Staff were observed supporting residents in a dignified manner whenever the need arose and most residents were able to move about the home independently, without any restrictions. An extensive tour of the kitchen was undertaken and a requirement made at the previous inspection regarding the cleaning of the kitchen has been met. The chef and the home’s management have ensured that a review of the kitchen was undertaken and as a result a thorough cleaning programme is now in place and all areas of the kitchen are kept clean and tidy. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Robust recruitment and training procedures ensure that residents are safe and are being supported by a competent and qualified staff team. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. However, some staff are not receiving regular supervision to ensure that their personal development is monitored and they are being sufficiently supported. Quality in this outcome area is poor. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: Throughout the inspection process staff of all grades, many of whom have worked in the home for many years, were spoken to formally and informally and indirectly observed carrying out their duties. Staff demonstrated the utmost professionalism towards the residents, visitors and their colleagues. They were able to demonstrate their knowledge and understanding of the care needs of the residents and their roles and responsibilities. Residents appeared to be comfortable and happy when interacting with staff. The registered manager stated that a number of staff have completed the National Vocational Qualification (NVQ) level 2 and 3 and that other staff are in the process of completing the course. Certificates for (NVQ) level 3 were seen in some staff’s files. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 20 At the previous inspection the ancillary staff did not have a file in the home and another staff’s file did not contain all of the required information as set out in the National Minimum Standards and a requirement was made. On checking the identified member of staff’s file all of the required information was available. In addition all of the ancillary staff have a file, which was seen to contain all of the required information. The files of ten staff were viewed and all contained a variety of training certificates relevant to the work that they do in the home. Certificates included: health and safety, food hygiene, moving and handling and various other courses. Jewish Care’s management report for February 2006 was viewed and contained a breakdown of the home’s individual and overall expenditure, including expenditure on staff training. The files of the ancillary and various other staff contained their supervision records. On viewing them, it was apparent that the majority of staff are now receiving regular recorded supervision but for two staff there was no evidence to indicate that they have received supervision this year. It was a requirement at the previous inspection that all staff working in the home must receive regular supervision. This requirement is restated. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The home is being managed by a competent manager and staff team who are ensuring that the quality of service delivery is continually monitored and improved and that the health and welfare of residents is taken seriously. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: The registered manager’s file was viewed and contained all the required information as set out in the National Minimum Standards. The file contained various training certificates relevant to managing such a home, including his (NVQ) level 4 certificate in management. Concerns were raised at the previous inspection about the style of management within the home and a requirement was made that the concerns are investigated. This was carried out by the home’s operation manager and a report forwarded to the Commission as requested. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 22 Records show that the issues raised were discussed at residents’ and staff meetings. Residents spoken to said that they were happier with the way in which the home is now being managed, this was also relayed by staff that were spoken to. One member of staff said that they had a better understanding of the roles and responsibilities of the manager. The home’s quality assurance information was available to view. This was a requirement at the previous inspection. According to the registered manager, Jewish Care has a quality assurance monitoring officer who ensures that information from, residents, relatives and staff questionnaires are collated and as a result statistical information is produced in the form of a “service improvement & quality assurance file” for the home. The registered manager stated that the information collated is used to ensure that the quality of care to residents is continually improved. The staff are ensuring that all health and safety checks are carried out regularly. Fire drills and tests have been occurring regularly and all safety certificates such as gas, lift, water, London Fire and Emergency Planning authority (LFEPA) and Portable Appliances Test (PAT) were seen and were up to date and in order. Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 23 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 X 2 3 3 X 4 x 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 1 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 x Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 24 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 YA20 Regulation 13 (2) Requirement The registered persons must ensure that the correct recording procedures are followed when administering medication. The registered persons must ensure that the socket in the kitchen is made safe. The registered persons must ensure that all staff receive regular recorded supervision. (Previous timescale of 31/10/05 not met). This requirement is restated. Timescale for action 21/04/06 2. 3. YA24 YA36 23 (2) (b) (c) (4) (a) 18 (2) 21/04/06 26/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rela Goldhill Lodge DS0000010535.V288280.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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