Inspection on 02/11/07 for Carlton Dene Elderly Resource Centre

This inspection was carried out on 2nd November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Carlton Dene Elderly Resource... 29/06/06

Carlton Dene Elderly Resource... 30/11/05

Carlton Dene Elderly Resource... 25/11/04

Carlton Dene Elderly Resource... 17/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Carlton Dene Elderly Resource Centre 45 Kilburn Park Road London NW6 5XD Lead Inspector Wynne Price-Rees Key Unannounced Inspection 10:30 2 Novemberber 2007 nd 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 Carlton Dene Elderly Resource Centre DS0000036330.V345731.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 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. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Dene Elderly Resource Centre Address 45 Kilburn Park Road London NW6 5XD 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) 020 7641 4890 0207 641 4836 anwaenie@westminster.gov.uk Westminster City Council Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42) of places Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2006 Brief Description of the Service: Carlton Dene is a purpose built home registered for up to thirty-seven older people of either gender, who may suffer with dementia, six of who can receive respite care. There is currently one permanent placement vacancy. The proprietors are Westminster City Council and the home is well located for transport links, shops and other local amenities. It is purpose built and contains a day centre that has been relocated to the first floor. The home is laid out over ground and first floors with lift and stair access. The home is accessible throughout for people who use wheelchairs or have restricted mobility. Each resident has their own room and there are adequate numbers of bathroom and toilet facilities that are located close to residents’ rooms and communal areas. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over nine hours on two days. During the inspection residents, staff and one relative were spoken with; records inspected and care practices observed. Six residents’ files were case tracked. A pre-inspection Aqaa was returned to the CSCI prior to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that medication administration records are fully and accurately completed. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 6 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. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 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 Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. Full assessments of all prospective residents carried out prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a pre-admission assessment policy and procedure that a sample of six residents’ files case tracked demonstrated was followed. The home provides a service for residents referred by Westminster City Council. Once this information is received the home initially identifies if needs can be met and then carries out its own assessment with the prospective resident and their family to confirm this. The same assessment procedure is followed whether the placement is permanent, respite or emergency as the home now has one identified emergency bed. The emergency bed is for a one or two night stay and as much information is gathered regarding the person being placed although this is not Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 9 always as comprehensive as when other placements are being made. Permanent and respite residents have access to the same facilities. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. Health and personal care needs well met in the relevant standards. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of six residents files demonstrated that each resident had an up to date care plan that identified needs and how they are to be met. This covered all areas required by the relevant standard. The plans contained identified goals that were regularly reviewed and amended as required by changing needs. The plans contained daily notes that fed the reviews and were underpinned by risk assessments. When the Inspector arrived a resident was in the foyer and voiced concerns about how the home’s cat was to be looked after as the member of staff who had assumed this responsibility had recently retired. The resident’s care plan stated that they had a life long interest in animals and their welfare indicating a good depth of information regarding the resident. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 11 The residents’ health care requirements were incorporated within the care plan. All the residents’ were registered with the GP attached to the home or their own. There was one issue where a resident’s wife wished to retain their GP and not transfer to the one attached to the home. The current GP stated that they did not wish to visit, as the resident was no longer in their catchment area. The home is working with the relative to resolve this situation. The residents have access to community based health care services including designated visiting services. The controlled drugs register was inspected and found to be correctly kept. The medication administration records were checked for all residents and a small number contained gaps where no entry had been made. There is a policy and procedure regarding residents’ rights to privacy and dignity. Privacy and dignity are also included as part of core staff induction training. Residents spoken with and care practices observed confirmed that dignity and privacy is upheld and the residents are respected. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. Wide range of activities provided to meet identified interests of residents individually and as a group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new activities co-ordinator has been appointed subject to CRB clearance. A resident was on the recruitment panel. The home provides a combination of individual and group activities and outside agencies such as Age Concern visit and carry out reminiscence sessions. The individual activities are geared to interests identified as part of the care planning process. A musician also provides a sing-a-long two weekly. In-house group activities include light exercise, newspaper discussion and quizzes. The home has access to transport and outings take place in conjunction with the day centre and have included visits to historic sites. Residents also attended a tea party at Buckingham Palace. Some residents also make use of local facilities for shopping and one resident enjoys visiting a local pub accompanied by staff. Friends of Carleton Dene meetings take place quarterly and are minuted. These are used as consultation forums and the next meeting is scheduled for Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 13 December. Dementia specialists have been invited to this meeting and will be answering questions people may have. Client unit meetings also take place monthly. The main meal of the day takes place at lunchtime and residents are given a choice of meals. The menu changes regularly and there is a kitchen committee that residents’ are represented on. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. Residents listened to, complaints investigated and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a written complaints policy and procedure that residents and relatives have been made aware of. A complaints record is kept and three complaints were recorded in 2007. These were fully investigated with outcomes. Residents also have access to the Westminster City Council complaints procedure as well as that of the home. The home sends out questionnaires to the residents and a sample of twelve were inspected. These were all generally positive particularly regarding staff and two suggestions were made regarding improving meals. All staff have received adult protection training that incorporates abuse identification and action to take if encountered. They receive annual refreshers as part of the council training programme. There is also a policy and procedure. Currently there is one POVA investigation being undertaken. All staff are CRB cleared prior to commencing work. Funds held on behalf of residents and any transactions made were fully documented with receipts. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. Appropriate environment to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A premises tour demonstrated that the home is safe, comfortable and fit for its stated purpose. It was clean, hygienic and odour free. The home was well decorated with good standard furniture. Where possible residents are encouraged to bring their own possessions to make the home feel more like their home. The residents’ spoken with said they liked their accommodation. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. Suitable trained, competent and diverse staff are employed in adequate numbers to meet needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota demonstrated that there were adequate numbers of staff on duty at all times to meet residents’ needs and this was demonstrated on the two days of the unannounced inspection. There are four rotas for day care staff, night care, administration and kitchen. There are also contracted cleaners. Currently there are vacancies for two night team leaders and these are being covered by long-term agency staff whilst a job evaluation exercise is being undertaken. There are also vacancies for a part-time care assistant and administrator. The zero hour employees cover shifts for illness and leave. 90 of care staff have achieved NVQ level2 or above. Staff have access to the council rolling training programme and there is specific mandatory training highlighted. Staff also receive induction training prior to commencing employment. The recruitment procedure is that of Westminster City Council and meets all the requirements of the standard. This includes CRB clearance and no one starts work until this is obtained. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 17 Residents spoken with and questionnaires seen indicated that staff are held in high regard. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. Efficient and focused management with clear lines of communication and defined areas of responsibility. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Care Manager has not changed since the last inspection, holds NVQ level 4 in management, has been in post for a number of years and has extensive previous experience. Currently they are seconded part-time to another Westminster home. The home has an extensive quality assurance system in place that is incorporated as part of the overall council one and contains identifiable Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 19 performance indicators. There is an annual business plan with set objectives and internal audits are carried out. Appointeeship for residents who require it is held either by the council, relatives or legal representatives. Weekly health and safety checks take place throughout the building that include the fire system and are fully documented. Any problems are recorded, reported and there is a designated health and safety officer. The fridge and freezer temperatures are checked and recorded daily. A kitchen inspection took place on 08/03/07 where two recommendations were made. These have now been met. Fire drills take place quarterly, PATT tests annually and fire-fighting equipment was checked on 18/10/07. Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 20 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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 21 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 OP9 Regulation 13 (2) Timescale for action All medication administered must 05/11/07 be correctly recorded. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Carlton Dene Elderly Resource Centre DS0000036330.V345731.R01.S.doc Version 5.2 Page 23 - 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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