Inspection on 03/02/06 for Vera James House

This inspection was carried out on 3rd 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 but made no statutory requirements on the home.

Other inspections for this house

Vera James House 08/08/06

Vera James House 01/07/05

Vera James House 25/10/04

Vera James House 28/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Vera James House Chapel Street Ely Cambridgeshire CB6 1TA Lead Inspector Alan Buttery Unannounced Inspection 14:00 3 February 2006 rd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Vera James House DS0000015109.V280559.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 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. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Vera James House Address Chapel Street Ely Cambridgeshire CB6 1TA 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) 01353 661113 01353 661829 verajames@cambridgehs.org.uk Cambridge Housing Society Ltd Care Home 39 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (39) of places Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: Following some internal changes in the last year, Vera James House now provides a service for a maximum of thirty nine people over the age of 65, including a separate unit for up to eight older people with dementia. They also provide a respite care facility. All rooms provide en-suite facilities and are appropriately furnished and decorated. The property is situated within a larger complex belonging to the Cambridgeshire Housing Society, which includes sheltered housing. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the current year, and an unannounced visit. One additional visit has also been made during the year to investigate a complaint. The inspection lasted about three hours, during which time the homes manager made available documents and information required. The home is registered for up to 39 older people, including up to 10 with a diagnosis of dementia, and currently has one vacancy. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that pre admission assessments are always carried out to ensure all the information needed is obtained, and from this the individual care plans written. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 6 These should be more outcome based, and signed by the person writing them. The new manager of the home must apply for registration withy the CSCI as soon as possible 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. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Although some pre admission assessments are carried out, it was not clear how service user needs are always identified. This should be resolved before the next inspection EVIDENCE: At the last inspection, pre admission assessment information was not seen on the service user files examined. The process of gathering information was discussed with the homes manager, and although the format used is not felt to be ideal, it is important that the information is obtained, to ensure the home can confidently meet the needs identified for new service users. Discussions are taking place within the organisation to review the format of this information, but in the meantime the information must continue to be obtained. Service user records indicated that this is generally the case, but one file had the information missing, although the home had discharge information for the service user, who was admitted as an emergency Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 Care plans should be more detailed, and offer service users outcomes to achieve. They should be written with the service user, and signed by their author, ensuring accountability. EVIDENCE: Individual care plans were examined for several service users, and although there was evidence of the care plans being reviewed regularly, a requirement from the last inspection, it was felt that the care plans lacked substance, and did not include a clear signature or date they were written. It was suggested that the home look at the care plans of other homes in the organisation, to ensure that they all follow the same format, but in the meantime to ensure care plans are signed and dated, and the person writing the care plans therefore accountable for the content and accuracy. It was also suggested that consideration be given as part of this review to how care plans can be more outcome focussed, at the current time they look more at tasks to be done. Although the above issues were identified with the care plans in use in the home, the health and social needs of service users are being identified and met appropriately. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 A range of social and recreational activities offer service users entertainment and stimulation, and the social aspect of meal times is being encouraged. EVIDENCE: The home continues to offer a variety of social and recreational activities, and these are ‘advertised’ on notice boards in the home. Staffing is being used more flexibly to obtain maximum benefit and enable more individual activities. In addition, work experience students assist with activities. The manager is currently looking at how meal times can be a more social event, and looking to improve the dining facilities, with new tables and tablecloths. At the same time the communal areas in the home are being redecorated, and a service user meeting will consider colour schemes. New menus have been introduced, and more snacks are available for service users to have during the evening, and in addition, the weight of service users is being checked regularly, and with support from local dieticians supplements such as cream and honey being used where required. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Comments and complaints are acted upon in accordance with the company’s procedures, which include policies to protect the service users from the risk of abuse. EVIDENCE: The home has a suitable complaints policy, and ensures that any issues are appropriately investigated. One complaint was received by the CSCI, and an additional visit took place on the 29th September 2005. However, no evidence was found to substantiate the complaint. The deputy manager has attended training in protecting vulnerable adults which will shortly enable him to provide the homes POVA training. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 The home is clean and tidy, but more communal space may be beneficial for service users living upstairs. EVIDENCE: The home continues to offer a safe well maintained environment, and on the day of the inspection was clean and free for any offensive odours. As mentioned earlier, the communal areas of the home are being redecorated, and in addition new improved lighting will be installed. The manager also hopes to improve the entrance hall, to make it more welcoming. The communal facilities upstairs are smaller than downstairs, and although a second quiet room is available, this is very detached from the rest of the home and not used a great deal. The facilities available should be considered further to see whether any further changes could be made to improve them. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Staff records are not held at the home, and were not examined on this occasion. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38 Although currently without a manager registered with the CSCI, the home is operated with regard to and for the benefit of the service users. EVIDENCE: The home has a new manager but at the time of the inspection, no application for registration had been submitted to the CSCI. This must be done as a matter of urgency. Service users are involved in some of the day to day decisions affecting the home, for example the colours scheme of the forthcoming redecoration, and regular service users meetings are held. Appropriate health and safety policies are in place to protect service users and staff, and relevant training provided. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 15 Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X X X X 3 Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(a) Requirement Pre admission assessments must be available for inspection at all times. Requirement carried forward as only partially met Care plans must be signed and dated An application by a person who proposes to be registered as the manager of the home must be submitted to the Commission for Social Care Inspection as a matter of urgency Timescale for action 31/03/06 2 3 OP7 OP31 15 8(1) 31/03/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP20 Good Practice Recommendations As well as signatures, the care plans should be more outcome focussed. Consideration should be given to how communal space in the home can best be used. Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Vera James House DS0000015109.V280559.R01.S.doc Version 5.1 Page 19 - 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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