Inspection on 11/12/07 for Craven Park Nursing Home

This inspection was carried out on 11th December 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

Craven Park Nursing Home 18/11/08

Craven Park Nursing Home 10/01/07

Craven Park Nursing Home 20/10/05

Craven Park Nursing Home 11/04/05

Craven Park Nursing Home 18/11/04

Craven Park Nursing Home 14/06/04

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 09/02/2009.

CARE HOMES FOR OLDER PEOPLE Craven Park Nursing Home 1 Craven Road Craven Park Harlesden London NW10 8RR Lead Inspector Judith Brindle Key Unannounced Inspection 11th December 2007 08:40 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 DS0000022925.V354764.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. DS0000022925.V354764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Craven Park Nursing Home Address 1 Craven Road Craven Park Harlesden London NW10 8RR 020 8961 5678 020 8965 2789 cravenpark@bmlhealthcare.co.uk www.cravenpark-nh.co.uk GSG Nursing Homes Limited BML Healthcare Limited Mrs Mary Ampah Care Home 26 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) Category(ies) of Old age, not falling within any other category registration, with number (26) of places DS0000022925.V354764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2007 Brief Description of the Service: Craven Park Nursing Home is a care home providing nursing and personal care, and accommodation, for up to 26 older people. The registered providers of services at the home are GSG Nursing Homes Ltd (in respect of the building) and BML Healthcare, a national care organisation (in respect of the business of staffing and care). The registered responsible person is Mr Lambert, Director of BML Healthcare. The home has been operating since 1995. The home is located within a residential area of Harlesden, within the London Borough of Brent. It is a few minutes walk from local amenities and Harlesden tube station. Bus routes are around the corner from the home. The home has a private driveway. There is parking for several vehicles on the forecourt of the care home. The building has three floors. Access is by passenger lift or stairs. One of the homes bedrooms is a double room. All bedrooms are fully furnished. All but two have en-suite toilet facilities. The home has three communal bathrooms that all have adaptations. One such room has a walk-in shower area. There are a number of additional toilets. The home has a large dining room that is also used as a day room for a number of service users. There is a separate main lounge. The home has medium-sized, enclosed garden, which includes a patio. Prospective residents and others have access to information about the service provided by the care home. Details in regard to fees can be accessed from the care home. The range of fees is presently £601-671 per week. DS0000022925.V354764.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day in December 2007. There was one vacancy at the time of the inspection. I completed the inspection with an ‘Expert by Experience’ who is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The ‘expert by experience’ spent three and a half hours at the care home talking with people using the service and with staff, and accompanied me during a tour of the premises. Following the inspection she completed a report. This information helped me to gain evidence about the care and support provided to residents in the home, and to verify any issues about the quality of the service provided to people living in the care home. Reference to the ‘expert by experience’s’ report is included within this inspection report. The ‘expert by experience’ has read and commented on this inspection report and feedback from her confirmed that she considered it ‘fair’. The registered manager was present for the whole of the inspection. I was pleased to meet and talk with people living in the home, several visitors and with staff on duty. The key unannounced inspection focussed on spending a significant period of time with people living in the care home, and observing interaction between residents and staff. Some of the people using the service, had various communication needs and abilities, and were only able to respond to questions to a limited degree, so observation was a significant tool used in this inspection. Documentation inspected included, resident’s care plans, risk assessments, staff training records, and some policies and procedures. The inspection included a tour of the premises. Staff were very helpful during the inspection, and supplied all documentation, and information that I requested. Assessment as to whether requirements from the previous random inspection (that took place 10th January 2007) had been met also took place during the inspection. 26 National Minimum Standards for Older Persons, including Key Standards, were inspected during this inspection. Prior to this unannounced key inspection the registered manager supplied the Commission for Social Care Inspection (CSCI) a completed Annual Quality Assurance Assessment (AQAA) document. This includes required information from the owner /registered manager about the quality of the care home and the plans to improve the service. The registered manager comprehensively DS0000022925.V354764.R01.S.doc Version 5.2 Page 6 completed all sections of this document. Reference to some aspects of this AQAA record will be documented in this report. The inspector and the ‘expert by experience’ thank all the people living in the care home, visitors, and the staff for their assistance in the inspection process. What the service does well: What has improved since the last inspection? All but two requirements from the previous inspection have been met. There is a new carpet in the sitting/dining room. Some improvements to the environment have been carried out. Procedures with regard to the management of resident’s monies have been improved. DS0000022925.V354764.R01.S.doc Version 5.2 Page 7 Staff training and opportunities to achieve National Vocational Qualifications in care continue to be developed. Some policies/procedures have been reviewed and developed. 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. DS0000022925.V354764.R01.S.doc Version 5.2 Page 8 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 DS0000022925.V354764.R01.S.doc Version 5.2 Page 9 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): Standards 1,2,5 and (6 is not applicable) People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective service users to have the information that they need to make an informed choice about where to live, and they have their needs assessed prior to moving into the care home. EVIDENCE: The statement of purpose, and the service user guide documents include information about the service provided by the care home. The statement of purpose has been reviewed this year. The manager reported that all the people living in the care home had received a copy of the service user guide. I was shown a ‘welcome pack’ of documentation including leaflets about the service, which is given to all those requesting information about the service including prospective residents. This ‘pack’ consists of information about the service, including the accommodation, facilities, meals and activities. DS0000022925.V354764.R01.S.doc Version 5.2 Page 10 I was informed that the care home has two ‘step down’ beds linked to a local hospital, which sometimes times can lead to a person being admitted to the nursing home at fairly short notice. There are also five ‘block’ contracted beds with the local Primary Care Trust. The care home has an admission procedure. The registered manager informed me that the care home receives a referral from the funding Local Authority Care Manager or Primary care Trust. This referral includes some assessment information. The registered manager reported that the referring Care Manager completes a comprehensive assessment. The manager assesses the person’s needs from this information and makes a judgement as to whether the home can meet the person’s needs. The manager or senior nurse and another member of staff also complete an initial assessment of the needs of the prospective resident, and relatives/significant others are invited (if agreed by the prospective resident) to participate with the service user in this assessment meeting. Records confirmed that the assessor signs the assessment. It should be more evident that residents participate in, and agree with the assessment, and are offered the opportunity to sign the documentation. Staff confirmed that this assessment process continues following the admission of the person. Care plans indicated that assessment of resident’s needs take place, and that this assessment information forms the basis of the individual care plan. A resident spoke of having chosen to live in the home, as he was familiar with it having ‘lived across the road from the home’. Another resident confirmed that they had visited the home prior to their admission. AQAA (Annual Quality Assurance Assessment) information supplied to the Commission informed me that prospective residents and their friends and families are supported and encouraged to visit the home prior to residents moving into the care home. It is evident that the manager has a good understanding of the challenges that residents face when moving in to a residential care service, and of the importance of staff being trained to provide residents with emotional as well as physical support. DS0000022925.V354764.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9, and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each person using the service has a plan of care, but these could be further developed to improve their accessibility, and to indicate residents’ full involvement in their care plans. Resident’s individual personal and healthcare needs are generally well met, but there are some areas where staff guidance to meet some resident’s health needs could be improved. Residents are respected and their right to privacy upheld. Medication is generally stored and administered safely. There needs to be review of a specific area of medication administration. EVIDENCE: Four residents care plans were inspected. These incorporated evidence of individual resident’s health, personal, social and emotional needs having been assessed. Assessment also included risk assessment, including nutritional risk assessment, risk of falls, dependency risk, and pressure sore risk. The care plans, included personal care needs, health care, emotional, social and cultural needs of the individuals and how these were addressed by the home. DS0000022925.V354764.R01.S.doc Version 5.2 Page 12 There were some areas where guidance to meet certain identified health needs, which could be developed. For example a person with diabetic needs had some recorded staff guidance in their care plan, but this did not include action to be taken by staff if the person developed symptoms of diabetes, nor was it recorded that the person need regular eye and foot care and treatment. Records confirmed that care plans and risk assessments are reviewed regularly. It should be evident that all recommendations agreed in care plan review meetings are recorded in resident’s individual care plans. There were some areas of the care plan records that indicated that some staff did not have an understanding of certain aspects of assessment for example in a section titled ‘dying’ it was recorded ‘nothing required’, and in a the sexuality section, it was recorded ‘has a daughter who lives in Ireland’. Other sections in some care plans were not completed these included religion, and funeral arrangements in one care plan. The registered manager needs to ensure that all staff completing these care plan records are competent to complete them fully. Development of care plans into a more ‘person centred’ format was discussed with the manager. There should be evidence of individually set ‘goals’ that have been agreed by each resident, which include individual social and cultural needs. There should be more evidence that care plans are working documents. The manager should continue to further develop care plans into a variety of formats that ensures that people using the service, can access the information, participate in the formation of the care plan, and so experience the life that each person wants. The people using the service should have the opportunity to sign their care plan. I asked a resident if he knew the content of his care plan, he reported that he did not know anything about it, but was ‘happy here’. ‘Daily’ and night records are completed by staff in regard to the progress of each person living in the care home. It was not always apparent that issues recorded in these ‘daily’ progress documents, and during resident’s review meetings were linked/added to the care plans. This was discussed with the manager who confirmed that she regularly audits a selection of care plans, and that there were plans to develop, and to improve these records. The manager reported that there were no residents who have a pressure sore. The residents have access to healthcare from a GP, dentist, option and chiropodist. A resident spoke of having recently seen her GP. The manager spoke of specialist healthcare professionals including physiotherapists, dietician, which offer advice and treatment to residents as and when needed. Residents weight is monitored. Records indicated that a resident had lost 8.1kg within ten months. It was not evident in the care plan that this was planned weight loss, or of what action was being taken to meet this need. DS0000022925.V354764.R01.S.doc Version 5.2 Page 13 AQAA information indicated that the manager had plans to further develop the skills of staff in caring for the dying, and that training in this is given to all staff. This is positive. The home has a medication policy/procedure. There is accessible staff guidance in regard to medication administration. There were no gaps in recording in the resident’s medication administration records, which were inspected. The senior nurse explained to me the medication storage and administration systems. I inspected the ‘controlled drug’ medication systems with the senior nurse, and it was found that a tablet of a medication was missing. It was noted that the medication container was not secure. This container/box was secured during the inspection. The manager and senior nurse investigated this issue following the inspection, and reported that systems of storage and administration of this medication had been improved. The manager needs to ensure that medication is stored safely at all times and also could review the recording of controlled medication administration to ensure that all tablets are accounted for at all times, and that an incident such as this does not occur again. DS0000022925.V354764.R01.S.doc Version 5.2 Page 14 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): Standard 12,13 14 and 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to participate in varied activities. The visiting arrangements are flexible and meet the needs of visitors and residents, so that residents have the opportunity to develop and maintain important relationships. Residents are supported to make choices. Meals provided are varied and nutritious, and meet cultural needs. The menu could be more accessible to people using the service. EVIDENCE: There is an activity worker who is employed by the home. She was on duty during the inspection. She works in the home five days a week, and was observed to provide residents with one to one attention regarding their preferred activities. The residents were observed to participate in a variety of leisure pursuits, including an arts and crafts session and 1-1 activities during the inspection. A resident spoke of enjoying participating in the activity that they were doing. There is general activities board that records some of the variety of activities, and is located outside the sitting/dining room. The weekly activity programme DS0000022925.V354764.R01.S.doc Version 5.2 Page 15 was displayed in the sitting/dining room, but it was difficult to see the content of the information, being in small print written format. The information on the activity programme should be recorded in a variety of formats that ensures that the information is clearly accessible to all residents. Activities include colour therapy, bingo, keep fit sessions, painting, board games, discussion of news items/current affairs, arts and crafts, music sessions, reminiscence, quizzes, activities including ‘Family fellowship sessions, that meet service users religious needs. Trips into the community also take place. These include visits to local parks, shopping and theatre trips. The manager informed me that a community trip out for some residents was planned to take place shortly. A resident spoke of having the choice as to whether to participate in activities or not. It was evident that the Activity Co-ordinator had a good understanding of individual service users needs including their preferences in regard to activities. The televisions located in the lounges were both switched on during the entire inspection. It was not always clear that residents were watching them, nor whether they had been offered a choice of what channel to watch. The issue of televisions being switched on all day could be reviewed. The visitor’s record book indicated that there were numerous visitors to the care home. During the inspection there were several visitors. A visitor spoke of visiting a relative (living in the home) several times a week, and said that her relative was ‘well looked after’. A residents said that his ‘sister in law and niece had visited yesterday’. Two other visitors were complimentary about the care home, comments included the home is ‘warm’ and that their relative is ‘happy with the home’. The home has a four week menu. This menu included varied, wholesome and nutritious meals, and it was evident that residents could choose from a variety of snacks, such as omelettes, salads if they preferred. The chef reported that this had been reviewed in 2007, and included resident’s preferences. She spoke of ensuring that she asks for feedback from residents on a daily basis. The ‘expert by experience’ noted that ‘unfortunately I could not see a menu anywhere’. I saw a menu displayed in the lounge/dining room, but it was recorded in very small print. The manager should ensure that the menu is available in a variety of formats to ensure that the information about the meals provided, is accessible to residents. Most residents are from the local area and a significant number of the people using the service are Afro-Caribbean and Irish. The chef spoke of the meals that were regularly provided to meet resident’s specific cultural dietary needs, including the provision of Halal meet for a resident. She reported that she ensures that there are fresh vegetables available at all times, and was knowledgeable of resident’s particular food preferences and needs. She spoke of informing residents individually on a daily basis of the choice of meals for the day, and gave examples of specific foods that she cooked to ensure that resident’s individual food preferences and choices were met. DS0000022925.V354764.R01.S.doc Version 5.2 Page 16 We observed lunch being served. The ‘expert by experience’ reported that ‘those that had their meals in their room were served first, and given assistance at that time, and not left’. The residents in the communal rooms were then provided with their lunch. The ‘expert by experience’ noted that one resident complained that her meal was cold, and that it was ‘immediately removed and a hotter one delivered’. We observed that the meals served at lunch looked appetising and that there were choices offered to people using the service. Staff were observed to assist residents with their meal. The ‘expert by experience’ observed that ‘there were six staff members feeding the residents or helping them cut up their food’. She noted that there were residents that could manage their meal without staff assistance and who ‘had to wait for their lunch’ whilst others were assisted with their meal. She reported that she ‘felt that they (the more able residents) should have been served first instead of having to wait. I discussed this with the manager and chef, and they agreed to review this procedure. The ‘expert by experience’ reported that those residents ‘that did not wish to have their meal in the dining area or to sit at the table were provided with their meal wherever they felt comfortable’. Drinks were offered regularly to residents. A` resident said that the food was ‘good’; another resident spoke of ‘enjoying’ her meal. AQAA information informed me that the home had plans to upgrade the communal areas to make dining more pleasurable for people using the service. DS0000022925.V354764.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and handled objectively. The format of the complaints procedure could be developed to improve its accessibility to people using the service. Residents are protected from abuse, neglect and self-harm. EVIDENCE: The care home has a complaints policy/procedure. This information is included in the service user guide, and the statement of purpose documentation. The manager reported that this documentation is provided to prospective residents, and others during the admission process. The complaints procedure is also displayed within the communal area of the care home. AQAA information confirmed that complaints, concerns and suggestions are welcomed by the home, and that the home ‘aims to deal with any complaints both speedily and effectively within fourteen days’. Records are maintained of complaints, and complaints are monitored closely by the manager. The home also has a book located in the reception area in which visitors, and others can record any comments and suggestion that they might have about the care home. This is positive. The home has a protection of vulnerable adults policy/procedure. This has been recently reviewed to include requirements from the previous inspection. The care home also has a copy of the lead Local Authority’s safe guarding adult’s procedure. Incidents and accidents are recorded as required. Staff DS0000022925.V354764.R01.S.doc Version 5.2 Page 18 receive protection of vulnerable adults training, on an annual basis. This is positive. Staff who spoke with me confirmed that they were fully aware of required reporting and recording procedures in the event of a suspicion or allegation of abuse. AQAA information confirmed that the home has policies/procedures with regard to restraint, and for the management of resident’s monies DS0000022925.V354764.R01.S.doc Version 5.2 Page 19 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): Standard 19, 21, 23 and 26 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely, clean and comfortable. The premises are suitable for the care home’s stated purpose, but there are areas of the environment that could be improved. Residents bedrooms are individually personalised, meet their individual needs. EVIDENCE: The home is located in a residential road, off a main road in Harlesden, close to a variety of shops and amenities. Public bus services are accessible near to the home. Train services can be reached within a few minutes walk or short drive from the home. The ‘expert by experience’ found the home difficult to locate due to lack signage on the main road close to the home. There is a sign for the care home at the entrance of the forecourt to the home, but is possibly not very apparent to everyone. The accessibility of the signage could possibly be reviewed. The manager spoke of some incidents of theft that had occurred DS0000022925.V354764.R01.S.doc Version 5.2 Page 20 in the past from cars in the parking area on the forecourt of the home. The possible use of CCTV cameras purely for monitoring the car park area was discussed with the manager and expert by experience. It is recommended that the use of CCTV cameras regarding monitoring of the car parking area on the forecourt of the home is examined by the registered person (owner), and that advice be sought from the local community police service. The home has an enclosed garden with seating for residents and visitors. The ‘expert by experience’ and I toured the premises with a member of staff. An attractively decorated Christmas tree was located in the reception area. A new carpet has recently been laid in the communal sitting/dining area. This is positive. The front door has a system in place in which visitors, and residents have to ask staff access the door system to enable visitors and others to exit the building. This could be seen as positive in minimising the risk to safety, but could also be a form of restraint. The manager should ensure that there is a risk assessment, with guidance, in place that demonstrates with regard to safety the need for this door safety system in place. Areas of the environment could be developed, and enhanced, particularly by redecoration, to improve the attractiveness of the surroundings. The ‘expert by experience’ reported that the home was ‘clean and tidy’, ‘but that there were many areas that really could do with refurbishment’, and that some areas were ‘shabby and tired looking’. The housekeeper informed us that some curtains were going to be replaced, but that the home was awaiting a decision regarding estimates of the cost. We noted during the tour of the premises that in one room (21) the curtain was hanging down. There are two lounges that residents can choose to sit in during the day; one of these rooms was also the general dining room. We both noted that the lounges could benefit from refurbishment and redecoration, to develop the attractiveness of the environment for people using the service, particularly with regard the often significant length of time during the day that residents spend in these rooms. We agreed that one lounge (not the sitting/dining room) in particular was rather dark. Following speaking to a staff member, the lights in this room were turned on, but even with the lights on this room was not particularly bright and light. There were also numerous chairs of an institutional nature/design within the room. We both noted that there were very few pictures on the wall anywhere in the care home except pictures drawn by residents, during their regular activity sessions. The registered person should seek ways of improving the attractiveness and lighting of the environment of the lounges particularly the lounge located away from the dining area. The home employs a maintenance person. Clocks were displayed in the lounges, but were located quite high up in the dining/sitting room area. A resident asked me the time, saying that she could not see the clock. The registered person should review the location and type of clocks located in the home to ensure that they are accessible to all residents DS0000022925.V354764.R01.S.doc Version 5.2 Page 21 including those with sensory needs. There could be a displayed record of the day and date, (and possibly weather etc), which is clearly visible and accessible to residents. During the tour of the premises the ‘expert by experience’ and I randomly assessed several bedrooms. Some residents kindly invited us to visit their room, and talk with them regarding their views of their room, and of the service provided by the home. Residents spoke of being ‘happy’ with their rooms. We noted from observation and from talking to staff that due to the size of some bedrooms it was difficult for staff to manoeuvre a passenger hoist. The registered manager should seek ways of possibly moving bedroom furnishings to a different location within the room to enable the hoist to be more easily manoeuvred. Also the registered manager should ensure that during the process of initial assessment, residents (due to their mobility needs) who need assistance with transferring are allocated a bedroom in which a hoist can be moved without difficulty. The décor of bedrooms needs to be reviewed. The expert by experience found that ‘on the whole, the rooms looked stark even when some of the residents had brought in some of their belongings’. In some rooms i.e. (15), (21) and (28) there was wallpaper peeling off, and the carpets in these rooms should be cleaned or replaced. The ‘expert by experience’ reported that ‘although some of the rooms had had new carpets fitted, there were others that had seen a ‘better day’, and had had the ‘life cleaned’ out of them’. A carpet in room 19 was ‘ruffled’ in some areas, and needs to be secured or the carpet replaced, as it could be a trip hazard. All carpets within the home should be reviewed and cleaned or replaced if needed. We were informed by the manager and a care staff member that several of the beds had been replaced with new improved adjustable beds, which allow for better safer ways of moving and handling those resident’s who have significant mobility needs. Beds that have not yet been replaced with these new beds should be replaced. And the registered person should always ensure that residents who have significant mobility needs have access to a new bed. We were informed by a staff member that the seating and ‘arms’ of the bath hoists were a ‘tight fit’ for some residents, due to their size. Residents who use that bathroom hoist need to be individually assessed regarding the use of the hoist, and included in this risk assessment, staff should ensure that each resident meets the safe carrying weight of each bath hoist. The ‘expert by experience’ noted that the ‘bathrooms were functional but somewhat stark’. Areas of chipped paint were seen in the ground floor bathroom, and the 2nd floor bathroom. Both could be more attractively decorated, with pictures possibly displayed. There is one specific shower facility, and also shower attachments to baths in the bathrooms. The expert by experience noted that that the water pressure from the shower attachments was low. The registered person should review the water pressure in regard to the bath shower attachments. DS0000022925.V354764.R01.S.doc Version 5.2 Page 22 There was observed to be a crack in the wall of the stairway area on the 2nd floor. The manager informed me that the home was awaiting an estimate for this work from a builder. It was evident that this needs to be fully repaired. There are areas of the kitchen that could be attended to. I was informed that there were plans for a new kitchen. This is recommended. An area of lining on the edge of the kitchen floor is in need of securing. I tripped on a small step. There needs to be clear signage to indicate where this step (in the kitchen) is to minimise it being a risk hazard. The registered person should consider putting a ramp instead of the step to allow for ease of manoeuvring food trolleys. The home has a call bell system but there is only one alarm panel located on the ground floor, which provides information as to which room the resident is calling from. There are lights that flash on the first and second floor, but this does not inform staff of the room number from where the resident is calling. The ‘expert by experience’ was informed by staff that ‘staff tended to go to the ground floor to check which room the person using the service is calling from. There is a light above each bedroom door, which lights up when the call bell is pressed. The manager spoke of this lighting system being checked very regularly. We were informed that if the passenger lift breaks down, the manager has to have the consent of a representative of the owner prior to calling the lift contractor. This policy should be reviewed to ensure that the registered manager does not delay in getting the passenger lift repaired. The ‘expert by experience’ noted that ‘the residents could be stranded for sometime and have to have meals carried to them’. The home has an infection control policy/procedure. The laundry service remains a quality service, with an experienced member of staff running the laundry. He spoke of his role and it was clear that he had recognised the importance to residents of having a good laundering service. He spoke of hand washing certain delicate items of clothes. The expert by experience noted that the domestic staff ‘did a good job to keep the place clean and sweet smelling’. Disposable gloves and aprons were seen to be accessible to staff. Soap and hand towels were located in the bathrooms. Records and staff confirmed that they received infection control training. DS0000022925.V354764.R01.S.doc Version 5.2 Page 23 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): Standard 27,28 29 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent and skilled with regard to carrying out their roles and responsibilities. Resident’s needs are met by the skill mix and numbers of staff. Residents are supported and protected by the care home’s recruitment policy and procedure. EVIDENCE: The staff rota was available for inspection. There were five care assistants, plus one extra staff member whose role during the shift was to accompany residents to appointments, on duty. The manager, a senior nurse and an administration staff member were also on duty during the inspection. There is a staff ‘on-call’ system. I was informed by the manager that she was in the process of recruiting a night staff post and that ‘bank’ staff (who know the home and residents well) work shifts to cover for staff sickness, annual leave etc. Staff confirmed that they had the opportunity to attend regular staff meetings to be informed of and to discuss issues relating to the care home. The ‘expert by experience’ reported that two recently employed staff spoke of ‘enjoying their work’, and noted that ‘there was evidence of good teamwork where everyone pitched in to do their job to the best of their ability and to help each other’. Staff were observed to be respectful to residents and to interact with them in a sensitive manner. A resident was observed to ask a staff member for a book and her glasses. The care staff worker promptly in a DS0000022925.V354764.R01.S.doc Version 5.2 Page 24 positive manner accessed these items, plus a drink for her. It was evident that staff knew the residents well, and spoke to them frequently in a pleasant manner. Staff were positive about the training that they received. A staff member spoke of having had ‘lots of training’, and of recently having completed a palliative care course. Records confirmed that staff receive statutory training and induction training appropriate for their role and responsibilities. This training includes moving and handling, health and safety, Basic 1st Aid, fire safety training and dementia care training. AQAA documentation informed me that staff receive training with regard to meeting diversity, cultural and religious needs of people using the service. We were informed by staff (and records) that staff are encouraged to achieve appropriate NVQ (National Vocational Qualification) level 2 or 3, and that staff receive time ‘off’ to go to college. Staff spoke of having achieved NVQ care qualifications, and spoke of how useful this course had been in developing an understanding of their role and skills as care workers. AQAA information confirmed that 35 of care staff have achieved an NVQ level 2 or above care qualification. The registered person should ensure that all care staff are supported and given the opportunity to achieve this qualification. A member of staff spoke of the ‘good teamwork’ in the care home. AQAA information informed me that the staff recruitment and selection policy had been recently reviewed and updated. Three staff personnel files were inspected. These included evidence of enhanced Criminal Record Bureau checks (a check as to whether an applicant has a criminal record) and other required checks having been carried out to ensure that people using the service are protected by the care home’s recruitment and selection practices. Staff have a three month ‘probation’ period from the commencement of their employment, and receive a staff handbook, and a contract of terms and conditions. DS0000022925.V354764.R01.S.doc Version 5.2 Page 25 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): Standard 31,33,35, 36, and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified, competent and experienced to run the care home. Effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home, and arrangements are in place to ensure that so far as reasonably practicable the health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: The registered manager is a registered nurse and has achieved qualifications in the Care of the elderly, and Mentoring in the Workplace. She also has a Diploma in Social Studies and an honours degree in Social Anthropology. She has also completed the Registered Manager’s Award level 4. It was evident DS0000022925.V354764.R01.S.doc Version 5.2 Page 26 during the inspection and from her on-going communication with the CSCI that the manager is very experienced, competent and motivated. She ensures that her skills are updated and developed. Staff, residents and visitors spoke of the manager as being approachable. It was evident that the manager works hard to meet inspection requirements and recommendations, and is keen to continually improve the service provided to residents by the care home. AQAA information confirmed that the manager aims to ensure that the home has a happy, positive and caring atmosphere. It is evident that there are clear lines of accountability within the home and with external management. The manager confirmed that questionnaires are supplied annually to stakeholders, including relatives, and residents. An up to date ‘improvement’ plan with regard to the service was available for inspection. The manager reported that she regularly completes a quality monitoring audit of all areas of the service provided to people using the service. Policies/procedures are regularly reviewed. These include policies that ensure all people using the service and others are treated with respect, and that their equality and diversity needs are met by the care home. AQAA information informed me that the home is planning to make further changes to the service as a result of listening to people who use the services. This is positive. Staff were observed to use ‘hoist’ lifting equipment in an appropriate manner. Accidents and incidents are recorded as required. Regular health and safety checks are carried out. Records confirmed that safety risk assessments with regard to staff working practices are in place. The resident’s money and records of expenditure, and incoming payments were inspected. These systems have been reviewed and improved since the previous inspection. Appropriate recording and monitoring of monies held by the resident takes place. Staff confirmed that they received regular 1-1 staff supervision when they discussed among several issues the residents, the staff role and responsibilities, and staff training. Up to date certificates of worthiness with regard to the electrical systems were available for inspection. AQAA information confirmed that all required system checks had been carried out. Records and staff confirmed that fire checks and fire drills are carried out frequently. External contractors carry out monitoring of the safety of the water supply, and carry out an annual fire risk assessment. Radiators are covered. The certificate of employers liability insurance was displayed and up to date. DS0000022925.V354764.R01.S.doc Version 5.2 Page 27 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 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X 2 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 4 X 3 X 3 3 X 3 DS0000022925.V354764.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 12(1)13 (4)14(1) 15(1)(2) Requirement The registered manager needs to ensure that all staff completing care plan assessment records are competent to complete them fully. Some staff guidance to meet certain health needs could be further developed to ensure that it is evident that staff know how to meet all identified health needs of people using the service. It needs to be always evident in the care plans that action is being taken to meet a resident’s need with regard to their nonplanned loss of weight. The manager needs to ensure that all medication is stored safely at all times and that a review of the recording of controlled medication administration is carried out to ensure that all tablets are accounted for at all times. There needs to be clear signage to indicate where the step located in the kitchen is located, DS0000022925.V354764.R01.S.doc Timescale for action 01/04/08 2 OP8 12 (1)13(4) 15 13(2) 01/04/08 3 OP9 01/03/08 4 OP19 13(4) 23 (2) 01/04/08 Version 5.2 Page 29 so as to minimise the risk of it being a trip hazard. The registered person needs to review, and if needed improve the call bell system to ensure that staff in areas of the home (as well as at present, the ground floor) can quickly respond to, and know what room a person using the service is calling from. The crack in the wall of the stairway area on the 2nd floor needs assessment and repair by a competent person. A large crack in an outside wall needs repair. Previous timescales 01/05/07 not met. Residents who use bathroom hoists need to be individually assessed regarding the use of passenger hoists, and it be included in this assessment, that it is evident that the weight of each resident meets the safe carrying weight of each bath hoist. Areas of peeling wallpaper located in some bedrooms need attention or replacement. To ensure that the environment of resident’s bedrooms are attractive and pleasant. All bedroom carpets, which have not been recently replaced, need to be reviewed and be replaced if necessary. A carpet in room 19 was ‘ruffled’ in some areas, and needs to be secured or the carpet replaced, as it could be a trip hazard. 5 OP19 23(2) 01/06/08 6 OP21 13(4)(5) 01/04/08 7 OP24 23(2) 01/05/08 DS0000022925.V354764.R01.S.doc Version 5.2 Page 30 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 OP7 Good Practice Recommendations The manager should continue to further develop (with residents) care plans into a more ‘person centred’ format to ensure that people using the service experience the life that each person wants. The people using the service should have the opportunity to sign their care plan. The information on the activity programme should be recorded in a variety of formats that ensures that the information is clearly accessible to all residents. The issue of televisions in the lounges being switched on all day could be reviewed. The manager should ensure that the menu available in a variety of formats to ensure that the information about the meals provided is easily accessible to residents. It is recommended that the use of CCTV cameras regarding monitoring of the car parking area on the forecourt of the home is examined by the registered person (owner), and that advice be sought from the local community police service. The manager should ensure that there is a risk assessment, with guidance, in place that demonstrates with regard to safety, the need for the door opening system being in place. The curtain in the room, which was observed to be ‘hanging down’, should be attended to. The registered person should seek ways of improving the attractiveness and lighting of the environment of the lounges particularly in the lounge located away from the dining area. The registered person should review the location and type of clocks located in the home to ensure that they are accessible to all residents including those with sensory needs. DS0000022925.V354764.R01.S.doc Version 5.2 Page 31 2 OP12 3 4 OP15 OP19 5 OP19 6 OP19 7 OP19 There could be a displayed record of the day and date, (and possibly weather etc) clearly visible and accessible to residents to aid their orientation skills. A refurbished kitchen is recommended. An area of lining on the edge of an area of the kitchen floor should be secured. The registered person should consider putting a ramp instead of the step (in the kitchen) to allow for ease of manoeuvring food trolleys, and to minimise the risk of tripping. This policy of responding to the passenger lift breaking down should be reviewed to ensure that the registered manager does not delay in getting the passenger lift repaired. The registered person should review the water pressure in regard to the bath shower attachments. And also review as to the reason why the toilet in the ground floor bathroom frequently becomes blocked. Areas of chipped paint seen in the ground floor bathroom could be repaired, and the bathrooms could be more attractively redecorated, and pictures possibly be displayed. Bathing hoist equipment should be reviewed and replaced if necessary. The signage of the name of the care home could be reviewed, and possibly include a sign on Craven Park Road to ensure that visitors can locate the home more easily. The registered manager should seek ways of possibly moving bedroom furnishings to a different location within rooms to enable hoists to be more easily manoeuvred. The registered manager should ensure that during the process of initial assessment, residents (due to their mobility needs) who need assistance with transferring are allocated a bedroom in which a hoist can be moved without difficulty. Beds that have not yet been replaced with adjustable new beds should be replaced. And the registered person should always ensure that residents who have significant mobility needs have access to an adjustable bed. The registered person should ensure that all care staff are supported and given the opportunity to achieve NVQ level DS0000022925.V354764.R01.S.doc Version 5.2 Page 32 8 OP19 9 OP21 10 11 OP19 OP24 12 OP28 2 or above care qualification so that staff can develop their skills and competency to continue to provide quality care and support to people using the service. DS0000022925.V354764.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000022925.V354764.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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