Inspection on 10/10/05 for St Judes House

This inspection was carried out on 10th October 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 Judes House 20/05/08

St Judes House 21/06/07

St Judes House 05/10/06

St Judes House 24/02/06

St Judes House 02/03/05

St Judes House 11/08/04

St Judes House 26/03/04

Similar services:

Ashlong House

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Delrose House Ltd

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

CARE HOME ADULTS 18-65 St Judes House 14 Canadian Avenue Catford London SE6 3AS Lead Inspector Kate Matson Unannounced 10 October 2005 th 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Judes House Address 14 Canadian Avenue, Catford, London, SE6 3AS 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) 020 8690 4493 020 86904501 Elizabeth Peters Care Home Limited CRH Care Home PC Care Home Only 10 Category(ies) of MD Mental Disorder registration, with number MD(E) Mental Disorder -over 65 of places PD Physical Disability PD(E) Physical Disability-over 65 St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for 10 persons aged 40 years and above with a past or present mental disorder 2 of whom can have a physical disability. Service users can be 65 years to include one named person aged 39 years until May 2006. Date of last inspection 02/03/05 Brief Description of the Service: St Jude’s is a large Victorian property offering care and accommodation to ten adults with past or present mental health problems, some of who may be over 65 years of age. The home is one of four owned and managed by a local provider, Elizabeth Peters Care Homes Ltd. The home is situated on a main road and is in within short walking distance of shops and facilities of Catford town centre. This provides the home with good transport links as the town centre has two train stations and is well served by buses. The house is unobtrusive and blends in with the surrounding properties. The home offers single bedroom accommodation and communal space including a large rear garden. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection was carried out over nine hours. It included discussion with five service users, the manager and the registered provider, a tour of the premises, examination of four service user files, ten staff files and other records. What the service does well: What has improved since the last inspection? The statement of purpose and service users guide had been reviewed and now ensure that service users have the information they need about the home. Service users had all been offered the option of a holiday, which four service users had taken. However, one service user stated they had wanted to go somewhere else and the provider must ensure that as far as possible individual preferences are met. Although service users spoken to confirmed that the home’s routines promote independence and that they now had the keys to their bedrooms, most service users did not have a key to the front door but there were no explanations for this in care plans. The details of CSCI had been included in the service user guide so that complainants are aware of options available to them. The home’s policies and procedures protect service users from abuse and all staff have now undergone training in abuse A downstairs room window had been made larger to allow in more light and radiator covers had been adapted to allow more heat out. Staff were now all undertaking NVQ training to ensure that they are qualified to meet the needs of service users. The home had developed a training plan for each staff member and the home though further work is required. The home has some effective quality assurance systems in place and service users views had been added to the service user guide as required. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 6 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 Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 5 Service users are provided with the information they need about the home. Service users’ needs are assessed before being offered a place but sufficient information about previous risk behaviours had not been sought. New service users had not been provided with a contract and existing service users have one with important information missing. EVIDENCE: It had been noted at previous inspections that information was missing from the statement of purpose and service user guide. At this inspection it was noted that both documents had been reviewed and although some minor amendments were suggested they now included all of the information prospective service users would need to make an informed choice about where they live. The files of three new service users were examined and all of these included details sent with the referral and the homes own assessment of the service users needs to ensure that the home could meet those needs. However two of the service users had risk behaviours in their histories there was little detail supplied about those risks. The registered provider must ensure that details about any risk behaviours are sought from providers in order to ensure that the home is fully aware of any risks and is fully able to meet the person’ needs. Previous inspections had noted that some important information was missing from the homes contract with service users. At this inspection it was noted that the contract had not been reviewed and none of the three new service users St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 9 had been issued with a contract. This registered provider must ensure that the contract is reviewed and issued to all of the service users in order to protect their interests. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8, 9 and 10 Service users’ care plans do not ensure that all of their needs are met. Service users have opportunities to participate in the running of the home, although the home could do more to proactively encourage service users to do so. Insufficient attention had been paid to identifying past risks in order to manage future risk safely. Confidential information is handled appropriately at the home. EVIDENCE: Previous inspections had noted that the home uses a care planning system that facilitates a clear and comprehensive assessment of service users changing needs, which were regularly reviewed involving the service user. However it was noted that some aspects of need were omitted such as cultural or faith needs, social interests and activities, and finance and mental health needs. At this inspection four care plans were examined and although some improvements in care planning were noted they still did not cover all of the required areas for example social interests and activities and although those examined included a care plan around mental health, these had not been reviewed at the same time as the others. Previous inspections had noted that service user meetings are held to ensure that service users participate in the day-to-day running of the home. It was St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 11 recommended that the minutes be recorded more formally to include previous meeting minutes and matters arising so that responses to issues raised can be easily tracked. At this inspection it was noted that this recommendation had not been implemented although some meetings had been held. The manager stated that service users do not participate very much in the meeting and a discussion took place about how service users may be supported to participate more fully in meetings, for example providing service users with previous minutes prior to the meeting, providing an agenda prior to the meeting for service users to contribute to, and discussions between service users and key workers about the meeting. As already noted under Standard 2, the risk history’s of two new service users had not been fully explored with referrers in order to ensure that staff had full awareness of these and to ensure their needs could be fully met. Also although the home has developed a risk assessment tool these had not been completed for the new service users. The registered provider must ensure that a detailed risk assessment is completed for all service users identifying past risks, potential triggers, risk indicators, and plans to manage risk. Previous inspections had noted that service user records are kept securely in the staff office. The home has registered with the Information Commissioner’s Office with regard to the Data Protection Act 1998. A previous recommendation that the home should produce a statement on confidentiality for partner agencies setting out the principles for governing the sharing of information has not been implemented. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15, 16 and 17 Service users participate in the local community and in appropriate leisure activities as far as they wish, though their preferences with regard to holidays must be met as far as possible. Service users have appropriate relationships. The daily routines of the home largely promote independence though reasons for restrictions are not properly evidenced. Meals provided are nutritious and flexible to meet service users preferences. EVIDENCE: Service users spoken to confirmed that they were free to access the local community as far as they wished. They use local shops, cafes, library, and places of worship. Most service users do this independently but the manager confirmed that staffing levels are sufficient to allow service users support where this is needed. It was found that the home had produced an activities timetable though apart from one, service users stated that there were no activities taking place in the home. The manager stated that only one service user tends to want to take part in organised activities and that staff regularly play cards and other games with this service user. Other service users stated they did not want to take part in activities though the home should continue to work with them to try to St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 13 engage them in meaningful activities. It was recommended at previous inspections that service users in long-term placements have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which they help choose and plan. At this inspection it was found that this had been done and four service users had been on holiday to Margate, however one service user commented that they would have preferred to have gone somewhere else and also stated that day trips that had been enjoyed in previous years had not been offered this year. The registered provider must ensure that service users are consulted about where they wish to go on holiday and their wishes and preferences should be taken in to account as far as possible. The manager stated that the home was planning some activities and trips shortly including a pantomime, theatre and a Halloween party at the home. All of the service users spoken with confirmed that visitors are welcome to visit at any time and that they are able to receive visitors privately. One service user commented that their relative was kept informed of their progress and was pleased about this. Although it had been noted at previous inspections that the daily routines in the home promote independence, choice and freedom of movement, it was noted that some service users did not have the keys to their rooms or the front door. It was required that unless a valid reason was recorded in service users care plans they must be given the keys to the home and the front door. At this inspection all of the service users asked, had the keys to their rooms but only one had the key to the front door. There was nothing in care plans to explain this. This must be addressed to evidence that restrictions are only imposed where necessary. Service users gave mainly positive feedback about the food. Comments included, “Meals are OK”, “I like the food”, “Meals are fine”, and “You get well fed”. Records of food provided indicate that for the evening meal, service users are provided with a variety of light meals to suit their preferences. The main meal is served at lunchtime and there is one or two choices provided. Service users confirmed that if they don’t want what is on offer something else will be provided. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 and 21 The homes medication systems largely protect service users though issues regarding homely remedies need to be resolved. Although existing service users had been consulted about their wishes with regard to illness and death, newer service users had not been. EVIDENCE: Although medication systems in the home are largely robust, there was a previous requirement that homely remedies used in the home must be approved by a GP. At this inspection it was found that some homely remedies such as laxatives, and cough linctus had been prescribed for individual service users. However this is wasteful and not very practical as there were 7 or 8 bottles and packets of the same remedy that would only be used as required. Also there was no signed approval for the remedies that had not been prescribed such as indigestion remedy and analgesia. The requirement is restated in this report. At previous inspections it was noted that each service user had a care plan around illness and death and this covered, who service users would wish to be informed in the event of their illness or their death, and final wishes such as what sort of funeral, favourite hymns, flowers or charities to which they may wish donations be made. At this inspection it was noted that none of the most recent admissions to the home had such a care plan in place and this must be addressed in order to ensure that these wishes can be carried out. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users had not felt the need to make complaints but stated they would if necessary. The home has systems in place to protect service users from abuse; however, not recording their possessions on entry to the home does not protect their interests. EVIDENCE: It had been required at previous inspections that full contact details of CSCI are included in the service user guide to ensure that service users have all of the information they need if they wish to complain. At this inspection it was found that this had been done. There had been no complaints recorded and all of the service users spoken to stated that they had not needed to complain and all but one stated they would complain if necessary. Previous inspections had noted that the home had appropriate policies and procedures in place in order to protect service users from abuse, although the homes policy on restraint required review and it was required that all staff undergo training in adult abuse. At this inspection it was found that both of these requirements had been met, the policy had been reviewed and all staff had undergone appropriate training. It was noted however that a possessions form had not been completed for new service users and this must be addressed in order to protect their interests. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 29 and 30 The home is homely comfortable and safe. Service users’ rooms promote their independence. Current service users do not require specialist equipment though the manager confirmed that as people’s needs change, occupational therapy assessments would be sought. The home is clean and hygienic. EVIDENCE: The home is a large Victorian converted property close to Catford with its shops facilities and transport links. The home is not identifiable as a care home and is homely and comfortable. The home is well maintained. A window in a downstairs bedroom had been made larger to allow in more light as required at a previous inspection. All of the rooms are single and four of these are en-suite. A number of the rooms were seen at the inspection and these contained the required items of furniture and reflected service users personalities. Radiator covers had been adapted to allow more heat out, as it was noted at the last inspection that the covers were reducing the output of the radiators. Although the home is registered for two service users with physical disabilities, none of the current service users are physically disabled though one service user utilises a wheelchair when outside the home. Some adaptations and equipment are provided such as grab rails on the ground floor corridors and a St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 17 bath hoist. It was recommended at a previous inspection that an occupational therapy assessment of the premises be carried out to ensure that the environment and equipment is suitable for the current service user group. At this inspection the manager stated that the person who is partially sighted is no longer at the home and currently service users do not have needs for adaptations and equipment, however she confirmed that when the needs of service users change this would be done accordingly. On the day of the inspection the home was clean, tidy and free from offensive odours. The home has appropriate infection control policies in place. Hand basins were well located throughout the home and protective clothing is available for staff. The laundry is sited away from areas where food is prepared and eaten and washing machines have programming facilities to meet disinfection standards. The wall and floor surfaces of the laundry were of appropriate materials. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34, 35 and 36. All but one of the staff team are undergoing training to ensure they are qualified to meet the needs of service users. The home’s recruitment practices do not protect service users. The home has developed a training programme that when utilised should ensure that staff are effectively trained. Although the frequency of supervision has increased it is not carried out at the required intervals. EVIDENCE: Service users gave positive feedback about the staff. Comments included, “The staff are good”, “They’re all nice” and “They look after you well”. At a previous inspection it was recommended that another three care staff are enrolled on NVQ level 2 in care to ensure that the home meets the 2005 requirement that a minimum of 50 of staff have NVQ level 2 in care. At this inspection it was pleasing to note that this had been implemented and all but the newest staff member were undertaking NVQ qualifications at level 2, 3 or 4. It was required at previous inspections that the registered manager must ensure that all staff files have two written references and evidence of a check with the Criminal Records Bureau (CRB). At this inspection all ten of the staff files were examined and these did not evidence that this requirement had been met. Seven files had two written references, (though for one staff member these were not on file but had been seen at another home in the group where the staff member also works), two had only one and one had none. Seven staff St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 19 had CRB checks in place and one outstanding check was for a long-standing staff member who had submitted a new CRB check following several delays with the original. However one check which was in place had been received after the person started work and the other two outstanding checks were for new staff, meaning that service users were left vulnerable to abuse before the provider could be satisfied that the workers had not committed offences or were considered unsuitable to work with vulnerable people. One of these had been recently identified at an inspection at another home in the group and the registered provider was required to submit a risk assessment to CSCI to evidence that it was safe to continue to employ the worker until the CRB check was received and this had been done. The registered provider completed another risk assessment for the other staff member on the day of the inspection and stated that she would not employ staff in the future until all of the checks had been received back. However the registered provider had confirmed her awareness of obligations placed on her since the commencement of the POVA list (list of people considered unsuitable to work with vulnerable adults) at previous inspections and it is of concern that these practices had continued despite this knowledge. In addition to these concerns it was also noted that three staff had confirmed on application that they required a work permit to work in the UK, however there was no evidence available that this had been checked though the registered provider stated that they were on student visa’s and was aware that they must work less than 20 hours per week. It was also noted that other documents were missing from files such as evidence that the person is physically and mentally fit (missing from two files), photographs (missing from three files) and contract (missing from six files). In addition there was no records of interviews and it is recommended that these be kept in order to evidence that the recruitment procedures are based on equal opportunities policies. At a previous inspection the registered provider was required to ensure that the homes training and development programme meets the Sector Skills Council workforce training targets. At this inspection it was pleasing to note that a training and development plan had been drawn up for each staff member and the home. Information had been sought from Skills for Care about competencies required for induction and foundation though there was no evidence that staff had been assessed against these competencies apart from one staff member who had attended an external induction programme. Further work is required in order to meet this requirement. A previous requirement that has remained unmet over several inspections is that the frequency of supervision must be increased to at least six times per year. At this inspection it was noted that the frequency had improved though was still not every two months as required. Continued failure to comply with this requirement will need to consideration of enforcement action being made. It was also noted that the registered provider had carried out all of the supervision. As the provider has four homes and is manager of one of them it is recommended that she delegate this responsibility to the registered manager. It has been recommended previously that staff who conduct supervision should receive formal training on the matter in order that all staff St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 20 receive the maximum benefit from the experience. Although the registered provider has had training in supervision she should ensure that the registered manager undergoes such training in order to delegate responsibility for supervision to her. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42 and 43. The manager has yet to apply for registration as required by regulation. The home has some effective quality assurance systems in place though reports of monitoring visits need to be sent to CSCI. Fire alarm tests need to be carried out weekly and effective window restrictors fitted in order to fully protect the health, safety and welfare of service users. The overall management of the service ensures the effectiveness and accountability of the home though a business and financial plan and annual development plan would better evidence this. EVIDENCE: The manager has been in post since just before the previous inspection. She had managed another home in the provider group since 1995. She is a Registered General Nurse and has worked in care homes since 1986. She is currently undertaking the Registered Managers Award and is due to complete at the end of 2005. At the last inspection she confirmed that she would submit an application for registration as manager of St Jude’s but this has not been St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 22 done. The registered provider must ensure that the manager of St Jude’s is registered with CSCI. Previous inspections had noted that the home has a quality assurance system in place that includes surveys of the views of service users, relatives, staff, and visiting professionals. It was required at a previous inspection that the results of these surveys be included in the service user guide. It was noted at this inspection that this had been done. It was also noted that the same survey was used for service users and relatives and it is recommended that surveys be designed more specifically for each purpose. It was also noted at previous inspections that the registered provider had recently commenced carrying out unannounced monthly visits to monitor the service though reports of these visits were not being sent to CSCI as required. A copy of a recent report was seen at this inspection though the format needed to be developed to better evidence that the visit had included discussion with service users, staff and inspection of the premises. The registered provider must ensure that reports of monthly visits conducted in accordance with regulation 26 are sent to CSCI. Records indicate that the electrical installation, electrical appliances, gas system, fire alarm, fire extinguishers, call system, and emergency lighting are all inspected appropriately. The fire records indicate that fire drills are held at appropriate intervals though fire alarm call points had not been tested for over three weeks, instead of weekly as required. All staff involved in food preparation had got certificates in food safety as required by a previous inspection. Although window restrictors had been provided in accordance with a previous requirement, they were not in use on the day of the inspection. This requirement remains in place. Previous inspections had found that the home had appropriate insurance cover in place and that an accountant is employed by the home. A financial forecast had indicated that the home was financially viable. It was recommended that a business and financial plan be produced for the home including an annual development plan reflecting aims and outcomes for service users. This has not yet been seen and the recommendation is restated in this report. This was received following the inspection. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 1 x x 1 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x 3 1 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x 3 3 Standard No 11 12 13 14 15 16 17 x x 3 2 3 2 3 Standard No 31 32 33 34 35 36 Score x 3 x 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Judes House Score x x x x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 1 3 G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 24 Yes 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 2 Regulation 14 Requirement The registered provider must ensure that details about any risk behaviours are sought from referrers in order to ensure that the home is fully aware of any risks and is fully able to meet the person’ needs. The registered provider must ensure that all service users are issued with a service user contract including all of the elements listed under Standard 5 of the National Minimum Standards (previous timescales of 31/12/04 and 31/05/05 not met). The registered provider must ensure that care plans cover all relevant aspects of service users lives (previous timescales of 31/12/04 and 31/05/05 not met). The registered provider must ensure that a detailed risk assessment is completed for all service users identifying past risks, potential triggers, risk indicators, and plans to manage risk. The registered provider must ensure that service users are Timescale for action 31/12/05 2. 5 5 31/01/06 3. 6 15 31/01/06 4. 9 12 (1) (a) 31/12/05 5. 14 12 (2) 31/01/06 Page 25 St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 6. 16 12 (4) (a) 7. 20 13 (2) 8. 21 12 (2) 9. 23 12 (1) (a) 10. 34 19 (1) (b) 11. 34 19 (1) 12. 34 19 (1) and 17 (2) consulted about where they wish to go on holiday and that their individual wishes and preferences are met as far as possible. The registered provider must ensure that service users are given the keys to their room and the front door unless a valid reason is recorded in their care plan (previous timescales of 31/12/04 and 31/05/05 not met) The registered provider must ensure that a list of homely remedies used in the home is drawn up and signed by a GP (previous timescales of 31/12/04 and 31/05/05 not met) The registered provider must ensure that service users wishes regarding ageing, illness and death are recorded on their care plans. The registered provider must ensure that when service users move in to the home their possessions are recorded in order to protect their interests. The registered provider must ensure that all staff files contain two satisfactory written references and evidence of a CRB check (previous timescales of 31/12/04 and 31/05/05 not met). The registered provider must ensure that staff do not commence work in the home until all of the appropriate checks have been completed. The registered provider must ensure that all of the documents required by regulation are available for inspection in staff files in each home in which the staff works, including work permits where required. 31/01/06 31/12/05 31/01/06 30/11/05 31/12/05 31/10/05 31/12/05 St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 26 13. 35 18 (1) (c) (i) 14. 36 18 (2) 15. 16. 37 39 8 (1) 26 17. 42 13 (4) (a) 18. 42 23 (4) (c) (v) The registered provider must ensure that the homes training and development programme meets the Sector Skills Council workforce training targets (previous timescales of 31/12/04 and 30/06/05 not met) The frequency of supervision must be increased to at least six times a year and cover the aspects detailed in this standard (previous timescales of 30/07/04, 31/12/04, and 31/05/05 not met). The registered provider must ensure that the manager of St Judes is registered with CSCI. The registered provider must ensure that reports of visits carried out in accordance with Regulation 26 are sent to CSCI The registered provider must ensure that window restrictors are in place unless a risk assessment indicates they are not necessary (previous timescales of 31/12/04 and 31/05/05 not met) The registered provider must ensure that fire alarm call points are tested weekly. 31/01/06 31/01/06 31/01/06 30/11/05 30/11/05 30/11/05 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 8 Good Practice Recommendations It is recommended that service user meeting minutes be recorded more formally to include previous meeting minutes and matters arising so that responses to issues raised can be easily tracked. It is recommended that more proactive ways be developed of supporting service users to participate more fully in service user meetings. G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 27 2. 8 St Judes House 3. 4. 5. 6. 7. 8. 10 34 36 36 39 43 The home should produce a statement on confidentiality for partner agencies, setting out the principles for governing the sharing of information. It is recommended that records of interviews be kept in order to evidence that the homes recruitment procedures are in accordance with equal opportunities. Staff who conduct supervision should receive formal training on the matter in order that all staff receive the maximum benefit from the experience. It is recommended that the registered provider delegate responsibility for supervision in the home to the registered manager. It is recommended that surveys of of the views of service users and relatives are specifically designed for each purpose. It is recommended that a business and financial plan be produced for the home including an annual development plan reflecting aims and outcomes for service users. This was received following the inspection. St Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Ground Floor 46 Loman Street Southwark SE1 0EH 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 Judes House G52-G02 S25643 StJudes V245596 101005 Stage 4.doc Version 1.40 Page 29 - 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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