Inspection on 24/02/06 for St Judes House

This inspection was carried out on 24th February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

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 10/10/05

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 Inspection 24th February 2006 09:45 St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Judes House Address 14 Canadian Avenue Catford London SE6 3AS 0208 6904493 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) Elizabeth Peters Care Home Limited Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0), Physical disability (0), Physical disability over 65 years of age (0) St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 over 65 years To include one named person aged 39 years, until May 2006 2. Date of last inspection 10th October 2005 Brief Description of the Service: St Judes 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 DS0000025643.V284806.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was carried out over 6.5 hours. The inspection included discussion with five service users, the registered provider who had recently taken over as manager of the home, the deputy manager, and examination of two care plans, ten staff files and other records. What the service does well: What has improved since the last inspection? What they could do better: The home’s contract still does not include all of the information required and must be addressed in order to protect service users rights. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 6 A previous recommendation regarding the recording the minutes of service user meetings has not been implemented and as a service user commented that sometimes things agreed are not followed through the provider is now required to ensure that previous meetings and matters arising are recorded to ensure accountability. The home’s medication system is largely robust but written approval from GPs for the use of homely remedies in the home is still awaited. Although the homes training plan appears to meet sector skills council specifications there was no evidence available that new staff had been inducted in accordance with those specifications. Although most staff had recently been supervised, all but one staff had not been supervised every two months as required at several previous inspections. Systems in the home largely protect the health, safety and welfare of service users, but window restrictors are easily overridden. The registered provider must address this or provide risk assessments stating they are not required as the manager suggested they were not. 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 DS0000025643.V284806.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 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 the following standard(s): 2 and 5 The home’s referral form has been reviewed to ensure that all information is available on which to base an assessment. The service users’ contract still does not include all of the required information to protect service users’ rights. EVIDENCE: At the last inspection 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 and there was little detail supplied about those risks. The registered provider was required to 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. At this inspection no new service users had been admitted though the deputy manager stated that referrers had been contacted and had confirmed that all risk information had been passed on. A new referral form had been devised to ensure that referrers are asked for all risk information at the referral stage. Previous inspections had noted that some important information was missing from the homes contract with service users. At this inspection it was noted that although service users had a contract and it had been reviewed it still lacked all of the information required in order to protect their interests. Continued failure to comply with this requirement may lead to enforcement action being considered. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6, 7, 8, 9 and 10 Care plans had improved though daily records did not accurately reflect the service users’ current situation in one case. Service users are supported to make their own decisions as far as possible though their participation could be better encouraged in service user meetings and the recording of meetings does not ensure accountability. Risks are identified and managed appropriately. Confidential information is handled appropriately at the home, though a statement to give other agencies has not yet been implemented. 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 two care plans were examined and both of these covered all of the relevant areas. However it was noted that one service user had a risk assessment that had been drawn up following some aggressive behaviour, however the daily records did not reflect this. The registered provider must St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 10 ensure that daily records fully reflect the service users actions/behaviour, as it must be an accurate overview of the service users situation. Service users are supported to make their own decisions as far as possible. All service users had been given keys to the front door and their room apart from one service user who had a risk assessment in place explaining why. Seven service users are independent in managing their money and two receive varying degrees of support. 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 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 the last inspection 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 ensuring discussion between service users and key workers about the meeting. At this inspection service users stated that an agenda was sometimes made available prior to the meeting but they did not receive copies of the minutes after the meeting. Meeting minutes were recorded in the same way and one service user stated that sometimes things got agreed at meetings but then were not followed through this must now be addressed to ensure accountability. As noted at the previous inspection 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 had developed a risk assessment tool these had not been completed for the new service users. The registered provider was required to ensure that a detailed risk assessment is completed for all service users identifying past risks, potential triggers, risk indicators, and plans to manage risk. At this inspection it was found that this had been done. Previous inspections had noted that service user records are kept securely in the staff office. The home is 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 DS0000025643.V284806.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12, 14 and 16 Routines in the home promote independence and service users participate in appropriate educational and leisure activities as far as they wish. However, evidence of the home’s attempts to meet individual preferences with regard to holidays is still required. EVIDENCE: All but one of the service users is able to go out independently, though key workers are available to accompany them where preferred. Most of the service users prefer not to attend organised activities and prefer watching television and listening to music. Service users are however encouraged to take part in educational and rehabilitative activities and one is currently learning German at evening class and another is supported to cook their own meals. Service users are supported to claim appropriate benefits. At the last inspection it was found that an activities timetable had been produced 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 St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 12 work with them to try to engage them in meaningful activities. It was found that four service users had been on holiday to Margate in accordance with a previous recommendation 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. 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 was required to 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. At this inspection the manager stated that holidays had recently been discussed and most people had said they wished to go. The manager said that holidays and day trips would be planned as far as possible to meet individual preferences but needed to evidence by discussion in care plans etc that this was the case. Although previous inspections had noted that the daily routines in the home promote independence, choice and freedom of movement, it was found 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 but one of the service users had the keys to the front door and their rooms and a risk assessment was in place to explain this for the one who didn’t. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 18, 19, 20 and 21 Service users received individualised care. Physical and mental health needs are addressed and monitored. Medication systems are largely safe though approval from GPs is still awaited for the use of homely remedies. Service users’ wishes with regard to ageing, illness and death are recorded in their care plans. EVIDENCE: All of the service users have care plans detailing personal care needs. Some of the service users require support with personal care though this is mainly supervision. Service users are able to choose their own clothes and hairstyles. The home has a key worker system to ensure consistency and continuity of care. Service users are all registered with one of two local GP practices. The inspector was informed they could choose another GP if they wished. Service users are supported to attend healthcare appointments where necessary. Service users have access to a range of healthcare professionals and daily logs indicate contacts with mental health teams, diabetic clinics, and district nurses. Service users are supported to eat diets appropriate to their needs. Service users are weighed monthly or more regularly where issues have been identified. The homes medication system and records were examined. Only staff who have undergone appropriate training administer medication and administration St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 14 recording was in order. Homely remedies had been provided in accordance with a previous requirement though written approval from a GP stating which service users and at what dose remedies may be given was still awaited. 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 the previous inspection none of the most recent admissions to the home had such a care plan in place and it was required that this be addressed in order to ensure that these wishes can be carried out. At this inspection it was found that the newest service users had such a care plan in place. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 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 the following standard(s): 23 The home has systems in place to protect service users from abuse; however, a requirement regarding the recording of possessions on entry to the home could not be assessed at this inspection. EVIDENCE: Previous inspections had noted that the home had appropriate policies and procedures in place in order to protect service users from abuse and that most staff had undergone appropriate training in adult protection. It was noted at the last inspection that a possessions form had not been completed for new service users and this needed to be addressed in order to protect their interests. At this inspection no new service users had been admitted so the requirement could not be assessed. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 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 the following standard(s): This group of standards was considered met at the last inspection. At the last inspection the following judgement was made :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: St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 17 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36 The home’s recruitment procedures protect service users though should evidence that equal opportunities policies are followed. The home’s training plan should ensure that staff and service users’ needs are met though evidence that new staff are appropriately inducted was unavailable. Staff supervision is still not carried out at sufficiently frequent intervals. EVIDENCE: 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 the last inspection all ten of the staff files were examined and these revealed that this requirement had not been met. In addition two staff had no CRB checks and one CRB check had been received after the person started work 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. 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 St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 18 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 some files were missing other documents such as evidence that the person is physically and mentally fit, photographs and contract. In addition there was no records of interviews and it was recommended that these be kept in order to evidence that the recruitment procedures are based on equal opportunities policies. At this inspection all 10 staff files were again examined and great improvement was noted. All files included all of the required documents and checks and two new staff had undergone POVA 1st checks before starting work with a risk assessment outlining how the risk was to be managed before a full CRB is received. However records of interviews were not available as recommended. Previous inspections had required the registered provider to ensure that the homes training and development programme meets the Sector Skills Council workforce training targets. At the last 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. Again at this inspection there was no evidence of the training that new staff had undertaken and further work is required in order to evidence that this requirement is met. 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 although most staff had received supervision within the last month, apart from for one staff member supervision had only taken place between one and four times in the last year. Continued failure to comply with this requirement will need to consideration of enforcement action being made. It was also noted at the last inspection 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. As the registered provider is now managing the home this recommendation is no longer relevant although some supervision is to be delegated to the deputy manager. It had been recommended previously that staff who conduct supervision should receive formal training on the matter in order that all staff receive the maximum benefit from the experience. Although the manager has had training in supervision she should ensure that the deputy manager undergoes such training if she is to share responsibility for supervision with her as described. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 19 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. The registered provider has recently taken over the management of the home, which should ensure that service users benefit from a well run home. The home has some effective quality assurance systems in place though surveys could be better designed. Systems at the home generally protect the health, safety and welfare of service users but window restrictors are still not in place. EVIDENCE: At the last inspection it was noted that although the manager had been in post since before the previous inspection an application for registration as manager of St Jude’s had not been submitted. The registered provider was required to ensure that the manager of St Jude’s is registered with CSCI. Prior to this inspection the registered provider had written to CSCI to state that the manager was no longer working at the home and the registered provider had taken over as manager. An application for registration had been submitted prior to this inspection. The registered provider is also required to write to CSCI with details of the circumstances of the previous managers departure as it may affect their “fitness” and need to be recorded for future reference. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 20 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. At the last inspection it was noted that the results of the most recent surveys had been included in the service user guide as required. However it was also noted that the same survey was used for service users and relatives and it was recommended that surveys be designed more specifically for each purpose. At this inspection it was found that further surveys had been carried out since the last inspection but the same format had been used. Although evidence of action taken was available the surveys were still to be made available to all those taking part. Reports of unannounced monthly monitoring visits were no longer required as the registered provider was now in day-to-day control of the home. Previous inspections had found that all staff involved in food preparation have food hygiene certificates and there is a first aider on duty at all times. 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 and fire alarm call points were now being tested weekly as required at the last inspection. Although as at the last inspection window restrictors are in place these are easily overridden and must be made more effective unless a risk assessment indicates they are not necessary as suggested by the homes manager. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 21 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 Standard No Score 1 X 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 1 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 2 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 X 2 X X 2 X St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 22 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 YA5 Regulation 5 Requirement Timescale for action 31/05/06 2. YA6 15 3. YA8 12 (3) 4. YA14 12 (2) 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, 31/05/05 and 31/01/06 not met). The registered provider must 31/05/06 ensure that daily records fully reflect the service users actions/behaviour. The registered provider must 31/05/06 ensure that service user meeting minutes are recorded more formally to include previous meeting minutes and matters arising so that responses to issues raised can be easily tracked and the home is held more accountable. The registered provider must 31/05/06 ensure that service users are consulted about where they wish to go on holiday and that their individual wishes and preferences are met as far as possible. (Previous timescale DS0000025643.V284806.R01.S.doc Version 5.1 St Judes House Page 23 of 31/01/06 not met) 5. YA20 13 (2) 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, 31/05/05 and 31/12/05 not met) The registered provider must ensure that when service users move in to the home their possessions are recorded in order to protect their interests. (Could not be assessed at this inspection) The registered provider must ensure that the home’s training and development programme meets the Sector Skills Council workforce training targets. (Previous timescales of 31/12/04, 30/06/05 and 31/01/06 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, 31/05/05 and 31/01/06 not met). The registered provider must ensure that the manager of St Judes is registered with CSCI. (Previous timescale of 31/01/06 not met though application has now been submitted) The registered provider must write to CSCI with details of the circumstances of the previous manager’s departure as it may affect their “fitness” and need to be recorded for future reference. The registered provider must ensure that window restrictors are in place unless a risk assessment indicates they are DS0000025643.V284806.R01.S.doc 31/05/06 6. YA23 12 (1) (a) 30/11/05 7. YA35 18 (1) (c) (i) 31/05/06 8. YA36 18 (2) 31/05/06 9. YA37 8 (1) 31/05/06 10. YA37 39 (b) 31/03/06 11. YA42 13 (4) (a) 31/03/06 St Judes House Version 5.1 Page 24 not necessary. (Previous timescales of 31/12/04, 31/05/05 and 30/11/05 not met) 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. 3. 4. 5. Refer to Standard YA8 YA10 YA34 YA36 YA39 Good Practice Recommendations It is recommended that more proactive ways be developed of supporting service users to participate more fully in service user meetings. 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 surveys of the views of service users and relatives be specifically designed for each purpose. St Judes House DS0000025643.V284806.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection SE London Area Office 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 DS0000025643.V284806.R01.S.doc Version 5.1 Page 26 - 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!