Inspection on 18/01/06 for St Joseph`s Care Home

This inspection was carried out on 18th January 2006.

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

The inspector 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

St Joseph`s Care Home 12/01/09

St Joseph`s Care Home 19/01/08

St Joseph`s Care Home 26/01/07

St Joseph`s Care Home 29/07/05

St Joseph`s Care Home 23/02/05

St Joseph`s Care Home 20/07/04

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

CARE HOMES FOR OLDER PEOPLE St Joseph`s Care Home St Joseph`s 38-40 Hindes Road Harrow Middlesex HA1 1SL Lead Inspector Clive Heidrich Unannounced Inspection 18th January 2006 8:40 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 St Joseph`s Care Home DS0000038579.V278805.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 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. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Joseph`s Care Home Address St Joseph`s 38-40 Hindes Road Harrow Middlesex HA1 1SL 020 8863 2868 020 8427 2146 wayne.hughes@tiscali.co.uk 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) Hazelwood Care Limited Wayne H. Hughes Care Home 19 Category(ies) of Dementia - over 65 years of age (19) registration, with number of places St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2005 Brief Description of the Service: St Josephs is a privately owned care home for up to 19 older people who have dementia or related conditions. There were no vacancies at the time of this inspection. The home is part of the Hazelwood Care Organization. The home is a conversion of two semi-detached houses that interlink on the ground and first floor. Service user accommodation is on the ground and first floor, with seven bedrooms downstairs including two double rooms. There is accommodation provided on the second floor for three live-in staff. Access to the first floor is by stairs, or chair-lift on the house #40 side. The large lounge and dining area is split into two distinct sections. There is a private garden of a reasonable size to the back of the home. The home is situated close to local shops and transport facilities. There is a small, open forecourt at the front that has some parking facilities. Parking restrictions apply on the road outside the home. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place across a dry morning in mid-January. It finished at 12.30pm. Its focus was both on compliance with previous requirements, and on assessing the core standards that were not inspected during the July 2005 inspection. Consequently, the inspector met with six service users and most of the staff present. The inspection also included the consideration of the home’s environment, the records available, and the observations of the care being provided. The manager was not due to be working in the home during the inspection, for reasons of leave, but nonetheless attended from about half-way through. Feedback was consequently discussed with the manager at the end of the visit. The inspector thanks all involved in the home for the patience and helpfulness during the inspection. What the service does well: What has improved since the last inspection? St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 6 All requirements from the last inspection report have been addressed. Staff stated that teamwork between themselves has improved. The inspector observed staff treating service users kindly and warmly throughout the visit. Staff training provision has happened to the extent that most staff have now received most statutory training. There were a number of new items of furnishing in place communally, including a number of sofas, a new television, a new washing machine and a new dishwasher. The service user guide has now been distributed amongst all current service users and representatives. Service users’ plans of care have been generally reviewed and updated, and are now judged as exceeding the minimum standard. Locks to bedroom doors are now provided to service users where wanted by the service user and considered safe. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 7 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 St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Prospective service users and their representatives are provided with appropriate information to help them make choices about whether the home is suitable for them. The manager ensures that he obtains assessment details about prospective service users, including through his own visits to the service user, to ensure that the home can meet the service user’s needs. EVIDENCE: The manager stated that all service users, or their representatives where applicable, had now been given a copy of the home’s service user guide, as previously required at the last inspection. Records confirmed this. The manager stated that only two service users had moved into the home since the last inspection. Checks of the assessment processes for one of them found that a copy of the social worker’s assessment had been obtained, and that the manager had met with the service user and conducted his own assessment of the service user’s needs. This latter assessment was seen to be suitably detailed, clearly individual to the service user, and included a St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 9 statement that the manager felt that the home could meet the service user’s needs. It is recommended that the assessment include reference to the service user’s social interests, hobbies, religious and cultural needs, and family and friends, to better enable appropriate planning to address these needs if placement is agreed. The care plan of this service user included information about how to handle the service user’s settling-in process. It was also noted by management that a formal review meeting with the service user and their social worker had recently been held to confirm the placement as suitable. Discussions with a number of service users found that most could state that the home is able to meet their individual needs. Records, and observations of care, found this to mostly be the case. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The detailed needs of service users are well set-out within their individual plans of care. Service users’ health and medication needs are fully addressed. Service users are generally treated warmly and with respect by staff. However improvements must be made to how staff support service users with wheelchairs and manual handling. EVIDENCE: Requirements from the previous inspection about service users’ plans of care were found on this occasion to have all been implemented. Checks of three such plans, that are easily available to staff, found that the plans stated each service user’s relevant needs, how these would be addressed, and what the objectives are. The plans had expanded to include statements about the service user’s key needs in terms of health, communication, and clothing. The plans referred to providing appropriate levels of choice, independence, safety, and stimulation, and were clearly written with the service users’ individual needs in mind. The plans were also sufficiently up-to-date. There was observed St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 11 evidence that the plans were usually being followed. It is consequently judged on this occasion that the standard of care planning has been exceeded. Records showed that most service users had had a formal review meeting involving their funding authority, where applicable, within the last 15 months. The manager monitors and calls for regular meetings, which is good practice. There were no concerns about how the home ensures that service users’ health needs are met. There was recent opticians’ and GP input according to records and feedback. The manager demonstrated how his computer system keeps track of service users’ health appointments, both with outcomes for those in the past and to flag up where further appointments are needed. This complements the newly-established summary health sheets that were in place on service users’ files. The home monitors the weight of service users monthly, making records of both the weight and whether there is any increase or decrease across time periods, so that action can be taken where needed. Pressure care equipment was seen to be suitably in place for a sampled service user, both within the bedroom and in the lounge. This was in accordance with the service user’s care plan. Service users’ files included up-to-date general and falls risks assessments, and included key actions in response to these assessments. A sample check of the medication cupboard and systems was undertaken. The home receives blister-pack dispensing systems from a pharmacy that were seen to be securely stored within a medicine cabinet. The home has facilities for controlled drugs but there were none being stored or used on this occasion. The inspection checks found no concerns with the recording and administration of medications, including for the receiving of medicines from the pharmacist. There has been recent training of some staff in medication procedures according to records seen. Checks of the homely remedies found that appropriate records are kept of administration and that the remedies are not used extensively. Those homely remedies in use had been approved of by the main GP in the home according to a letter seen. The inspector observed a number of interactions between staff and service users that showed that staff treat service users kindly and warmly. Staff were seen to take time to chat and interact with service users as they walked past, and they paid attention to service users’ requests. One service user and a staff member were heard singing together whilst the service user received support to dress in their room. Most service users fedback positively about how staff treat them. Care plans guided staff towards treating service users respectfully. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 12 The inspector viewed a few transfers of service users from wheelchairs into chairs under staff supervision. In one case, the side of the wheelchair was removed and the service user given time and encouragement to transfer herself into the chair. In another, staff left the wheelchair brakes off, and lifted the service user under the arms to move her into the chair. One of the staff was overheard to say that they should have used the hoist. The hoists themselves were not seen to move from their positioning in one corner of a hallway, and were later found to have service users’ laundry drying on them pending the repair of the tumble-drier. This was discussed with the manager, who noted an awareness of hoists not always being used despite recent manual handling refresher training for staff. He stated that he undertakes checks of appropriate practices in this respect from time to time. The evidence from this inspection suggests that hoists are not always used where assessed as needed, which puts service users and staff at risk of injury. The manager must ensure that appropriate hoisting, of service users who have been assessed as needing it for key transfers, is always undertaken. In observing three service users being brought into the lounge in wheelchairs, the inspector noted that all three did not have footplates on which to rest their feet. This may cause the service user discomfort, and puts them at risk of injury. The manager agreed to ensure that footplates are always used for service users’ wheelchairs unless any specific service user has been safely assessed as not wanting or needing them. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Service users are generally enabled to exercise choice and control over their lives. One minor improvement is needed with respect to information that is provided to service users about meals. The home works to ensure that service users’ lifestyles match service users’ preferences and meet service users’ needs. Service users are able to maintain contact with family and friends, and with the local community. EVIDENCE: At the time of arrival, there were two service users in the split lounge areas. Later on, at 10:15, most service users were in the lounge. The cook served tea and biscuits to all at this stage. Discussions with staff established that they had intended to provide games for service users’ entertainment during the morning, as is usual, but this had on this occasion fallen through. However, those service users spoken with stated that they have enough to do in the home. Additionally, the quality audit report referred to under standards 31-38 noted significant improvements with activities and stimulation of service users, and those care plans seen paid good attention to this aspect of service users’ needs. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 14 Photographs are taken of some activities that take place in the home. The inspector was shown the album, and saw amongst other things shots of the pantomime that was presented in the home for service users. Lunch was being served at around midday. Comments from service users about the food in general was positive. One service user was able to say that they can ask for, and be given, a different meal if they do not want the main meal that is being served. There was no indication prior to lunch as to what was being served that day. The manager stated that they used to display this information but that the displaying equipment had become broken. This process must be re-instated, to enable service users to be informed of the meal choices in advance of meal. There were records of phone calls and visits from relatives and friends of service users. Care plans noted about both family input and about other community input such as weekly hairdresser visits. Service users generally fedback that there are no concerns with visitors or visiting arrangements. Service users’ plans of care included general and specifically-individual statement about providing service users with choice and control over their lives, for instance in attempting to recognise what the communication of certain service users means and therefore how to respond, and in how to assist service users with choosing clothing for the day where needed. One service user was able to state that they now have a key to their room that they can lock the door with if they wish. They sometimes do this, and it was noted to be useful. Service users generally fedback that they are satisfied with the amount of control they have over their lives. Some were able to note that they can choose when to get up and go to bed, for instance. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users are protected from abuse through the actions of the home. The policy in this respect should be updated. EVIDENCE: Service users were generally able to state that they feel safe in the home. There was one recent incident of a service user kicking another service user that had been recorded about. The manager stated that a prompt referral to the psychiatrist, for support for the aggressive service user, had been made, and additionally that an urgent formal review meeting had been called. This suggests that physical aggression from service users is not accepted in the home, as is appropriate. The manager supplied the inspector on request with a copy of the organisation’s adult protection procedure. It was dated from 2002. Whilst it made good reference to upholding the safety of service users and informing the relevant social worker should an allegation occur, it lacked some details about the procedures the home should take in that scenario, including about consideration of staff suspension if an allegation is made against a staff member, and about upholding appropriate confidentiality. It is recommended that the manager revise the policy in conjunction with the adult protection procedures of relevant funding authority boroughs involved in placements in the home. The manager ensures that all employees have Criminal Record Bureau checks, according to records and a suitably policy that were seen. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. Service users live in what is generally a safe, clean, and reasonably-maintained environment. Some faulty equipment issues, and one issue of malodour, must be promptly addressed, but the manager has made begun to make arrangements in respect of all of these. Service users’ bedrooms are safe and comfortable. EVIDENCE: There were a number of new items of furnishing in place communally, including a number of sofas, a new television, a new washing machine and a new dishwasher. The manager reported however that both the dishwasher and the tumble drier were not working, the former breaking-down over Xmas. Laundry was hence being dried around the home, including on the mobile hoists that were being stored out of the way in a quiet area of the home. The home itself was suitably warm. Arrangements were in place to have these broken items fixed or replaced, but this must be promptly achieved to uphold health and safety standards. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 17 The manager noted that there had recently been a small leak from the roof of the home into the interior. He stated that this had been fully fixed through extensive refurbishment of parts of the roof, and that the leak had not significantly impinged on service users. This shows appropriate reactive procedures. There were reasonable standards of cleanliness seen throughout the home. There were no malodours evident except for in one bedroom that the manager volunteered to inform the inspector about. The manager stated that this issue had arisen at the service user’s recent review meeting, and that he was planning to have the carpet therein and in other areas of the home professionally cleaned. This is required. The inspector noticed that staff change disposable gloves in-between providing personal care to service users. This helps to prevent the spread of infection. Staff noted that some of them have had infection control training since the last inspection. It was previously required for the manager to audit whether service users wished for, and could safely use, locks on their bedroom doors. The manager noted that this audit had taken place, and had resulted in three such locks being installed. One service user was able to confirm satisfaction with this process. Records showed that there have been checks of the alarm bell systems within the rooms of service users who can use them. There were no other concerns observed with those bedrooms viewed by the inspector. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Service users’ needs are addressed by appropriate levels of knowledgeable and qualified staff. There has been ongoing training of staff. Service users are protected and supported by appropriate recruitment procedures. EVIDENCE: There were four care staff including a senior carer, along with a cook and a cleaner, working at the start of the inspection. These levels were maintained throughout the visit. The rosters checked indicated that there continue to be four care staff on duty in the morning, three in the afternoon, two in the evening, and one between 9pm and 7am. This meets the general staffing level requirements agreed for this home. No agency staff were used within the rosters checked on. The home has a low staff turnover. Records showed that one staff member had left, and two had joined, since the last inspection. Staff stated that teamwork between themselves has improved. Staff presented as knowledgeable about service users’ individual needs during discussions with them, and from most observations of them. Service users mostly fedback positively about the staff. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 19 The business plan noted that three staff achieved NVQ qualification in care in 2005, and a number of others are starting or completing such study in 2006. Training records found that seven staff have the appropriate NVQ or an equivalent qualification, which represents almost the expected standard of 50 . Checks were made of the recruitment files of two staff who began employment in 2005. The files showed that appropriate checks of references, identification, and Criminal Record Bureau (CRB) disclosures take place. Records showed that there had been training in manual handling, 1st aid, fire safety, medication, the prevention of abuse, and infection control, since the last inspection. Staff confirmed this verbally. These training courses were typically for about half of the staff team, which consequently meant that most staff have now received most statutory training. The manager should ensure that further training is provided where there are any individual gaps in training, or where training is out-of-date. There were recorded plans to address this. Records of completed induction processes for new staff were seen. The induction book refers to the standards of the national training organisation throughout. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37, and 38. Service users benefit from the home being run by a competent and registered manager. Staff are appropriately supervised. Good attention is paid to running the home in the best interests of service users. Minor improvements are needed to uphold the health and safety of people in the home, and to ensure that service users’ rights are safeguarded by appropriate record-keeping practices. EVIDENCE: The manager has in post since late 2004, having previously been the assistant manager in the home. He was successfully registered by the CSCI in January 2005. Dealings with the manager during this visit, and since the last inspection, have found him to be honest, conscientious, and knowledgeable. Records showed that he has achieved the NVQ level 4 in management in 2005. One service user was able to say that the manager is approachable. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 21 Checks of a sample of staff files found that recorded supervision meetings are undertaken on a regular basis. The manager explained about further examples of how staff are appropriately supervised. Both the manager and the deputy noted that they routinely undertake care checks at night. They can therefore be more confident that night care of service users is appropriate. The manager had provided the CSCI with a copy of the home’s business plan and quality audit report since the last inspection. Copies of these were found to be available to staff during the visit. The quality audit involved asking each service user’s representative to answer set questions. It was reported that most people returned the forms. It was found that almost all questions had slightly better responses than the previous year, and that there were few areas of concern. Where issues arose, the report stated plans to address the issue. One service user was able to confirm that a meeting of service users, their relatives, and the home’s management had recently and successfully taken place. Records and regularly-used files about service users were on display and easily-available to staff along one wall of the dining room, including on one of the dining tables. The inspector expressed concern to the manager that this private information is consequently easily available to service users and visitors. The manager agreed to make arrangements to keep these files and records more secure, as is required. The inspector found that, according to records seen, service users’ individual daily records noted details about their mornings and their nights, but not the afternoon and early evening period. A summary diary is used to keep a record of any significant service user issues during the day, but it is recommended that daily records be regularly and consistently kept of what happened to each service users during the afternoon and early evening. The requirement from the previous inspection, of the home ensuring that a professional check of portable appliances be undertaken, was seen to have been addressed. The manager recently asked for the local crime prevention unit to visit and assess the house. A report he had prepared of the outcomes of the visit was viewed by the inspector, and it was seen to identify a number of possible hazards that the manager had planned to address through a priority-schedule. Following a recently-notified possible intruder into the garden one night, it is recommended that the key hazards from the consequent assessment be implemented. St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 22 The inspector pointed out to the manager that the wires from the TV next to the kitchen serving-hatch were loose and trailing on the floor, which could present a tripping hazard to people. A similar trip hazard was observed outside the main back door to the garden, in that a mat was seen to have a protruding upturned corner. Service user’s written risk assessments were found to include good attention to the prevention of falls, but the manager must ensure that a practical audit of the home is undertaken to ensure that tripping hazards are minimised. St Joseph`s Care Home DS0000038579.V278805.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 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X X 3 2 2 St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 24 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 The manager must ensure that appropriate hoisting, of service users who have been assessed as needing it for key transfers, is always undertaken. The manager must ensure that footplates are always used for service users’ wheelchairs unless any specific service user has been safely assessed as not wanting or needing them. It is required that the meal choices for the day be clearly displayed in the lounge or dining room, to help inform service users of their choices. The manager must ensure that both the broken-down dishwasher and tumble-drier and promptly fixed or replaced. The manager must ensure that any offensive odours within the home are promptly eradicated. This includes for the one bedroom that the manager identified during the inspection. The manager must make arrangements to securely store the service users’ records that DS0000038579.V278805.R01.S.doc Timescale for action 08/02/06 1 OP10 12, 13(5), 18(1)(a) 2 OP10 12, 13(5), 18(1)(a) 01/03/06 3 OP15 12(3), 16(2)(i) 01/03/06 4 OP19 23(2)(c) 08/02/06 5 OP26 12, 16(2)(k) 08/02/06 6 OP37 17(1)(b) 01/04/06 Page 25 St Joseph`s Care Home Version 5.1 7 OP38 13(4) are kept in the dining area. The manager must ensure that a practical audit of the home is undertaken to ensure that tripping hazards are minimised. 08/02/06 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 OP3 Good Practice Recommendations It is recommended that the home’s written assessment of prospective service users include reference to the service user’s social interests, hobbies, religious and cultural needs, and family and friends, to better enable appropriate planning to address these needs if placement is agreed. It is recommended that the manager revise and update the home’s policy on the protection of service users from abuse, to bring it in line with the adult protection procedures of relevant funding authority boroughs involved in placements in the home. Wire radiator covers should be replaced with more homely versions. It is recommended that daily records be regularly and consistently kept of what happened to each service users during the afternoon and early evening. It is recommended that the key hazards from the visit of the crime prevention officer be addressed. 1 2 OP18 3 4 5 OP19 OP37 OP38 St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Joseph`s Care Home DS0000038579.V278805.R01.S.doc Version 5.1 Page 27 - 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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