Inspection on 18/07/07 for Spanish & Portuguese Jews Home For The Aged

This inspection was carried out on 18th July 2007.

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

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

Other inspections for this house

Spanish & Portuguese Jews Home... 28/11/06

Spanish & Portuguese Jews Home... 07/11/05

Spanish & Portuguese Jews Home... 20/04/05

Spanish & Portuguese Jews Home... 06/12/04

Spanish & Portuguese Jews Home... 20/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Spanish & Portuguese Jews Home For The Aged Edinburgh House 36-44 Forty Avenue Wembley Middlesex HA9 8JP Lead Inspector Julie Schofield Key Unannounced Inspection 09:25 18th and 19th July 2007 X10015.doc Version 1.40 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 Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.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. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spanish & Portuguese Jews Home For The Aged Address Edinburgh House 36-44 Forty Avenue Wembley Middlesex HA9 8JP 020 8908 4151 020 8908 3103 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) Spanish & Portuguese Jews Home for the Aged Ms Christine Gilmore Care Home 51 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (41) of places Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 Brief Description of the Service: Edinburgh House is a home accommodating up to 51 elderly Jewish residents and provides personal care. It is part of a complex, which includes sheltered housing units and a day centre and is situated on Forty Avenue. This is a busy road linking Wembley Park with East Lane. Transport facilities include bus routes and a nearby underground train station (Wembley Park). The home has a large car park in the grounds and there are garden/patio areas around the building, which are attractive in appearance. The home consists of three floors (ground, first and second) and there are residents’ bedrooms and toilet/bathing facilities on each floor. There are a number of lounge areas on the ground floor including a large entrance hall that opens into a conservatory and there are residents using each of the communal spaces in the home. One lounge (Sunflower) is for the mentally frail residents. Rose Lounge is for the high dependency/very frail residents and is situated on the second floor. The home has a spacious dining room for most of the residents although Sunflower lounge and the Rose lounge have their own dining area/room. There are separate meat and milk kitchens, in accordance with dietary laws. There are offices on the ground floor for the manager and other senior staff. There is also a suite of offices on the first floor, which are used by the finance staff. The home has a number of pets. Fees charged for residents vary between £530.50p and £610 per week. Details may be obtained, on request, from the manager of the home. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of 3 visits to the home. The first and third visits were carried out by Julie Schofield and on the second visit Gail Freeman, the Regulation Manager, accompanied the Inspector. The first visit was on the 18th July and began at 9.25 am and finished at 3.50 pm. Discussions took place with the manager, records were examined and policies and procedures checked. The second visit, which took place between 9 pm and 10.30 pm on the 18th July included a tour of the premises and talking with members of staff on duty and with residents. The third visit took place between 10.30 am and 5.05 pm on the 19th July and during this visit records were examined and case tracking took place. The Inspector also talked with residents and with members of staff. A survey of relatives, carers and advocates was undertaken and 10 completed forms were returned. They provided a wealth of positive comments regarding the service provided. A relative wrote of a “loving and homely atmosphere”. Another relative commented that many care homes they had visited “could do well by visiting Edinburgh House”. One relative said it met the needs of the resident “100 ”. A survey of residents was also carried out and those that were able to, responded. Again comments were positive about the overall standards of care. What the service does well: The home provides a full programme of activities for residents to enjoy both inside and outside the home. It is to be commended for involving relatives in some of these and for offering residents the opportunity to have a holiday. The atmosphere in the home is lively and a resident said, “The place is buzzing with laughter”. They said that they were “loving it” when talking about living in the home. Another resident said that they were happy that they had come to Edinburgh House. The pets help to build a “homely” environment and the Inspector noted the pleasure that they gave to many residents. Stroking the cats and making a fuss of the dog had a calming affect on some residents and watching their movements gave them an additional interest in life. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 6 The home recognises the individual needs of residents and one resident shared their memories of their recent birthday. The resident had not wished to make a fuss because the resident didn’t have any relatives to invite to the party. The staff reassured the resident that they were now the resident’s family and that they were happy to make a party for them. The resident said that it was wonderful and that they felt special What has improved since the last inspection? What they could do better: During this inspection 6 statutory requirements were identified. The recording of the administration of medication must be complete and up to date. (This is an outstanding requirement). Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 7 A record must be kept of all complaints received. Records must include the date on which the outcome was relayed to the complainant. (This is an outstanding requirement). All references, checks and required documents must be obtained before a member of staff commences duties in the home and kept on file. (This is an outstanding requirement). The authenticity of references must be checked before they are accepted. The annual quality assurance survey must take place. (This is an outstanding requirement). 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. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.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 Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.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): 3, 4, 6 People who use this service experience good outcomes in this area. Carrying out an assessment of the resident, prior to admission, ensures that the needs of the resident are identified and that the home is able to determine whether these can be met. Specialist care offered by the home is underpinned by training for the staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is the home’s policy that the manager, or senior member of staff, meets the prospective resident as part of the pre-admission procedure. A full and detailed assessment of need is undertaken and recorded. Relatives, and the resident if possible, visit the home prior to the admission. For many new Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 10 residents the home is known to them or their family or has been recommended to them by a friend. Two case files of residents that had been admitted to the home since the last inspection were examined. The local authority funded one resident and their file contained a copy of the local authority care plan, social worker’s report and hospital information. A comprehensive pre-admission assessment profile had been carried out by the home and a copy of the report was on file. The initial placement review had taken place. The second resident was privately funded and the file also contained a pre-admission profile and the minutes of an initial review meeting. There was evidence that relatives were involved in the assessment and review process, where possible. The home provides a service for Jewish residents and the home honours each Jewish festival. Meals prepared and served in the home are in accordance with Jewish dietary laws. Most of the staff team are non-Jewish and they receive training in the Jewish culture and religion. This specialist training begins during their induction and includes sessions given by an executive member of the committee overseeing the home. Specialist training is given on an ongoing basis and this is often delivered in advance of particular festivals e.g. Passover. Staff have also received training in respect of the rituals surrounding the death of a Jewish person. A relative commented that the home “catered for all the needs of observant Jews”. Another relative confirmed that all the resident’s “religious requirements are met”. Residents said that all aspects of the home respected their beliefs. Within the home there is a dementia care unit and all staff working on this unit have undertaken dementia care training. The home does not offer an intermediate care service. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.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, 10 People who use this service experience good outcomes in this area. Residents are assured of a service that meets their individual needs by regular reviews and evaluation of their care plans. The health and well being of residents is promoted through regular health care checks and appointments. Residents are supported in taking their medication, as prescribed by their GP, in order to maintain their general health but records need to be complete and up to date. Discreet and caring support is given to residents by staff so that the privacy and dignity of the resident is respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has recently been training for the senior staff in respect of developing care plans for residents. The format of the care plan is being made more user Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 12 friendly and includes a document called “My Story”. There is a new care needs assessment, completed after admission, where the present identified needs are recorded, action to be taken is detailed, goals are listed and an evaluation is carried out. Care plans include a manual handling care plan and a risk assessment in case of falls. Two statutory requirements were identified during the previous inspection. The first requirement was that a comprehensive review of the care plan and placement takes place every 6 months and is convened either by the home or by the placing authority. The resident, and their representative, must be invited to attend. Five case files of residents that had been admitted to the home prior to the previous inspection were examined. There was evidence that the home has started a programme of convening 6 monthly review meetings and that relatives had been invited to attend, according to the wishes of the residents. The new format for the 6 monthly reviews included a review of personal care, dietary, health, social and emotional needs and the format is being introduced for all clients. The requirement is now met. One resident had moved from Poppy lounge to Sunflower lounge (dementia care) and there had been a review meeting after 1 month to review the decision and to evaluate its success. This is good practice. The second requirement was that the monthly progress reviews of the care plans are carried out and recorded on a consistent basis. It was noted on the five case files examined that these were now being carried out on a regular basis. The requirement is now met. At the time of the inspection 1 of the residents had a pressure ulcer that was receiving treatment from the District Nurse. Special equipment e.g. pressure relieving mattresses and cushions are in use in the home. Residents are encouraged to walk as a form of exercise and an exercise class (providing gentle exercise for residents sitting in a chair) takes place each week in the home. A relative commented, “My mother’s health has greatly improved. She is now able to walk without a frame”. A statutory requirement was identified during the previous inspection that when a local authority is funding the placement of a resident, they are involved in the decision regarding the use of cot sides, where a risk assessment has identified a need. This is to be discussed at the next review meeting attended by the local authority so the requirement is now met. Case files contained evidence of access to health care services in the community including the dentist, optician, chiropodist, physiotherapist, district nurse and GP. There was a record that the resident had access to a flu jab, if they wished. Residents also had access to out patient appointments at the hospital including the cardiac, dermatology and plastic surgery departments. Staff assist residents with their personal care needs. A relative commented, “My mother always looks nice. Her hair is cut and styled; nails varnished” while another relative wrote that the home “cares well for the physical needs of residents”. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 13 A statutory requirement was identified during the previous inspection that all records of the administration of medication are up to date and complete. Initials had not been recorded on 5 occasions on the 18th or 19th July and this involved 3 members of staff. Therefore this requirement remains outstanding. The home uses the blister pack system for administering medication. All staff administering medication have received training. Each resident has their own single bedroom and some rooms have an ensuite toilet. Two residents that had an ensuite bedroom confirmed that they appreciated the additional privacy that this gave. Residents confirmed that if they needed assistance with bathing etc their privacy and dignity were respected. It was noted during the inspection that if a member of staff wished to speak to a resident that was in their room, the member of staff knocked on the bedroom door and waited to be invited in before entering. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.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, 15 People who use this service experience good outcomes in this area. A comprehensive programme of activities, both inside and outside the home provide residents with opportunities for stimulation and enjoyment. This is commendable and residents expressed their satisfaction with these. Residents said that they enjoyed the company of their visitors, who were made welcome by the staff when they visited the home. Residents praised the atmosphere in Edinburgh House and said that they were able to exercise choice in their daily lives. Residents’ nutritional needs are met through the provision of a diet that is wholesome and varied and which is in accordance with religious and dietary laws. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activities take place both inside and outside the home. The home has a minibus to facilitate outings. Activities taking place in the different lounges are Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 15 appropriate to the skills and needs of the residents. A discussion group takes place on a weekly basis and there is a monthly Yiddish session. There is also a monthly knitting group to which relatives and members of staff are invited. The squares knitted are sent to the Feed the Children Society. Some residents attend a club and/or a day centre during the week. The home had recently arranged for 2 groups of residents to take part in a holiday to the Isle of Wight, staying in a holiday cottage. Nine residents went on the holiday during the first week and 8 residents went on holiday in the second week. Two residents that took part in the holiday said that they enjoyed themselves. Although the weather during the summer has been poor, up to date, there have been outings to Henley and to Aldenham Country Park. Relatives were invited to take part in the outing to Aldenham, as it was a sponsored walk to raise money for the McMillan Service. A resident listed all the activities they took part in including word games and keep fit. Relatives said that they were pleased that outings and regular entertainment was offered to residents. A relative thought that perhaps music or even television could be played more in Rose lounge. One relative thought that a little more encouragement might persuade their resident to take part in activities and outings and stop the resident saying that they are bored. A relative suggested that a timetable of activities is put on the notice board so that visitors can see what is going on day-to-day. Residents said that they are able to receive visitors, either in their room or in one of the lounges, or sit with them in the garden. The manager said that there have been occasions where the resident has declined to see a visitor and their wishes have been respected. While visitors are welcome they are asked to respect the privacy of residents at mealtimes and not enter the dining room. Certain religious festivals are times for quiet reflection and visitors are asked to respect this. Information about visiting is contained in the brochure. A relative wrote of the home’s “welcoming and friendly environment” while another commented “I am welcome to visit the home at any time of day”. A relative confirmed that they are able to keep in touch as the resident is called to the telephone when the relative rings. One relative said, “They engender a family atmosphere. All relatives are encouraged to take part in activities”. Residents are encouraged to make choices in their day to day lives and residents said that they were able to choose whether they wish to take part in activities, choose whether they want to spend time in their rooms, choose whether they want to socialise, choose from dishes on the menu and choose when they get up in the morning and when they go to bed at night. The Inspectors noted that at 9.00 pm a large number of residents were sitting in the lounges and that after this time residents were returning back to Edinburgh House, after visiting relatives. The manager said that all the residents receive support with their financial affairs, mostly from their relatives. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 16 The manager said that a new cook is in post and that he has developed a wide range of home cooked vegetarian options. The home also provides meals suitable for low fat diets and for diabetic residents. Staff give assistance with feeding, when required. A relative wrote that the food “was of an excellent standard” and residents confirmed that the food was good and that it met Jewish dietary laws. Residents said that the menu included choice. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 17 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, 18 People who use this service experience adequate outcomes in this area. A complaints procedure was in place and residents said that they were able to bring any concerns to the attention of the senior staff. However records must be more detailed to assure complainants that their concerns have been listened to and investigated. Protection of vulnerable adults training for staff and familiarity with the home’s procedure and the interagency guidelines contribute towards the safety of residents. However, recruitment practices need to protect the safety and welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy and procedure in place. The brochure includes a copy of the complaints procedure. It is also on display in the home. A complaint was made to the Commission for Social Care Inspection (CSCI) since the last inspection. The home was asked to investigate and the report forwarded to the CSCI responded to the issues raised. The complaint was not upheld. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 18 Two statutory requirements were identified during the previous inspection. The first requirement was that information in the complaints procedure about the regulatory authority for the home is up to date. The manager said that this has now been updated and so the requirement is met. The second requirement is that complaints records include the date on which the outcome of the investigation is made known to the complainant. The manager said that 1 complaint had been made in 2007 and this had been at the Annual Court and had been dealt with at the time. Therefore the timescale for compliance with the requirement has been extended. However there was no record of the complaint made at the Annual Court in the complaints book. Residents taking part in the inspection said that if they had a complaint they would speak to someone in the home, mentioning managers or senior staff and said that it would be listened to and acted upon. However a resident that completed a survey form wrote that they did not think that staff passed on any of the resident’s complaints to senior staff. There is a protection of vulnerable adults policy and procedure in place. It includes a link to the whistle blowing procedure and the manager said that staff have received a reminder about the need for whistle blowing if a member of staff were to be concerned about poor care practices. Training is given to staff during NVQ training and during in house sessions. The manager has attended a refresher course since the last inspection. There is a copy in the home of the local authority interagency guidelines in the event of abuse. The manager said that no allegations or incidents of abuse have been recorded by the home. Policies and procedures are in place in relation to the safe handling of residents’ monies and in relation to the conduct of staff e.g. not accepting gifts or gratuities from a resident. Recruitment practices do not promote and protect the welfare of service users (see Standard 29). Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 19 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, 26 People who use this service experience good outcomes in this area. Residents enjoy comfortable surroundings that are maintained to a good standard. Residents are assured of hygienic surroundings as good standards of cleanliness prevail. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The location of the home is on a main road in Wembley and is close to a synagogue. It is conveniently sited for bus routes, underground stations and shops. During the inspection a site visit was carried out and it was noted that the home was in a good state of repair with furnishings and fittings of a good Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 20 quality. Lounge areas are “homely” in appearance. Residents said that they liked their rooms and 1 resident said that it was big enough for two people. Two residents that had their own ensuite facility said that they appreciated this. The home has attractive garden and patio areas and when the weather is good they are popular with residents, and their visitors. A resident said that they liked to sit out in the lovely garden. One resident described the home as like a 4 star hotel, but without a swimming pool. Staff receive training in food hygiene and infection control procedures during their NVQ studies. There has also been the opportunity to attend training for caring for a resident with MRSA. The manager and resources manager recently attended training in relation to waste management for businesses. It was noted during the site visit that all areas of the home were clean and tidy and free from offensive odours. Laundry facilities are sited away from any areas where food is stored, prepared or consumed. Washing machine programmes have a sluicing cycle. Residents and relatives commented that the home is kept clean and fresh. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 21 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, 30 People who use this service experience adequate outcomes in this area. Residents are assured of sufficient staff on duty to meet their needs. Residents benefit from a service provided by carers that have demonstrated their skills and understanding through NVQ training. Recruitment practices fail to protect the safety and welfare of residents. A comprehensive programme of training for staff encourages good working practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the rota was seen. There are dedicated staff for each of the Sunflower, Rose and Camilla units. A group of carers work across the remaining 2 units, Poppy and Jasmine. It was observed that there were sufficient staff on duty to meet the current needs of existing residents. There is a separate rota for managers and senior staff and in addition, a duty rota. At night there are 4 staff on duty consisting of a senior and 3 carers. Separate catering and domestic staff are employed in the home. A relative wrote that there is a good staff to residents ratio. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 22 Residents said that staff were very good and that “they anticipate your needs”. A resident described the staff as “her friends”. One relative thought that some staff are hampered in communicating with visitors and residents by a lack of English and by their accent. However the manager confirmed that training in English as a second language continues to be offered to staff. Relatives’ comments regarding the staff team included that they could not fault the carers in any way, “can’t praise the staff team enough”, that the staff “are very kind and caring”, “very cheerful and take the time to talk individually to my mother” and “first class, caring and cheerful staff”. One relative commented that it was inevitable that many staff are very good but others less so. A statutory requirement was identified during the previous key inspection that 50 of care staff achieve an NVQ level 2 qualification. A discussion took place with the manager regarding progress towards meeting this target. After comparing the number of carers on the rotas and the number of qualified carers it was noted that the home has now met the target, and the requirement. In addition to the staff holding either an NVQ level 2 or level 3 qualification a further 3 staff are studying for an NVQ level 2 qualification and another member of staff is studying for an NVQ level 3 qualification. A statutory requirement was identified during the previous inspection that each staff file contains 2 satisfactory references, proof of identity and evidence of right to work, if required. Five staff files were examined on the first inspection visit but some of the following information was provided on the third inspection visit, after the manager had spoken to the recruitment agency. The 5 files included a file belonging to a member of staff recruited since the last inspection. It was noted that 3 of the 5 files contained an enhanced CRB disclosure, 1 file contained a pova first check (pending the return of the CRB disclosure) and 1 file contained an Israeli police check. The manager said that the agency has forwarded the application for a CRB and that the police check is a “holding requirement” according to the Home Office scheme for students. Each file contained proof of identity e.g. passport details. One file contained 2 satisfactory references. Three files each contained 2 references that were addressed “to whom it may concern” and had been provided by the applicant. However 2 of the 3 files belonged to students that were recruited through an agency and the agency had the responsibility for checking the authenticity of these references. One of the five files did not contain any references. One of the 5 files did not contain evidence of right to work when the person held an Algerian passport. Within the staff team there are a number of staff for which English is not their first language. These staff are encouraged to undertake a 6-week training course in “English as a Second Language”. Staff confirmed that they had undertaken training in safe working practices and had undertaken courses tailored to meet the needs of residents. Staff working on the dementia care unit confirmed that they had received dementia care training. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 23 Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 24 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, 38 People who use this service experience good outcomes in this area. Continuing to undertake further training enables the manager to develop her knowledge, skills and understanding and to provide a service that is responsive to the needs of residents. Information gained through the quality assurance systems is used to shape the future development of the service and ensure that the changing needs of residents are met. However the annual satisfaction survey is overdue. Support is given to residents who need assistance in managing their finances so that residents’ financial interests are protected. Training for staff in safe working practice topics promotes the health and safety of residents, staff and visitors to the home although the storage of food in the fridge needs to be checked. Testing and servicing of equipment and systems in the home demonstrate that they continue to be safe to use. This judgement has been made using available evidence including a visit to this service. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager has completed the RMA. She was appointed to the post of manager of the home prior to the Commission for Social Care Inspection and prior to its predecessor, the National Care Standards Commission. Since the last inspection she has undertaken palliative care training and a refresher protection of vulnerable adults training course. Certificates on display in the manager’s office were in respect of dementia care training, risk assessment training, managing and working safely and an NVQ internal verifiers award. Several relatives commented on the competence of the manager. One relative wrote “I think that the Head of Home and her executive staff are to be congratulated for carrying out their work in a professional manner, with efficiency and understanding”. Two statutory requirements were identified during the previous inspection. The first requirement was that an annual quality assurance survey is undertaken, which includes comments from residents, their relatives, professional visitors to the home and members of the placing authorities. This has still to be arranged for 2007 and although the requirement remains outstanding. The second requirement was that residents’ meetings, involving all residents wishing to take part, are held on a monthly basis. A resident confirmed that these are held on a monthly basis and that she keeps a copy of the minutes in a file. The requirement is now met. The Annual Court (AGM) has taken place and included a question and answer session. Relatives were invited to attend. Relatives can also attend the Friends of Edinburgh House meetings. Day to day feedback is given by residents by speaking directly to the manager or senior staff or by raising points during the discussion group, which are then relayed to the manager. It was observed during the inspection that the manager and senior staff have an “open door” policy, which applies to residents and their relatives. Committee members visit the home, including on an unannounced basis, and feedback their comments to the home during committee meetings attended by the manager of the home. Only 5 residents have assistance from the home with their personal allowances. No one in the company acts as an appointee. Two residents prefer to receive their allowance in cash each week and records are kept. The resident signs to acknowledge receipt of the money. The other residents have their own accounts and their personal allowance is transferred into their account. The records include a running total, details of any items of expenditure (accompanied by receipts) and details of credits into the accounts. Detailed records of money left with the home by relatives on behalf of residents are also kept. Accounts are subject to auditing by an accountant. Policies and procedures are in place in respect of handling residents’ finances. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 26 A statutory requirement was identified during the previous inspection that the testing of the portable electrical appliances takes place. The requirement has now been met. There were valid certificates for the servicing/checking of the hoists, lifts, fire alarms and emergency lighting, fire extinguishers and the electrical installation. There was an up to date Landlord’s Gas Safety Record. There was evidence that fire drills are carried out on a regular basis and that a list of attendees is kept. Fire alarm testing is carried out on a weekly basis and was up to date. A visit by the LFEPA has taken place since the last inspection. The manager said that the matters identified are in hand and that an external company has been contracted to produce a fire risk assessment for the home. There was evidence that staff have received training in safe working practice topics. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 27 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13.2 Requirement Timescale for action 20/08/07 2 OP16 22.1 & 22.3 3 OP16 22.4 4 OP29 19.1 The registered person must ensure that at all records of the administration of medication are up to date and complete to demonstrate safe working practices are in use to promote the welfare of the residents. (Previous timescale of the 1st January 2007 not met). The registered person must 01/09/07 ensure that all complaints are recorded to demonstrate that the investigation and outcome has addressed the complainant’s concerns. The registered person must 01/09/07 ensure that all complaints records include the date on which the outcome of the investigation is made known to the complainant to demonstrate that the complainant is satisfied that their concerns have been listened to and addressed. The registered person must 01/09/07 ensure that each staff file contains all the necessary references, checks and required documents to ensure that DS0000017448.V340826.R01.S.doc Version 5.2 Spanish & Portuguese Jews Home For The Aged Page 29 5 OP29 19.1 6 OP33 24.1 and 24.3 unsuitable persons are not recruited to work in the home. (Previous timescale of the 1st February 2007 not met). The registered person must only 20/08/07 accept references where they are satisfied of their authenticity to ensure that unsuitable persons are not recruited to work in the home. The registered person must 01/10/07 ensure that an annual quality assurance survey is undertaken to enable this information to be used in the development of a service that meets the changing needs of residents. (Previous timescale of the 1st April 2007 not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP12 OP12 OP16 Good Practice Recommendations That a review of the use of music or the television in Rose lounge is carried out. That a list of activities is placed on the notice board so that residents can see what takes place during the week. That a copy of the complaints procedure is left in the bedroom for each new admission to the home. Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 Spanish & Portuguese Jews Home For The Aged DS0000017448.V340826.R01.S.doc Version 5.2 Page 31 - 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. 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