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Inspection on 08/09/05 for St Josephs Rest Home

Also see our care home review for St Josephs Rest Home for more information

This inspection was carried out on 8th September 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home 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. 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?

A refurbishment programme of the home has resulted in all the communal areas being attractively decorated, providing a pleasant environment. The staff team have received relevant training to equip them to care for people with special needs particularly dementia. An additional member of staff is on duty in the mornings to coordinate activities for the residents. The home have developed the sensory room, which has a wide range of appropriate equipment, and all residents are offered an opportunity to use this room regularly. All the staff currently working in the home have received relevant training in order to operate the equipment to make best use of it for the benefit of the residents.

What the care home could do better:

Areas where the home could be doing better were discussed and agreed with the manager. 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. The home accommodate 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.

CARE HOMES FOR OLDER PEOPLE St Josephs Rest Home 16 The Drive Ilford Essex IG1 3HT Lead Inspector Harina Morzeria Unannounced 8 September 2005 - 12:30 hrs 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 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 Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 554 3755 Mr Avtar Sandhu Ms Louise Kane CRH - Care Home 26 Category(ies) of DE - Dementia 10 registration, with number OP - Old Age 16 of places St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9 December 2004 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. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for four hours and began at 12:30 p.m. to coincide with the observation of the lunchtime routine. It was the first of two inspections each home must have during the inspection year. A tour of the home and garden took place, including entering some bedrooms. Some residents were asked for their views and experience of living in the home. Many of the residents were able to comment and were complimentary about the service. The relatives’ and visitors’ views were sought, who were equally satisfied with the care provided in the home. Staff were also asked for their views on the service being provided. Staff, care and other records were checked as part of the inspection process. 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 Josephs 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. The visiting times are flexible and visitors commented that they are always made to feel welcome by the staff. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 and 5 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 it 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 Statement of Purpose and Service Users Guide included detailed information about the service provided by the home, in a clear and precise manner to enable prospective residents and their representatives to make an informed choice about where to live. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 9 Evidence was seen that prospective residents and their relatives/ representatives are encouraged to visit the home, and talk to residents, visitors and staff about the service. The home has a standard format for assessing prospective residents which is comprehensive and information from this is used to develop initial care plans. This means that the care staff are aware of residents’ needs and how to meet them upon admission. Assessments by social workers are received by the home together with referrals. Evidence was seen that prospective residents their relatives/ representatives are invited to visit the home prior to deciding whether they wish to come and stay for a trial period. The residents spoken to said that they enjoyed living at the home and thought that their needs were met. Two of the residents said that the food is very nice, they treat us very well here.’ A visitor for one of the resident’s said that, “we couldnt ask for a better home to care for our friend.” The files checked for two of the most recently admitted residents had a preadmission assessment form, as well as an assessment by the social worker, of the needs and wishes of the resident. Privately funded residents have a contract and a statement of terms and conditions with the home. A separate contract exists with residents placed by local authorities. A plan of care setting out how their needs and wishes would be met is also in place. A key worker system is in place and each resident is allocated a key worker who is responsible for ensuring that the care plan is accurately followed and any changes regarding the resident’s needs and wishes are immediately put into practice. Risk assessments are also completed to ensure that any risks identified can be managed by the home. Risk assessments must be regularly reviewed according to the residents, changing needs. Intermediate care is not provided at the home. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 Residents benefit from the close attention paid by staff at St Josephs to meeting their health, personal and social care needs. Residents plans contain information so that staff can meet their needs and support them in a way that they prefer. However not all care plans are reviewed and updated regularly. Some residents have challenging behaviour and there are no clear strategies for 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 need to be more proactive when residents are not co-operative. Residents medication is administered safely and regularly. Personal support in this home is offered in a way which promotes and protects residents’ privacy, dignity and independence. EVIDENCE: Individual care plans are available for each resident and the records of three residents were examined. The records for these residents were found to be detailed and comprehensive around the social, personal and health care needs and followed on from a full assessment. Relatives are invited to attend reviews which was confirmed by the visitors spoken to. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 11 However the inspector was 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. 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. 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 assessment 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, residents 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. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 and 15 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: An additional staff member is rotered on each shift in the mornings, to take responsibility for arranging activities and outings. The sensory room in the home is very well equipped and is extensively used for the residents’ benefit. All staff working in the home have received training regarding how to use this equipment. A group of residents, particularly those with dementia, are offered the opportunity to use the sensory room on a regular basis and daily records indicated that the residents enjoy using this room, which has a calming and beneficial effect on them. Other activities such as bingo, gentle exercise, board games, shopping trips or walks, external entertainers and various outings are enjoyed by the residents. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 13 Photographs showing residents participating in these activities were displayed on the walls in the lounges. A visitor of one of the residents said that they are always made to feel welcome and offered drinks. They sometimes spend time in the lounge or will use other quiet areas if they want to. They said that the home had a comfortable and relaxed atmosphere. It can be difficult for some residents to make choices but staff were observed to encourage them to choose what to eat and where to sit. Staff also said that they try to encourage the residents to choose what they want to wear and to do things for themselves. All of the staff spoken to said that they had learned a lot from the training that they had received from the Alzheimers Society. This had helped them to support residents and to understand their needs. Residents can choose what to eat from the menu and choices are always available. The inspector observed the lunch routine and was pleased to note that the tables were attractively set with matching crockery, cutlery and tablecloths. The inspector also spoke with the cook who takes pride in food preparation and has liaised closely with the residents to seek their views and preferences. The inspector was informed that the kitchen is going to be refurbished soon and the cook was looking forward to working in the new environment which he helped to design. Cold drinks are available in the lounge and residents were offered biscuits with their afternoon tea or coffee. The home achieves a high standard in this area with the dedication and commitment from the proprietor, manager, cook and staff to provide good quality meals for the residents in a pleasant environment. Hence a score of 4 has been given for the standard. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 The home has a satisfactory complaint system in place and residents and their relatives felt that their views 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 home has policies and procedures in place in relation to reporting and investigating complaints. Copies of the complaints procedure are displayed around the home and records are kept of complaints and compliments. It is also placed on a notice board at the entrance to the home and residents stated that they are aware of the procedure. Residents said that they felt able to make a complaint and raise issues if they needed to with the manager. Residents said that they were pleased with the staff and did not report any concerns. The record of complaints was examined, and there was evidence that the manager had taken these seriously by investigating and responding to them fully, within the timescales. The home has an adult protection policy and staff have received adult protection training. They are aware of what to do if there is any suggestion or suspicion of abuse. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 The standard of the environment within the home is very good, providing residents with a clean, attractive, safe and comfortable place in which to live and individual bedrooms meet their needs. However, although there are sufficient communal lounges available, there is a lack of space where hairdressing and other communal activities, for example, chiropody can be carried out. There are sufficient and suitable lavatories and washing facilities as well as a 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 except in the one double bedroom. This was brought to the managers attention. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 16 The standard of the decor, 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 and relatives were seen to be enjoying the garden. Specialist equipment such as hoists are in place where needed, and all areas have full disabled access. Although sufficient communal space is available, the inspector was concerned to note that one of the ground floor bedrooms occupied by a resident, is used by the hairdresser and chiropodist, during their visits. This is unacceptable practice and must stop immediately. Suitable alternative arrangements must be made for the provision of these services. On the day of the inspection, the inspector observed that residents were sitting on chairs in the lounge with direct sunlight upon them. It was a hot day and this would have been detrimental to their well-being. The inspector asked the care staff to draw the curtains. Staff must be observant and mindful of taking adequate precautions for the well-being and comfort of the residents and take appropriate measures accordingly. 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 the residents whilst resting here. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 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 the inspection there were four care staff plus a senior officer and ancillary staff and students on duty. An extra member of staff is on duty each morning to coordinate activities. The home has a well-equipped sensory room for the residents’ benefit. All staff have received adequate training regarding the use of this equipment and they now bring small groups of residents to use this room. Staff commented that this facility is very well enjoyed by the residents who benefit greatly from its use, particularly when they are feeling agitated or upset. The staffing levels are sufficient to meet the needs of the residents and feedback from the staff was that the staff team is supportive, backed up by seniors and managerial support. Staffing levels for both care and domestic staff are adequate to ensure that the residents’ needs continue to be met. Staffing levels must be kept under continual review to ensure that residents get sufficient care and attention at all times. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 18 A good comprehensive training programme is in place, enabling staff to continually acquire and update their skills in order to meet the needs of the residents. The home has a thorough and appropriate recruitment procedure. There are application forms, interviews and appropriate references and checks are made. Staff also said that they get support from the seniors and the manager and if they had any issues, or concerns they are listened to and discussed. Staff records examined showed that they have done training in the essential areas, such as food hygiene, health and safety, and administering medication, working with people with dementia, first aid and adult protection. The inspector recommends that ancillary staff also receive this training. Most of the staff working in the home have completed their NVQ level 2 training with many going on to do NVQ level 3 courses. Many of the staff working at the home have completed the advanced dementia care training course provided by the training officer. Staff then go on to take an examination set by the Alzheimer’s society. All the staff spoken to commented on how good this training has been and how useful it has been to their work. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 and 38 The home is being managed well by the registered manager and provides a safe environment for the residents. The manager is good at making sure that residents are kept safe and secure in the home. Staff receive appropriate support and supervision from the manager. Residents’ and staff health, safety and welfare are promoted and protected by the policies and procedures adhered to within the home. EVIDENCE: The manager has completed her NVQ level 4 qualification and has over 20 years experience of working in the care field. Feedback from both the residents, relatives and staff was positive about the way in which the home is run. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 20 Regulation 26 visits are undertaken by a designated responsible individual on a monthly basis. A copy of that report is supplied to the CSCI to show that the registered providers are effectively monitoring the service provided in the home. The home is well maintained and provides a safe environment for the residents and staff with regular health and safety checks being carried out. Staff spoken to stated that they received good support and supervision from the manager and the seniors, on a regular basis and this ensures that they are effectively supported in their work. During the inspection process, the inspector checked a number of records, policies and procedures and was satisfied that the residents’ rights and best interests are safeguarded by the home’s record-keeping, policies and procedures. Quality assurance and monitoring takes place, implemented by the manager and the responsible individual on a continual basis. Residents, relatives, staff and other professionals views are sought by the manager via questionnaires, in order to assess the home’s success in achieving its aims and objectives. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 2 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 3 3 3 3 3 3 3 3 3 St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Where a resident exhibits challenging behaviour the care plan must include strategies/guidance in managing this behaviour. 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. The registered person must ensure a more proactive response to monitoring and promoting the health care needs of residents especially those suffering with dementia. The registered person must ensure that a suitable area is identified for use by the hairdresser and chiropodist. This activity must not take place in any of the residents bedrooms. 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 the residents whilst resting here. The risk assessment must be G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Timescale for action 30/11/05 2. OP7 15 30/11/05 3. OP7 12 30/11/05 4. OP20 23 30/11/05 5. OP20 23 30/11/05 6. OP7 15 30/11/05 Page 23 St Josephs Rest Home Version 1.40 regularly reviewed according to the residents changing needs. 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 OP30 OP7 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. St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford, Essex 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 St Josephs Rest Home G55_G05 S25925 St Josephs V248171 080505 Stage 4.doc Version 1.40 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. 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