Care Home: Jasmine House

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What the care home does well Throughout the day we observed good care practices. Staff actively encouraged residents to do things for themselves and provided support where appropriate. Examples of this included residents helping prepare the evening meal. We saw evidence that they are involved in shopping and meal planning. Residents were encouraged to answer the front door. The AQAA stated, "We support people to try different activities". Example givens included playing zone hockey and attending the Aquarius club. We asked staff what the home does well and the staff said there was good teamwork and residents were happy. The majority of the staff had worked at the home for many years and were clear about how to meet residents` needs. Staff said the home provided a good environment for residents and residents loved being out in the garden. The AQAA stated that they had employed a local gardener who supported residents in maintaining the garden. What has improved since the last inspection? The home has not had a registered manager in the last year, after the previous manager retired. A new manager has been appointed in recent weeks and she has a wealth of experience and is proactive in identifying improvements. She has been working along side staff and giving all staff as much support as she can. All staff have had recent supervisions, most have received an appraisal and she has identified gaps in staff training. Refresher training is planned. The home has had a number of staffing vacancies which have been difficult to recruit to because the council are in the process of restructuring the service, which means the existing staff will have different employment conditions. Recent interviews in July were successful and several staff were appointed to posts, subject to criminal record checks. The requirements made at the last inspection have been met. What the care home could do better: During this inspection some staff were concerned that residents social needs were not being fully met because of low staffing ratios. Staff stated it was not possible to take all the residents out together because of their different needs. Small group activities could also be difficult at peak times, such as weekend. We looked at records, which indicated residents spent a lot of time at home, outside of their attendance at day services. The care plans are going to be revised as a priority and this was discussed at the time of the inspection. The care plan seen did not give sufficient information about meeting the resident`s needs and did not show how staff were promoting their independence. Social needs were also poorly recorded. CARE HOME ADULTS 18-65 Jasmine House Jasmine House 1a Upherds Lane Ely Cambridgeshire CB6 1BA Lead Inspector Shirley Christopher Unannounced Inspection 19th August 2008 11:00 Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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 Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jasmine House Address Jasmine House 1a Upherds Lane Ely Cambridgeshire CB6 1BA 01353 662261 F/P 01353 662261 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) www.cambridgeshire.gov.uk Cambridgeshire County Council Post Vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person over 65 years of age in the category LD(E) Date of last inspection Brief Description of the Service: Jasmine House provides a long-term home to up to six residents with a learning disability. It is owned and operated by the local authority. Some of the residents have associated physical disabilities. The home is situated close to the centre of Ely, and within walking distance of the city centre. Residents are encouraged to use the nearby local facilities. The accommodation is on two floors, with one ground floor bedroom and communal facilities, and the remaining five bedrooms on the first floor. There is a lift to facilitate access to the first floor. The fee levels vary depending on the needs of individuals accommodated; the fees at the time of the last inspection were between £62.35 and £94.45 per week. A copy of the last inspection report was in the office and available to residents and families. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. We, The Commission of Social Care inspection carried out an unannounced key inspection on the 19 August 2008. During this inspection we met and spoke to the administrator, the newly appointed manager, the operations manager and four care staff. Three residents were at home during the day and two were spoken to. A further three residents were spoken to when they returned from their respective day services late afternoon. We looked round the home and looked at a number of records. We did some case tracking, which involved looking at one person’s records and then talking to them about what their needs were. Staff were also asked about meeting this persons needs. Before the inspection we asked the home to complete an Annual Quality Assurance Assessment, (AQAA). This document was well completed and gave good, clear information. We sent out a number of staff and residents’ surveys and 7 were returned, 5 from residents and 2 from staff. We have included comments from these in the report. What the service does well: What has improved since the last inspection? The home has not had a registered manager in the last year, after the previous manager retired. A new manager has been appointed in recent weeks and she has a wealth of experience and is proactive in identifying improvements. She has been working along side staff and giving all staff as much support as she Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 6 can. All staff have had recent supervisions, most have received an appraisal and she has identified gaps in staff training. Refresher training is planned. The home has had a number of staffing vacancies which have been difficult to recruit to because the council are in the process of restructuring the service, which means the existing staff will have different employment conditions. Recent interviews in July were successful and several staff were appointed to posts, subject to criminal record checks. The requirements made at the last inspection have been met. 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. The summary of this inspection report can be made available in other formats on request. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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 Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. The home should complete their own assessments instead of relying purely on local authority assessments to ensure they are confident about meeting the person’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide needs to be updated to take into account changes in management and staff. Although this document is readily available to people using the service it has not been adapted for people using the service. The majority of residents have lived at the home for many years. One file was inspected and contained a detailed assessment from the local authority. This resident had been admitted to the home in the last year. Staff explained that the resident was able to visit the home on several occasions and staff from the home visited them in their previous home before they moved in. The home did not complete their own assessment and relied on information given to them by the previous home and the local authority. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 9 The local authority has recently reviewed the needs of the people living at the home. Reviews had also been completed by the local day services attended. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate Residents assessed and changing needs and personal goals should be clearly described in their care plans to assist staff in meeting their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We case tracked one resident and spoke to them . The information in the care plan was adequate, but some gaps were identified. The manager stated she was going to revise all the care plans and standardise them. Key workers had the responsibility for writing and updating the care plans so the care plans varied considerably. The one we looked at was to be used as the model. The care plan inspected contained very little information about meeting the residents needs. The resident was on medication to help them sleep and had been for years. There was no evidence that this had been reviewed or that staff had promoted a positive bedtime routine, which may enable this resident to have a good nights sleep without medication. The care plan referred to Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 11 routine and stated this person did not like their routine to be changed, but it did not describe what this person’s routine would normally be. Health care needs were recorded in a health care action plan but this had not been updated. Social needs were recorded but gave very little information such as likes television, music and football. We spoke to them and learnt what they liked to watch, what their favourite music was, what sports they liked and what their favourite colour was. There was limited evidence of how staff were promoting their independent living skills. A weekly timetable of activities was restricted to day services, a number of clubs in the evening and participation in a number of household chores such as loading the dishwasher and emptying the bins. There was no evidence that their skills had been recently assessed in terms of managing their own finances, their own medication or developing independent living skills such as road safety and household tasks. There was very little life history for this person, or details of significant events, or circles of support from family and, or friends and relatives. The manager said care plans would be reviewed and that an advocate would be helping them devise a person centred plan. A number of the residents were described as having ‘challenging behaviours.’ For one resident there was a detailed management plan in place and staff had received training in managing behaviour in a positive non physical way. The use of restraint is clearly defined and only permitted in certain circumstances. We looked at incident records and found an incident dating back to three months ago. It was recommended that a behavioural management plan be put in place referred to as (SCIP.) for one resident Staff stated this was not in place. Risk assessments were in place on the file inspected but were generic and not specific to the person such as needs support from staff when cutting up food. There had been no assessment of what the person could or could not do for themselves. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good Residents can expect to take part in a range of activities and have their independent living skills promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents take part in activities at home and most attend day services during the day and some night classes. We spoke to a number of staff and residents about social activities. Staff stated that the number of staff on duty restricts activities. There are two care staff on shift and a full time manager who is not counted in the number of care hours. There is also an administrator. One staff member said staff also are expected to cover other hours to assist people living in the community. It was not clear how this is organised because it was not shown on the rota. Weekends were seen as particularly problematic because a number of residents need 1-1 staff assistance due to limited physical mobility and some residents exhibit behaviour which can be Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 13 challenging. One of the biggest concerns for staff was that residents no longer have an annual holiday because of staffing levels. Photographs of residents’ holidays were seen but these were dated 2005, 2006. One resident was on holiday, but this was with family. Some residents spoken to confirmed the things they had been doing this week including attending day services, going to the hairdresser, into town and having aromatherapy. One resident was doing some shopping with staff and another resident helped to prepare tea. Whilst we were at the home we asked for a sandwich for lunch. Staff supported a resident to make it. One resident was not seen engaging in activity throughout the day and when asked about evening activities he did not seem sure. He told us the chiropodist was coming. Some staff stated residents helped out in the garden and enjoyed spending time outside when it was nice. One person was case tracked and they attended activities throughout the week, which included three evenings. Weekend activities were very limited. This persons care plan gave very little information about friendships, but their daily records indicated that they occasionally went out with friends or had a friend over for tea. Residents were asked about what they liked doing and what they liked about the home. One resident commented on his bedroom, another on the garden. Residents said they would ‘talk to staff’ ‘or the lady in the office if there was anything wrong’. One resident said they “ would like to go into town on their own.” One resident said “ I like it here, no one tells me what to do.” They said “ the staff are nice.” “I can talk to them.” “ I would like to go swimming.” The manager told us residents do their own laundry and decide on and write out the weekly menus. We were told that residents go into town, and join in karaoke, visual arts, and music groups. They also have full day services. One person is supported at home and has some one to one time. One person has an advocate. A number of residents are going to attend next steps in September, which will help teach them steps towards greater independence. One resident spoken to has a job locally. Another resident works at Burwell print. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good The home appropriately supports residents in accessing appropriate health care and there are systems in place for the safe administration of medicine. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were observed as they supported residents. Care plans indicated what support residents needed but this was limited in the plan inspected. The person case tracked had a health action plan. Some of the information was not up to date, such as weight records. The annual review indicated this person had lost weight and needed to be monitored. No recent weight records were seen. There was evidence that residents’ medical needs are being monitored and met. Medication reviews have been carried out and staff help residents access health care services where required. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 15 One resident was insulin dependent and care staff had been trained in the administration of insulin. This is renewed every year. The manager told us that staff are trained in the administration of rectal diazepam, although no resident is written up for this. Staff receive medication training. A competency assessment is carried out following staff training. Medication records were checked for a few residents and appeared to be accurate. External medication audits are not completed and the manager stated a senior member of staff is responsible for ordering medication and stock control. No gaps were identified. Some residents’ medication had been reviewed and some residents still had psychiatry input for their mental health needs. Last wishes for a few residents were not recorded. The staff support residents with bereavement. One person recently attended the funeral of a family member. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good Residents can expect to be listened to and their views and concerns taken seriously and where necessary acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has received no complaints since the last inspection. Residents’ have had their needs reviewed recently and were involved in the review. They would be given the opportunity to raise concerns. Resident surveys were completed, but residents need support completing them. No areas of concern were identified. Residents have regular meetings the last one was in June. One of the agenda items was how to make a complaint. Staff stated they were able to raise concerns and did not feel there was any bad practice in the home. The surveys completed by staff before the inspection indicated that it had been difficult to raise concerns in the past because of low staffing numbers and no clear management structure. Some staff have received recent training in adult protection. Some staffs training requires updating. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good Residents can expect to be consulted about the home and any improvements identified such as redecoration and colour schemes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and fresh on the day of inspection. No obvious maintenance issues were identified. The manager and operations manager confirmed that the environmental health and fire services had completed recent inspections at the homes request and these visits did not raise any serious issues. A number of maintenance records were inspected and were up to date. Some areas of the home have been re decorated and the manager said other areas of the home were due for redecoration. A number of bedrooms were Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 18 seen and were clean, bright and spacious. The manager stated that residents are involved in decision making about colour schemes for the home. The home was maintained to a high standard. Cleaning materials were locked away and staff said they had all the equipment they needed to do their job. Training on infection control had been provided. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good Residents are protected from abuse by the staff selection and recruitment policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home currently has 5 full time support workers in post. New appointments were made in July 2008 subject to satisfactory checks being received. The service is being restructured from a residential to supported living model of care, which will mean the residents will have a tenancy agreement with a local housing provider and support will continue to be provided by the local council. Under this model the staffing ratios will increase to 7 full time support workers, 2 being paid at senior grade. This will mean 3 care staff on duty, instead of 2. There is a new manager in post who has experience of managing supported living services. Staff have been unsettled by all the proposed changes and the lack of management support. Staff meetings were being held regularly but have not taken place for a while. The manager had planned one for this week. She was Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 20 also in the process of bringing staff supervisions, appraisals and staff training up to date. Staff records showed some gaps. New training dates have been identified and some training already planned for 2008. No requirement has been made on this occasion. Examples of recent or planned training included Better Food Better Business, Principles of Supported Living, Manual Handling, and Risk Assessment. Gaps in mandatory training including adult protection training are being addressed. The manager said she was looking into training in equality and diversity and the mental capacity act. A number of staff files were inspected and were satisfactory. The criminal records checks seen were over 3 years old. The operations manager stated these would be renewed as a matter of good practice. Four care staff were spoken to and confirmed that they had completed all the required training. Many had completed a national vocational course. Staff commented on low staffing and low moral but felt residents needs were always met. The staff felt that the administrator did an excellent job and knew all there was to know about the home. The new manager was also said to have made a good impression by supporting staff and working along side them on shift. The induction records seen were basic. The manager stated induction covered common induction standards and new staff would be mentored and shadowed for at least 2 weeks. During the probationary period of 6 months there are 3 appraisals. Residents were involved in recent staff interviews. Questions from the person specification were identified for residents to ask. The manager has had training on recruitment and selection. The council have a person specifications, job descriptions and guidance around key behaviours they expect all their employers to have. Correction fluid should not be used on the staff rota and staff surnames must be included on this document. It was noted on the day of inspection that there were 2 female care staff on in the morning and 2 male care staff in the afternoon. We understand that assistance with personal care is minimal but it may be more appropriate to have care staff of each gender thus promoting residents choice. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 Quality in this outcome area is good Residents’ benefit from a small, cohesive staff team who know them well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The newly appointed manager is in daily contact with the operations manager and is being well supported. She has many years experience. Her last job was working for a local council, and managing a supported living service for people with learning disabilities. She has an NVQ qualification and has registered for NVQ4. She has also registered for the leadership and management in social care, previously known as the registered managers award. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 22 The operation manager confirmed that he was in the process of developing a business plan for 2008/09. Through supervision key objectives have been identified for the manager to continue to take the home forward and manage future change. The home benefits from an administrator who was extremely knowledgeable about both residents and staff. The office was run in an efficient, organised way. Monthly budget surgeries are held and budgets devolved. We asked about quality assurance systems and were told this was being developed and would be identified as a priority in the business plan. The home know what they do well or where they need to improve by feedback from tenants meetings, their reviews, by the local authority and the home, staff meetings, supervision and appraisals. The home has asked other agencies for their input including the environmental health department and fire authorities, which have not reported any serious concerns. The home had a fire risk assessment drawn up by health and safety officers working for the council. A sample of records were inspected and were satisfactory. A number of policies were requested. The homes registration certificate, statement of purpose and service user guide require updating. Policies and procedures appeared out of date, but these are updated on the intranet and staff sign to say they have read them as and when they are updated. Some of the staff records required updating, such as the training matrix, but the manager was doing this along side staff appraisals and staff supervisions. Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 3 2 3 2 3 x Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 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 YA6 Regulation 12(1)(b) Requirement Care records must be up to date and address resident’s health, social and physical care needs as fully as possible to enable care staff to know how to meet needs comprehensively. The plan must be kept under review and highlight any progress made towards meeting individual goals or unmet or changing needs. There must be an effective quality monitoring system based on seeking the views of the service users, their representatives and other stakeholders, for the purpose of reviewing and improving the quality of care. This requirement was not considered fully met and has been carried forward with a new timescale. Timescale for action 31/12/08 2. YA39 24 31/12/08 Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 25 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. Refer to Standard YA1 Good Practice Recommendations The statement of purpose and service user guide should be updated and in an appropriate format for those it is intended for. Residents should have the choice of at least one annual holiday per year. Staffing rotas are legal documents and should include staff surnames. Correction fluid should not be used on legal documents. YA14 YA41 Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Jasmine House DS0000033483.V370325.R01.S.doc Version 5.2 Page 27 - 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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