Care Home: Jericho Lodge

What the care home does well People who use this service told us they ‘like’ living at Jericho Lodge. Individuals told us the staff treated them ‘very well’ and that they felt ‘comfortable’ there. The service has received a letter of thanks from the family of one person using the service. Staff have worked well to develop good relationships with people who use the service. Staff were found to have a very good understanding of the strengths and needs of the individuals they support. Staff also have an understanding of the importance of maintaining and strengthening family links for individuals. The pre admission assessments carried out by the service provide very good information for staff to develop initial care and action plans. People who use the service and staff have worked well to set up social networks and activities in a relatively short period of time. Individuals we spoke to were pleased with the activities they took part in. What has improved since the last inspection? This is the first inspection of the service since registration with the Care Quality Commission. What the care home could do better: Jericho LodgeDS0000073060.V377499.R01.S.doc Version 5.2 To ensure the safety of people who use the service the organisation must have a complete employment history for each member of staff before they start work in the service. This record must also include satisfactory explanations for any gaps in employment. Care needs to be taken to make sure that documents on file relate to the staff member concerned. To ensure the safe management of medication all staff who administer medication must be provided with accredited training. The record of medication must be up to date and accurate. To ensure the safety of people using the service bathrooms and toilets need to be fitted with locks which can be opened from the outside in the event of an emergency. To provide people who use the service with a more homely environment lampshades should be provided for all ceiling lights. Care planning should be further developed to include more details of how the needs of individuals will be met, clear goals and areas of responsibilities. Where changes have occurred the care planning and action plans need to be up dated. Key inspection report CARE HOME ADULTS 18-65 Jericho Lodge Jericho Lodge 22 Links Avenue Morden Surrey SM4 5AA Lead Inspector Liz O`Reilly Key Unannounced Inspection 1st July 2009 10:00 Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jericho Lodge Address Jericho Lodge 22 Links Avenue Morden Surrey SM4 5AA 020 8545 0030 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) Supreme Care Services Limited Majekodunmi Omosanya Otubanjo Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 3 N/A Date of last inspection Brief Description of the Service: Jericho Lodge is a registered care home providing accommodation and care for up to three adults with mental health needs. The building is a domestic property with two bedrooms on the first floor and one on the ground floor. A kitchen, dining room and lounge are available on the ground floor. The service is situated in a residential area of Morden, close to transport, entertainment and shopping facilities. Fees for this service are from £750 per week. Jericho Lodge DS0000073060.V377499.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. This unannounced inspection was carried out on 1st July 2009 by one Regulation Inspector. The inspector had discussions with the people using the service, staff and the service manager. At the time of this inspection two people were living at Jericho Lodge. This is the first inspection of this service since it was first registered with the CQC. Jericho Lodge is managed in conjunction with Jubilee Lodge which is situated a few minutes walking distance away. Both services were opened at a similar time and many of the comments on the service are similar to those made following the inspection of Jubilee Lodge. What the service does well: What has improved since the last inspection? What they could do better: Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 6 To ensure the safety of people who use the service the organisation must have a complete employment history for each member of staff before they start work in the service. This record must also include satisfactory explanations for any gaps in employment. Care needs to be taken to make sure that documents on file relate to the staff member concerned. To ensure the safe management of medication all staff who administer medication must be provided with accredited training. The record of medication must be up to date and accurate. To ensure the safety of people using the service bathrooms and toilets need to be fitted with locks which can be opened from the outside in the event of an emergency. To provide people who use the service with a more homely environment lampshades should be provided for all ceiling lights. Care planning should be further developed to include more details of how the needs of individuals will be met, clear goals and areas of responsibilities. Where changes have occurred the care planning and action plans need to be up dated. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Jericho Lodge DS0000073060.V377499.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 Jericho Lodge DS0000073060.V377499.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care is taken to ensure that individuals have enough information about the service and are offered opportunities to visit before making a decision about moving in. Detailed assessments are carried out for each person before they move into the service to ensure that their individual needs and aspirations can be met. EVIDENCE: People who use the service told us they were given enough information to make a decision about moving into the home. Each person is provided with a Service User Guide which gives information on what they can expect from the service. We were provided with a copy of this document. The details for contacting the Care Quality Commission require updating. In the section on complaints an addition should be made to inform people that they can approach the placing authority at any time should they have any concerns. Pre admission assessments were seen to be carried out before any agreement is reached about individuals moving in. We looked at the assessments carried out for each person and found these to be detailed and of good quality. The Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 9 service also receives copies of assessments carried out by the placing authorities. This information is used to make sure that the service can meet the needs of each individual and provides good information for staff to have some understanding of the individual from day one. The manager told us that the admission process is carried out over a period of time to allow individuals to try the service before moving in. Individuals visit for one day and a weekend and then move in on a three month trial basis. People who use the service told us they had visited the service on a number of occasions before they made the decision to move in. We saw that people who use the service are provided with their terms and conditions for staying at the home. These were signed by the individuals concerned. Jericho Lodge DS0000073060.V377499.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is developing person centred care planning. Individuals are involved in the planning of the support they receive. Risk assessments are carried out and reviewed for each person to ensure that individuals receive the right levels of support. EVIDENCE: Each person who uses the service is provided with a care plan and a Wellness Recovery Action Plan (WRAP). These documents set out individual needs, objectives and actions. We looked at these records for the people living at the service. A wide range of issues are covered, including individual mental and physical health, activities of daily living, medication compliance, community and social inclusion and anti social behaviour. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 11 People who use the service were seen to be involved in the care planning process. Staff carry out a monthly review for each person which was seen to record activities and any progress made. People who use the service are allocated a key worker. Each person meets with their key worker every month to discuss plans for the future and any concerns they may have. These meetings were seen to be recorded and people who use the service are given the choice of where to have these meetings, in the service or in the community. Staff have made a good start in setting up care planning documents. However the planning could be expanded to be more person centred. Information around personal goals and targets along with how these will be met could be expanded. Consideration should be given to setting clear timescales and allocating responsibility within the staff group for assessing the progress made in meeting targets or goals. Although staff are carrying out monthly reviews which show individuals are making progress this is not reflected in the care planning or WRAP documentation. These care documents should be updated when changes occur or targets are met. Consideration could be given to completing WRAP documents over a longer period of time to allow people to set more targets or goals once they have settled into the home. We saw that risk assessments are in place for individuals. These were seen to be set up using initial information from pre admission assessments and discharge information. Staff were seen to be up dating these documents which ensures the individuals receive the right levels of support. Risk assessments were seen to be shared with the individual concerned. Staff were seen to be keeping daily records which include information on activities during each day along with information on the general well being of individuals. A daily report is completed for each person which covers a wide range of issues including risks. This document is used at staff handover and assists in ensuring good communication within the staff group. Jericho Lodge DS0000073060.V377499.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): This is what people staying in this care home experience: 12, 13, 15, 16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service take part in a variety of activities in the local community. Staff have a good understanding of the individual interests of the people they support. The service understands the importance of maintaining or re establishing family contacts. People who use the service enjoy the food provided. EVIDENCE: People take part in a variety of activities including attending social events at a local family centre, walks, meals out, art classes, trips to places of interest and attending a local gym. People who use the service told us that they enjoyed the various activities. Staff were seen to support and encourage people in their individual interests. One person particularly enjoys attending a writing Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 13 and poetry group in the community. One person had expressed an interest in playing pool and staff were in the process of seeking out a pool club for this person to try out. A joint meeting, with the people who live at Jubilee Lodge, had been carried out to suggest join social activities and trips over the summer. A barbecue was being planned and a visit to London. Each person has their own Freedom Pass for public transport. People who use the service told us they enjoy the meals provided. The service keeps a record of the meals which showed a good variety of food. People using the service decide with staff on what food shopping is needed for the following week. Staff and individuals who use the service told us that staff members prepare the meals. People who use the service can make their own snacks and drinks throughout the day if they wish. The manager informed us that the service works to encourage family contacts. The service has received a letter of thanks from the family of one person using the service. Staff were found to understand the importance of maintaining social links outside of the service. Plans were being made for one person to be supported to visit their family in the near future. People who use the service are registered to vote and staff provided support to attend polling stations. Jericho Lodge DS0000073060.V377499.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The healthcare needs of individuals using the service are met. Medication is adequately managed but regular checks should be carried out to make sure records are accurate. EVIDENCE: Each person using the service is registered with a local GP practice. Discussions with staff indicated that they were alert to the physical and mental health needs of individuals. This was reflected in the records we looked at. Good information is available to staff about possible early warning signs of deterioration in individual’s mental health. The service has good links with community psychiatric services who they can call on for advice. Staff are working with individuals to promote a healthy lifestyle. Risk assessments have been carried out in relation to smoking and agreements on Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 15 reducing smoking have been signed by one individual who uses the service. This person told us that this was working well for them. We looked at the record of medication kept by staff. Medication administration records were mostly up to date. However in one instance the amount of medication available did not match the medication received and administered. This issue was discussed with the manager. The records kept on this type of medication should include a running total of the medication left each time it is administered. We noted that staff are now adding the number of any medication still in the service to that delivered which will allow for a full audit of medication to be carried out at any time. Regular checks should be carried out to make sure that records are accurate. Staff have been provided with training on medication but it was not accredited training. The manager informed us that accredited training would be provided to all staff by the end of July 2009. Jericho Lodge DS0000073060.V377499.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure in place with systems for the recording actions taken. Staff are provided with training on safeguarding people. EVIDENCE: People who use the service told us they were aware of who they could speak to if they had any complaints or concerns. People who are new to the service are provided with a Service User Guide which includes information on how to make a complaint. We looked at the complaints information provided in the Service User Guide. This gave good information on how complaints would be dealt with by the organisation. However the information on how to contact the Care Quality Commission needs to be updated. Information should also be added to let individuals know they can approach the placing authority at any time should they have any concerns. Staff should make sure that the contact details of their placing authority are provided to each person. The manager informed us that no complaints had been received about the service since registration. Systems are in place for complaints to be recorded along with actions taken and outcomes. The Care Quality Commission have received no complaints about this service. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 17 Arrangements can be made for small amounts of money to be held in the service for individuals. Records of money held were found to be up to date and accurate. Not all staff have been provided with training on safeguarding people. The manager informed us that this training had been booked for the 30th July 2009 with the London Borough of Croydon. Staff spoken to have taken part in training on safeguarding through NVQ courses they are attending. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service are provided with a comfortable domestic style environment which meets their needs. EVIDENCE: People who use the service told us they felt ‘comfortable’ in the service. Individuals said that they had all they needed in their room. People were seen to use their private bedroom and communal areas according to their own choice. One bedroom is on the ground floor with two on the first floor. Communal areas of a lounge, kitchen and conservatory are on the ground floor, with a garden to the rear of the house. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 19 The building was seen to be well maintained. We noted that none of the ceiling lights were fitted with lampshades. This should be addressed. To ensure the privacy of individuals along with their safety locks which can in an emergency be unlocked by staff from outside should be fitted to bathrooms and toilets. The majority of the areas we saw during this visit were clean and fresh. However the carpet to the stairs and landing was not as clean as the rest of the service. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were seen to be available to meet the needs of the people living at the service at the time of inspection. Staff are provided with good opportunities for training. Further work should be done to ensure that the training provided is at the appropriate level. The majority of records required in relation to staff recruitment were in place. EVIDENCE: People who use the service told us they got on well with individual staff members. We observed staff provide support and advice to individuals in a friendly and positive manner. Discussions with staff showed they had a good knowledge of the people they support. A minimum of one member of staff was seen to be on duty in the service at all times. One project worker also works between the two services. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 21 The staff rota seen on the day of inspection was not up to date or accurate. It is important that a clear record of who was working and at what times each day is kept. The staffing levels seen were not as those agreed when this service was registered. However the service is not fully occupied and the levels of support individuals require were not as high as envisaged when the service was being planned. People using the service told us they felt well supported and were not in any way restricted by the lower levels of staffing. The staffing levels will need to be reviewed on a regular basis as the number of people using the services increases and taking into consideration the needs of the individuals. The service does not use agency staff. Staff have been provided with training on, the Mental Capacity Act, deprivation of liberty legislation, mental health, drug awareness, medication and first aid. As noted previously further training needs to be provided on the management of medication. The manager should also ensure that sufficient staff have received training to an appropriate level to ensure a qualified first aider is available at all times. The manager informed us that plans were in place for further mental health training to be provided. We looked at a sample of three staff files. These showed the majority of the required checks were carried out before staff started to work in the home. This assists in safeguarding people who use the service. A full employment history was not available on the files we looked at. The manager of the service is in the process of seeking this information and understands that in future this information should be sought before people start working in the service. One Criminal Records Bureau check on file did not relate to the person concerned. The manager informed us that this was an administrative error. Staff told us they received regular one to one supervision and supervision records were seen to be in place. This assists in ensuring they are working in line with the service aims and objectives. Staff meetings are also recorded. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the skills and knowledge to run the service. Systems are in place to consult with people who use the service and others about how the service is performing. Regular checks are carried out to ensure the health and safety of people who use the service, staff and visitors. EVIDENCE: The manager has completed NVQ level 4 in care management and the Registered Managers Award. Jubilee Lodge and a second home are managed jointly. The second service is within a few minutes walking distance and so the manager can be called upon quickly if he is not in the home. We found the Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 23 manager had a comprehensive knowledge of the people using the service and we observed good supportive interactions between the manager and individuals. Regular meetings are held with people who use the service so that their views can be sought on the day to day running of the service. This was confirmed by people who use the service and we saw that minutes of the meetings are kept. The organisation has developed systems for monitoring the quality of the service which includes seeking the views of people who use the service and their relatives through surveys. Consideration could also be given to including feedback from other professionals and visitors to the service in this process. We saw a suggestion box was available in the entrance hall so that individuals can make comments on the service. We looked at a sample of the records kept in relation to the health and safety of people who use the service. We found these to be well maintained and up to date. Staff make weekly checks on the fire alarm system and regular fire drills are carried out which ensures that staff and people who live at the service have a clear understanding of what to do should the alarms be activated. A record of any problems with evacuation of the premises is kept. A record of any accident or incident is kept and reviewed by the manager. This assists in ensuring that risk assessments are kept up to date and actions are taken to minimise any future accidents or incidents where ever possible. Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 24 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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Version 5.2 Page 25 Jericho Lodge DS0000073060.V377499.R01.S.doc Are there any outstanding requirements from the last inspection? N/A 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 YA20 Regulation 13 (2) Requirement To ensure the health and welfare of people who use the service regular checks must be carried out on medication held in the service to make sure that individuals are receiving the right amount of medication at the right time. To ensure the safety and privacy of people who use the service locks, which can be opened by staff from outside in an emergency must be fitted to bathrooms and toilets. An up to date and accurate record of the staff working at the service at any one time must be kept. This ensures that should the need arise information on who has worked in the service on any one day or night can be accessed. Timescale for action 01/11/09 2 YA24 23 (2) 01/12/09 3 YA33 17(2) Schedule 4 paragraph 7 01/11/09 Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations The contact details for the Care Quality Commission should be updated in the Service User Guide and complaints procedure. 2 YA6 Care planning documents should be updated when changes have occurred such as goals or targets being achieved. More detailed information on how the service will be supporting people to meet targets or goals should be included in care planning documentation. Consideration should be given to allowing people who use the service more time to set their own goals. Information should be added to the complaints procedure to let individuals know they can approach the placing authority at any time should they have any concerns. Staff should make sure that the contact details of their placing authority are provided to each person. All ceiling lights should be fitted with lampshades. The manager should carry out a review of the training provided to make sure this provides staff with the appropriate levels of knowledge. First aid training should be provided to a level so that a qualified first aider is available at all times. 3 YA6 4 5 YA6 YA22 6 7 YA24 YA35 Jericho Lodge DS0000073060.V377499.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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