Inspection on 08/11/05 for St Josephs Rest Home

This inspection was carried out on 8th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Josephs Rest Home 23/11/06

St Josephs Rest Home 08/09/05

St Josephs Rest Home 09/12/04

St Josephs Rest Home 08/06/04

St Josephs Rest Home 28/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Spring Lane Care Home

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

CARE HOMES FOR OLDER PEOPLE St Josephs Rest Home 16 The Drive Ilford Essex IG1 3HT Lead Inspector Ms Harina Morzeria Unannounced Inspection 8th November 2005 10:00 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 DS0000025925.V270680.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. DS0000025925.V270680.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Josephs Rest Home Address 16 The Drive Ilford Essex IG1 3HT 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) 020 8554 3755 Mr Avtar Sandhu Mr Ajvinder Sandhu Ms Louise Kane Care Home 26 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (16) DS0000025925.V270680.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: St Josephs Rest Home is registered to care for 26 elderly residents and includes 10 beds for people with dementia. It is located in the London Borough of Redbridge and is situated close to the centre of Ilford. The home is within walking distance of a park and a bus route for easy access into the town centre. There are 24 single rooms and 2 double rooms, all of which have a wash basin. The rooms are situated on the ground and first floor which is served by a lift and stairs. Bathing and toilet facilities are suitable for the needs of older people. There are two lounges plus a separate dining area and a large well-kept garden. The external grounds and premises are well maintained and secure. The home employs sufficient numbers of experienced and skilled staff to meet the needs of the residents. Personal care is provided on a 24-hour basis, with health needs being met by visiting professionals or by staff accompanying service users to hospital appointments and other healthcare specialists as required. Various activities and entertainment are enjoyed by the residents such as music and movement, in-house entertainment, outings and bingo. DS0000025925.V270680.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is was the second statutory inspection visit of the inspection programme for 2005/06. Over the course of the two visits, all core standards have now been assessed. Five requirements and two recommendations were set at the previous inspection and the registered person has yet to comply with these except one requirement, which has been met. These requirements have been re-stated with new timescales set for compliance. Further information about unmet requirements can be found in the relevant standards. This inspection was unannounced, starting at 10am and lasted for approximately 3 hours. The inspector spoke to two service users during the course of the morning, who were able to express their views. The manager was present during the visit. A number of service users files were examined as well as the daily records. A tour of the building also took place with the responsible individual. What the service does well: The home has a comfortable atmosphere and visitors feel welcome. Residents said that the staff are kind. The staff were observed to support residents in a caring and professional manner. They continue to develop their skills in working with people with dementia. Residents have said that they enjoyed living at St Joseph’s and were happy with the quality of care they were getting. Residents have said that they feel able to talk to the manager or the owner if they had any concerns or worries. The manager, staff and the owner have set high standards for the home and aim to provide a good standard of care, which is being achieved in an attractive and comfortable living environment. The home is clean and hygienic with no offensive odours. The routines of daily living and activities are generally flexible and varied to suit/meet the residents capacities. During the inspection, staff were seen to be interacting well with the residents. All residents were well groomed. DS0000025925.V270680.R01.S.doc Version 5.0 Page 6 The visiting times are flexible and visitors commented that they are always made to feel welcome by the staff. What has improved since the last inspection? What they could do better: The manager and the responsible individual for the service must ensure that the requirements from the previous inspection are addressed by the new timescale. Areas where the home could be doing better were discussed and agreed with the manager. The manager and the responsible individual must ensure that improvements made are sustained and become part of the caring routine. The manager must ensure that accurate care plans are drawn up for each resident, which are reviewed monthly and updated as required on an ongoing basis. Residents, especially those with more specialised needs, would benefit from a wide range of social and daytime activities. Further information and training should be acquired by staff from specialist agencies, in order to learn how to motivate residents especially those with more advanced dementia to participate in a wider range of social daytime activities. The involvement of residents and relatives in the written care plans made by the home needs to be increased. DS0000025925.V270680.R01.S.doc Version 5.0 Page 7 The home accommodates residents with challenging behaviour. Clear plans and guidance as well as appropriate risk assessments for managing this must be in place. Systems must be in place to ensure that all incidents relating to the residents are properly recorded and that the senior staff monitor these so that any further action needed can be taken immediately. 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. DS0000025925.V270680.R01.S.doc Version 5.0 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 DS0000025925.V270680.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that a detailed statement of purpose and service users guide are available to prospective residents to help them make an informed choice about where to live. They have an opportunity to visit the home and assess the quality and facilities, and know that the home will meet their needs. Each resident has a contract/statement of terms and conditions with the home. A comprehensive pre-admission assessment is undertaken for all prospective residents prior to admission to the home. This ensures that all their care needs are understood and can be met by the home. EVIDENCE: The above standards were not specifically tested on this visit and there were no outstanding requirements in relation to these standards. At the time of the DS0000025925.V270680.R01.S.doc Version 5.0 Page 10 last inspection, all of the outcome standards were assessed as met. These standards will be retested at a future inspection. DS0000025925.V270680.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Residents benefit from the attention paid by staff at St Joseph’s to meeting their health, personal and social care needs. Residents’ care plans contain basic information so that staff can meet their basic needs and support them in a way that they prefer. However not all care plans are reviewed or updated regularly. Some residents have challenging behaviour but there are no clear strategies for dealing with this. Staff and residents are placed at risk because of this. In general the staff team support the residents to get the health care that they need but a more proactive approach must be adopted when residents are not co-operative. Residents’ medication is generally administered safely and regularly, however attention must be paid to residents who refuse to take medication and early advice must be sought from the pharmacist as well as the GP, about how best to deal with these situations. Personal support in this home is offered in a way which promotes and protects residents privacy, dignity and independence. EVIDENCE: DS0000025925.V270680.R01.S.doc Version 5.0 Page 12 Individual care plans are available for each resident and the records of three residents were examined. The inspector was concerned to note that the improvements noted at previous inspections have not been maintained. Care plans must be reviewed monthly and updated for residents whose needs have changed. New care plans must be drawn up, which reflect accurately how the home are going to meet the residents’ changing needs. As stated in the previous inspection report, the inspector is not satisfied with the care planning review for one of the residents, who has aggressive and challenging behaviour. The care plan for this resident did not demonstrate how their specific needs were to be met, nor was there a consistent response to managing the behaviour. Some recordings were made involving these incidents but there was no written evidence that these had been seen by senior staff or followed up at the time. This potentially places both staff and residents at risk as well as that particular resident, who had been assaulted by another resident due to their behaviour. Where a resident exhibits challenging behaviour that care plan must include a clear strategy/guidance in managing their behaviour. Any incident must be appropriately recorded and reviewed by senior staff. Any action taken as a result of incidents must be clearly logged. During this inspection, the inspector noted that no action had been taken regarding the above situation. Feedback from residents and relatives was very positive about the commitment of the home to keeping residents as healthy as possible. A monthly health check routine is established at the home with nutritional and weight charts being kept. All the senior staff have completed the medication administration training and therefore have the competence to administer medication. However, attention must be paid to residents who refuse to take medication and early advice must be sought from the pharmacist as well as the GP, about how best to deal with these situations. None of the residents are responsible for administering their own medication. In addition each file contains an assessment of any areas where there was considered to be any risk to the resident and how these risks were to be dealt with and reduced as far as possible. However the inspector was concerned that for those residents who exhibit challenging behaviour appropriate safeguards are not in place to protect both residents and staff. Appropriate risk assessments must be drawn up in order to ensure that the resident exhibiting challenging behaviour as well as all the other residents and staff are protected and know what to do in these situations. In some cases, resident and relatives had not seen the written care plan. The inspector recommends that in order that care plans reflect the views and wishes of residents and their relative/representatives, it is important that they are involved as much as possible in this process. DS0000025925.V270680.R01.S.doc Version 5.0 Page 13 DS0000025925.V270680.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that there is a varied programme of activities available for the residents. However more needs to be done to demonstrate how the social and recreational needs of individuals are met, particularly those with dementia. Visiting times are flexible and people are made to feel welcome in the home so that residents are able to maintain contact with their family and friends as they wish. Residents are offered choice in as far as they are able to contribute to making decisions about matters that affect their lives. Residents receive a wholesome, appealing and well-balanced diet in pleasant surroundings. Both the care and catering staff make every effort to ensure that their nutritional needs are met on a daily basis. EVIDENCE: The above standards were not specifically tested on this visit, and there were no outstanding requirements in relation to these standards. At the time of the last inspection, all the outcome standards were assessed as met. These standards will be retested at a future inspection. DS0000025925.V270680.R01.S.doc Version 5.0 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): These standards were not tested on this visit. However evidence from the last inspection was that the home has a satisfactory complaint system in place and residents and their relatives are listened to and acted upon. Staff working in the home have received training in adult protection/abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The above standards were not specifically tested on this visit, and there were no outstanding requirements in relation to these standards. At the time of the last inspection, all the outcome standards were assessed as met. These standards will be retested at a future inspection. DS0000025925.V270680.R01.S.doc Version 5.0 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): 20, The standard of the environment within the home is good, providing residents with a clean, attractive, safe and comfortable place in which to live and individual bedrooms meet their needs. Sufficient communal lounges are available and activities such as hairdressing and chiropody are now carried out in a separate designated area. There are sufficient and suitable lavatories and washing facilities as well as specialist equipment to maximise residents independence. The home is clean, pleasant and hygienic. EVIDENCE: A tour of the building took place and some bedrooms were either entered or seen from the corridors and all the bathrooms and communal toilets were entered. All lounges and dining areas were seen, as well as the gardens and outdoor seating areas. There is a good standard of cleanliness in the home and there were no offensive odours noted during the visit. DS0000025925.V270680.R01.S.doc Version 5.0 Page 17 The standard of the décor, furnishings and fittings in the home are maintained to a high standard following a recent refurbishment programme. There is an ongoing programme of refurbishment and redecoration. There is a large garden which is well kept, with the active involvement of one particular resident who enjoys gardening. On the day of the inspection residents were seen to be enjoying various activities with the staff for example, playing bingo in one of the lounges and staff playing board games with residents in the other lounge. Specialist equipment such as hoists are in place where needed, and all areas have full disabled access. Following requirement made at the previous inspection regarding the use of one of the residents bedrooms for hairdressing and chiropody, the inspector was informed that a separate designated area upstairs is now used for these activities. Following concern expressed at the previous inspection, regarding the residents sitting in direct sunlight, the proprietor has arranged for a canopy to be installed to the front of the building, during springtime for the residents’ comfort and protection. DS0000025925.V270680.R01.S.doc Version 5.0 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): These standards were not tested on this visit. However evidence from the last inspection was that the procedures for the recruitment of staff are robust and provide safeguards to offer protection to people living in the home. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. The residents benefit from an experienced team of staff who have the skills and training to meet their individual and specialised needs. This includes specific training in working with people with dementia. EVIDENCE: On the day of inspection although the above standards were not fully tested, the inspector noted that staffing levels in the home were satisfactory and at the time of the visit, staff were interacting with the residents with appropriate activities taking place. The manager is aware that staffing levels must be kept under continual review to ensure that residents get sufficient care and attention at all times. DS0000025925.V270680.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): These standards were not tested on this visit. However evidence from the last inspection was that the home is being adequately managed by the registered manager and provides a safe environment for the residents. Staff receive appropriate support and supervision from the manager. Residents and staffs’ health, safety and welfare are promoted and protected by the policies and procedures adhered to within the home. The manager must ensure that residents’ health, safety, and security in the home are promoted and protected at all times. EVIDENCE: The above standards were not specifically tested on this visit, and there were no outstanding requirements in relations to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. DS0000025925.V270680.R01.S.doc Version 5.0 Page 20 However, the inspector was concerned to note that these improvements have not been maintained during this inspection. The inspector wishes to comment that the manager and the responsible individual must ensure that the care planning systems, risk assessments and evidencing how the care plans are being met, are implemented and followed thoroughly in order to show that the standards continue to be met. The improvements made previously with the care planning process must be maintained with regular reviews of care plans taking place which must then be updated as residents needs change. Staff must be adequately supported and guided in order to provide appropriate care to meet the residents’ needs with the senior person and manager taking responsibility to ensure that appropriate recording takes place to evidence how each residents’ needs are being met according to the care plans. DS0000025925.V270680.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 X X X X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X 2 X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 DS0000025925.V270680.R01.S.doc Version 5.0 Page 22 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 OP7OP7 Regulation 15 Requirement Where a resident exhibits challenging behaviour the care plan must include strategies/guidance in managing this behaviour. Previous timescale of 30/11/05 not met. Any incidents of aggressive or inappropriate behaviour must be appropriately recorded and reviewed by senior staff. Any action taken as the result of incidents must be clearly logged. Previous timescale of 30/11/05 not met. The registered person must ensure a more proactive response to monitoring and promoting the health care needs of residents especially those suffering with dementia. Previous timescale of 30/11/05 not met. The registered person must ensure that adequate protection is provided for the residents in the communal areas by the use of appropriate blinds or curtains to block out direct sunlight on DS0000025925.V270680.R01.S.doc Timescale for action 31/01/06 2. OP7OP7 15 31/01/06 3. OP7OP7 12 31/01/06 4. OP20OP20 23 31/01/06 Version 5.0 Page 23 5. OP7OP7 15 the residents whilst resting here. Previous timescale of 30/11/05 not met. The risk assessment must be regularly reviewed according to the residents changing needs. Previous timescale of 30/11/05 not met. The registered person must ensure that the care planning systems, risk assessments and evidencing how the care plans are being met, are implemented and followed thoroughly in order to show that the standards continue to be met. Regular reviews of care plans must take place which must then be updated as residents’ needs change. 31/01/06 6 OP38OP38 15 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP30OP30 OP7OP7 Good Practice Recommendations The inspector recommends that ancillary staff are included in the essential training provided to staff, particularly dementia care. The inspector recommends that in order that care plans reflect the views and wishes of residents and their relative/representative, it is important that they are involved as much as possible in this process. DS0000025925.V270680.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000025925.V270680.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!