Inspection on 30/11/05 for St Josephs

This inspection was carried out on 30th November 2005.

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 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 Josephs 26/07/07

St Josephs 06/06/06

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE St Josephs The Croft Sudbury Suffolk CO10 6HR Lead Inspector Jill Clarke Unannounced Inspection 30 November 2005 10:57 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 Josephs DS0000065099.V265167.R01.S.doc Version 5.0 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 Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Josephs Address The Croft Sudbury Suffolk CO10 6HR 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) 01787 888460 Carefore Homes Limited Lorraine Hodges Care Home 51 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (17), Old age, not falling within any other of places category (34), Physical disability (2) St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection for this home. Brief Description of the Service: St Joseph’s is owned by Carefore Homes Ltd, and are registered to provide residential care for up to 51 people, from 55 years of age and over. Although the home can care for a maximum of 51 people, they have flexibility to take up to 34 frail older people, up to 17 older people who have a diagnosis of dementia, and up to 6 people within the age range of 55 – 64 years, who have a physical disability or dementia. The home opened in August 2005, and is located within walking distance of the town of Sudbury, which offers a range of amenities. These include public rail and bus links, shops, restaurants, hotel, banks, post office and public houses. The home is located on 2 floors, which can be accessed by the 2 passenger lifts or stairs. All 51 bedrooms are of single occupancy and have en-suite toilet and wash hand basin, 22 of which, also have en-suite shower. The home is divided into 2 units, one of which is specialist dementia care unit, which has restricted access and a sensory room. Both units have their own lounges, dining rooms, assisted bathrooms and access to landscape gardens. The home has been decorated and furnished to a high standard throughout. There is hairdressing room, and car parking is available at the front of the home. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over 6 ½ hours, during a weekday in November. As the home only opened in August 2005, this was the home’s first inspection following registration. During the inspection, time was spent in private with 3 residents, and a visiting relative, to hear their views on the home. General feedback was given during conversations with residents (9) throughout the inspection. Time was also spent with members of staff, which included the Registered Manager, Director, Operations Manager, Senior Care Assistants and Care Assistants. A tour of the building, took in all the communal rooms and a sample of 5 bedrooms. Records viewed included care plans, Home’s policies and procedures file, Fire Safety records, staff files and financial accounts (residents). Discussions during the day with people living at the home, and staff, identified that they preferred to be known as residents, rather than service users. This report respects their wishes. What the service does well: The home offers residents a homely environment, in a good located, within walking distance of the town centre. Residents views on the home included, “beautiful place – all new”, “can’t find a criticism”, “can’t fault it – like being on holiday”, “can’t ask for anything better” “I hope they can keep it up when they are full”, and “excellent food”. Their comments on staff included “staff always anxious to please”, “Staff treat us with respect” and “courtesy of the staff – impress me most of all”. This was also reflected in a comment made by a relative who described staff as “very caring” and “good”. A resident, asked if there was anything they would change about the home -if they were running it, replied “if I was doing it myself - there is nothing that I could improve on”. The home has been decorated and furnished to a high standard, and supports residents to maintain links with the community. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 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 Josephs DS0000065099.V265167.R01.S.doc Version 5.0 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, 4, and 5. People wishing to use the service are given sufficient information, and are invited to visit the home, to support them in identifing if the home can meet their needs. EVIDENCE: As part of their registration process, the home was asked to submit copies of their Statement of Purpose, and Residents Guide (Brochure), which gave detailed information on the level of service offered. The resident’s brochure gave people living at the home useful information, which included, meal times, laundry, hairdressing, housekeeping, Church, and Library services. A resident confirmed that they had been given a copy when they arrived, copies were also seen in resident’s bedrooms. Time spent with 1 resident confirmed that they had visited the home prior to moving in, and had taken the lead in deciding which home they wanted to move into. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 9 A relative confirmed that members of their family had come and looked around first. They said that staff showed them around, let them choose which bedroom they wanted for their next-of-kin, and answered any questions. They confirmed that they were given information on the home, felt comfortable to ask any questions, and were made to feel welcome. During the inspection, the manager spent time showing a prospective resident’s relative around the home. Another resident, asked about their admission, said that their family found the home “on the internet”, then arranged to look around. The resident who had moved from another home to be closer to their family, praised the home saying that you “couldn’t compare this” to the care home they had previously lived in. Another resident said that although they were “unhappy at first”, due to having to give up their home, they were now settling in, and “had made friends with everyone”. Time spent privately with 3 residents and a relative, confirmed that they felt the home was able to provide the level of care they were looking for/required. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 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 and 10. People using the service can expect staff to monitor their health, and seek further advice from relevant health professionals, when required. However, the home needs to obtain further information on residents, who have dementia, behavioural and communication needs. EVIDENCE: Time was spent with 1 resident looking at their care plan, to discuss and identify if the information written by staff, agreed to the level of support they wanted, and were receiving. The resident felt the information was correct, as they required minimal help, as they wanted to remain as independent as possible. Another care plan for a resident who had dementia, whose care was tracked during the inspection, was also looked at. ‘Tracking’ the resident’s care involved meeting the resident, speaking to their relative, observing and discussing with staff the level of support given. The resident’s care plan gave information on the resident’s physical needs, and support given, when required by visiting health care professionals (Occupational Therapist, Community Nurse, General Practitioner). St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 11 The information gained from staff over the residents mental health and communication needs, was not fully reflected in the residents care plan. One entry made by staff said “unable to communicate”. This led to discussions about using more detailed behavioural charts and communication sheets, as it was felt the resident would be able to communicate on some level. This may be through their body language, use of message boards (talking mats) or through gestures and sounds. This led to further discussion over the importance of ensuring that staff, who do not know the resident, should be able to have a clear understanding, of any communication difficulties and what level of support a resident needs. It was suggested that this should also be linked in with a behavioural chart, to be able to identify any ‘trigger’ points, which might result in the resident becoming frustrated and distressed. Once identified the care plan should clearly state what action staff are to take, to avoid putting the resident in a situation which may lead to them becoming distressed. Care records held information on any bruises, or injuries that may have occurred during a fall, and completed falls assessment. This led to further discussions, where staff have concerns over residents falling regularly – that they should seek advice from a Falls Co-coordinator. Some entries in the care plans were not always signed and dated. Care plans did not clearly show what on-going involvement, residents and/or their representative had, in developing and monitoring information held in the care plan. This is to ensure that residents or their representative were aware of what was being written about them, and could clarify that the level of care being provided, was what they wanted – and met their needs. Good practice was seen in the use of ‘Life Histories’, although staff said that not all families were happy to complete them. Staff felt completed life histories were very useful in being able to know more about the resident, and could be used to support the resident. For example identify the different members of their family, and any previous hobbies or interests, which could be used to start conversations, or identifying what activities the resident would like to join in with. Discussions with residents confirmed that they felt staff treated them with respect, and were always polite. This included delivering their mail unopened, and knocking (and waiting), prior to entering their bedroom. This was also observed during the inspection. One resident who said that they “couldn’t get used to people calling them by the first name”, confirmed that they had been asked what they preferred to be called, and admitted being called by their first name was more friendly. Staff were observed addressing residents differently, using first and/or surnames. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 12 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): 12, 13,14 and 15. People using this service can expect to be offered a range of nutritious, well presented meals, and supported to maintain contact with the local community. EVIDENCE: Time spent with 1 resident who had just come back from a walk in town, which included stopping off for a drink in a local Public House, confirmed that they were able to take full advantage of the location of the home. They felt Sudbury had a good range of shops, and that they enjoyed going for walks along the river. Another resident spoken with, had just booked transport to go into town, “to sort the newsagent out”, to ensure the right papers were delivered. Discussions with residents who had lived in the area for a while, evidence that they continued to maintain friendships and attend clubs were applicable. Residents spoken to, said they did “not feel restricted” at all, and could come and go as they pleased. A resident went on to say that they could get up and go to bed when they wanted – and as they had trouble sleeping at night – staff would make them a cup of tea, and “have a chat”. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 13 One resident said they were looking to buy a fridge, so they could order sandwiches from the kitchen and eat them for supper when they wanted to. They were aware that they could ask for food at any time, but wanted the extra freedom of not having to ask – but use the fridge as they would in their own home. Staff said some residents had their own kettle, so they could also make their own drinks, although there were facilities available for residents and visitors to make their own drinks. A resident asked if they received enough refreshments replied, “tea and coffee comes around all day”. Residents described the food as “very good”, saying, “if you prefer brown bread – you get it”, that residents are “always offered a sherry before lunch”. Wine was also offered at lunch and evening meal. Time was spent with the residents living on the dementia unit, whilst they eat lunch. The atmosphere was relaxed – very quiet, as residents eat. On 1 table, 2 relatives sat and assisted the resident with their lunch. Staff (2) sat between residents at another table, offering assistance as needed, in a sensitive manner. The third member of staff sat on another table, who although joined in with conversations, and offered assistance as required, was busy writing. Residents and relatives described the food as “excellent”, saying the food was well presented and that “everything is put out neatly”. Time spent with 2 residents, gaining feedback on the home’s routines, said that they enjoyed being able to have their evening meal on a tray – so they could sit, relax, and “watch the news”. Residents spoken to, who were aware that the home was not full, hoped the home would be able to maintain the current level of service when the home became full. This led to discussions about the role of the CSCI, and that another unannounced inspection would be undertaken before March 31st. This would give residents another chance to feedback directly to the CSCI, in person, or using the CSCI comment cards, to give their views. To build up links with the community, staff had invited tenants from a local sheltered housing project, to join the residents for “lunch and entertainment” (15 December 2005). Posters displayed on the resident’s information boards also gave information on the local primary school’s Christmas visit, and ‘InHouse’ activities, which included an “Arts and Crafts Night”. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 14 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): 16. People living at the home, can expect any concerns they have to be listened to, and acted on in an appropriate manner. EVIDENCE: A copy of the Home’s complaint procedure is contained with the Statement of Purpose, and Resident’s Brochure (a copy of which was seen in residents bedrooms). Residents and relatives confirmed that if they had any concerns they felt comfortable to raise the issues with staff. The home records any Complaints, Concerns and Compliments in a book. The home discussed the action taken following 1 complaint, as the book the compliant was recorded in did not give sufficient space to be able to give a clear picture of what action had been taken. The home produced letters and records of meetings to evidence what action they were taking. To be able to keep a clear record, it was suggested that all the information was held in 1 place, and the format used should clearly identify what action had been taken and the outcome of their investigation. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 15 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, 20, 21, 23, 24, 25, and 26. People using the service can expect a comfortable, homely, well-maintained environment, to live in. However, staff must ensure that they follow safe infection procedures, to reduce the risk of any infection being passed on. EVIDENCE: As part the registration process (being granted permission by the CSCI to run as a care home), the home was visited twice before the home opened, to ensure that the building work undertaken met the required standards. This included looking at all the bedrooms, and communal rooms, to ensure they met safety standards, were furnished appropriately, and offered a clean and safe environment. Both the site visits, and this visit, identified that the home was clean, bright, furnished and decorated to a high standard. Bedrooms are supplied with good quality matching furniture and coordinating soft furnishings. Residents are encouraged to bring in their own belongings, to personalise their bedroom. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 16 During the inspection a relative was seen to bring in personal items, which included a basket for the residents dog, prior to the resident moving in. Time spent with 1 resident identified how “helpful” the staff had been in supporting them to personalise their room, which included putting up pictures and shelving units. Whilst walking around the dementia unit, the atmosphere felt cold – although the radiators were on. Further investigation found some windows had been left open, which staff were asked to close, to ensure residents were kept warm. The owner said that they had, had problems with the heating that morning, which had caused the home to be too hot, and the windows, had been opened to give some fresh air. The inspector raised concerns that windows were not being left opened to air the home, and get rid of any odours (although none were detected at the time). If this was the case, staff were informed that they must monitor to ensure that it did not effect the areas the residents were sitting or walking around, to ensure they were kept warm. The owner said that they had been problems with odour, and they were trying out specialist cleaning fluids to eliminate any odours (urine and faeces on carpets) at source. A relative was asked if they felt the dementia unit was kept clean and odour free – they confirmed that the unit was “cleaned regularly”, and although normally odour free, there had been an odour present during 1 of the weekends they had visited. The laundry area was clean and well set out, however on the sink was an item of clothing, stained with bodily fluids, which had been left. Discussion with staff confirmed that they use specialist wash bags which staff place items soiled with bodily fluids (for example faeces, blood) into the bag, which is put straight into a sluice wash. In using the specialist bags, which open during the wash, which reduces the risk of infections being passed around the home. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 17 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): 27, and 29 People using the service should expect the home to monitor staffing levels , and follow safe recruitment procedures, to ensue they employ sufficient staff, to be able to meet residents assessed needs. EVIDENCE: Discussions with residents through-out the inspection, confirmed that they liked the staff, and felt well cared for. One resident commented that “staff pay attention to little details”, and said staff went out of their way to make sure they felt at home. Asked if they thought staff had the training and knowledge to provide them with the level of care they required?, the residents said it was difficult to answer – as they required little, or no support with their personal care. Discussions with a relative, who’s next-of-kin, required a high level of support, confirmed in their view, that staff did have the skills and knowledge. A thank you letter (dated 16/11/05), received from a relative, stated ‘many thanks for all your help and guidance’, that the resident ‘felt most comfortable with you’. A compliment about a resident’s care, entered in the home’s record book, recorded ‘how well looked after’ and thanked staff. Due to the home not being full yet (23 of the 51 places were occupied by at the time of the inspection), the home is reviewing their staffing levels to match occupancy levels. Prior to St Joseph’s opening, the home submitted their expected staffing rotas, which will apply once the home is full. The St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 18 Management confirmed that they are continuing to monitor the staffing levels to ensure that they have sufficient staff on duty to meet all residents’ needs. The current staffing levels (care) for the whole home is 1 senior carer and 4 carers in the morning (8 to 2pm) and 1 senior carer and 3 carers in the afternoon. The registered manager works in-addition to the care rota and is supported by the operations manager, who has an office onsite. The staffing levels on the dementia unit at the time of the inspection were 2 staff, plus a ‘floating’ member of staff who worked between the 2 units. A relative was asked if they felt this was enough staff? Replied that “there seems to be enough staff “ and confirmed that staff “answered the buzzers” quickly when they went off. To ensure that the home was following safe recruitment procedures, 3 staff recruitment records were checked. These showed that the home was in receipt of written references and paperwork to validate the person’s identity before starting work at the home. Although Criminal Bureau Clearance had been received for all 3 staff, these had been issued before the person started work. However, 1 staff file did hold information to confirm that a POVA First referral had been undertaken, prior to the person starting work. The Manager confirmed that they had applied for a POVA First clearance for all staff before they started work – through their umbrella company. They went on to say that the umbrella company, who applied for the checks on their behalf, would notify the home that clearance had been obtained – but did not always send written evidence. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 19 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): 32, 34, 35, 36, 37 and 38. People using the service can expect to be cared for by approachable staff, who are committed to working in the best interest of people living in the home. Fire records must be fully completed to evidence safety checks have been undertaken. EVIDENCE: On the office wall, was a list of staff names and planned supervision sessions for December. Records looked at showed that supervision had taken place and the home has policies in place, to ensure staff receives regular supervision. Prior to the home being registered, the building was checked by the Fire Safety Officer, Building Control Officer and Environmental Health, to ensure that the home met required Health & Safety legislation. The owners supplied the CSCI with copies of servicing contracts, and required installation paperwork. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 20 Walking into the laundry, staff pointed out the potential trip hazard due to the step. It was not clearly signed to alert people straight away. Although all the bedroom windows on the first floor were checked during the second site visit, to ensure window restrictors had been fitted, 1 window on the first floor landing did not have a window restrictor fitted. This led to discussions of undertaking a full environmental risk assessment of the home, to ensure all the appropriate signage is displayed, and action has been taken to eliminate or reduce any identified risks. Fire records looked at showed staff ‘Fire instruction and drills’ had taken place during August, and November 2005. Although the home had completed a Fire Risk assessment, records did not show that the emergency lighting was being checked regularly. Staff said that the lighting was being checked but not recorded; they also said that they were waiting for a key. Records viewed showed that the home had procedures in place to cover Fire, Power Failure, Gas and water leakage. This led to discussions about having an ‘evacuation’ plan as part of the homes emergency procedures, to identify in the case of residents having to be moved from the home in an emergency – information would be given to where they could be safely carried for. During the inspection a resident came into the office requesting staff to give them some of their money, which was held for safe keeping. The amount of money held by the home, for that, and another resident was checked, against records held, and found to be correct. Records showed a list of all deposits and withdrawals made, which where applicable included receipts. It was suggested that where the resident was unable to sign for themselves, that a second member of staff should witness the transaction, as an added security measure. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 21 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 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 3 2 2 St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 OP25 Regulation 23 (2) (p) Requirement Where windows are opened to air the home, staff must monitor the temperature to ensure that residents are warm and there are no cold drafts. The home must ensure staff handle soiled linen safely, in-line with the home’s infection control procedure. The home must regularly test the emergency lighting, as given in the Fire Risk Assessment, and record that the check has been carried out, including any action taken – if applicable. Timescale for action 23/12/05 2 OP26 13 (3) 30/12/05 3 OP37OP38 23 (4) (c) 30/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Although the residents are involved in their care plans on admission, the home should now look to see how they are going to ensure the on-going involvement of residents DS0000065099.V265167.R01.S.doc Version 5.0 Page 23 St Josephs 2 OP7OP8 3 OP8 4 5 OP8OP37 OP16 6 7 OP25 OP38 and/or their representative, in checking the contents, and ensuring it reflects the residents currents wishes on how they want to be looked after. The home should introduce behavioural and communication sheets/charts, to support staff in monitoring a residents behaviour, in identifying any ‘trigger’ points or communication difficulties which might result in the resident becoming frustrated or distressed. To be more informative to the reader, in monitoring any bruising or minor injuries, the home’s bruise charts should also include information when the bruise or wound has healed. To give the reader clearer information residents changing condition, all entries should be dated and signed. The home should review how their complaints are recorded, to enable all the information (investigation, outcome, correspondence) to be held in 1 place, to give the reader a clear record of events. It is recommended that thermostats be placed at points around the home, so staff can monitor the temperature of rooms and corridors. The home, as it becomes a working/living environment, should undertake another full environmental risk assessment, to ensure any hazards (appropriate signage for step leading into laundry, upstairs windows requiring restrictors) have been identified and addressed. St Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Josephs DS0000065099.V265167.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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