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Inspection on 20/10/05 for Craven Park Nursing Home

Also see our care home review for Craven Park Nursing Home for more information

This inspection was carried out on 20th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service is focussed on caring. The home provides an excellent service with staff that are enthusiastic and friendly. During the inspection the service users appeared to be well cared for and content.

What has improved since the last inspection?

The home has commenced a refurbishment. Some of the rooms are being re carpeted and some re painted and re papered.

What the care home could do better:

Although the writing of a care plan does involves the service user and/or their representative, service user agreement and involvement in their plan should be documented.

CARE HOMES FOR OLDER PEOPLE Craven Park Nursing Home 1 Craven Road Craven Park Harlesden London NW10 8RR Lead Inspector Virginia Allen Unannounced Inspection 20th October 2005 08:00 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 Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 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. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 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 8961 9254 cravenpark@bmlhealthcare.co.uk 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) GSG Nursing Homes Limited BML Healthcare Limited Mrs Mary Ampah Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2005 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 conveniences, and is quite close to Harlesden tube station. Bus routes are around the corner from the home. The home has a private driveway that could hold around eight cars. 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 a medium-sized, enclosed garden that is mainly patio Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on a fine Thursday morning. The inspector attended the night staff/day staff handover and observed breakfast and lunch being served. Service users and staff participated in the inspection. Service users could not praise the care they received highly enough. The reported that staff were very kind to them and they felt listened to. The inspector looked at the lay out of the home including the bedrooms, the individual files of 6 service users, staff training records, activities charts, complaints file, health and safety certificates and policy and procedures. What the service does well: What has improved since the last inspection? 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. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 6 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 Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Service users are fully assessed prior to admission and the service user and relatives are assured that the home can meet the service user’s needs. Service users have the information they need to make an informed decision about where to live. Each service user has a written contract. Relatives and friends have the opportunity to visit the home prior to the admission. EVIDENCE: The manager reported that prospective service users are given a copy of the home’s Statement of Purpose that details the home’s philosophy of care, services and facilities and the terms and conditions of residency. The inspector viewed the service users guide given to prospective service users. It sets out the services and accommodation offered by the home, along with the factual information such as the qualifications of the manager and the number of places in the home. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 8 The complaints procedure is given to prospective service users and their families and a copy is kept in each bedroom. A copy of the statement of terms and conditions is kept in the policy and procedure manual. The inspector noted that it covered all relevant topics. The manager reported that new service users are admitted only after she has conducted a full and comprehensive assessment of their needs and can assure the prospective service user that the home can meet their needs. A plan of care is devised from the assessment. There has been one admission since the last inspection. The manager explained to the inspector that a prospective service user is invited to visit the home before admission and can move in on a trial basis. Relatives can visit the home at any time. Specialist services are offered to each service user on the basis of need. Referral is made directly from the nursing home or through the GP. The manager reported that the Chiropodist visits the home regularly. Referrals are also made to the Ophthalmologist, audiologist, dentist, physiotherapist and occupational therapist as necessary. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10, The personal, social and medical needs of the service user are met and the service user is well cared for. Service users are treated with respect and privacy. EVIDENCE: The inspector sampled six of the service users files. The care plans were comprehensive and dealt with all relevant issues. The files included risk assessments for manual handling, falls, pressure areas and nutritional needs. Care plans are reviewed monthly with the service user and signed by the registered nurse. However, there needs to be visible documentation of service user agreement to the care plan and reviews along with documentation of their likes and dislikes. The service user plans met relevant clinical guidelines with specialist medical recommendations being outlined in the care plans. Skin viability is reviewed regularly and each service user has either an Alpha Xcell, aura or an air system mattress on the bed to help prevent pressure. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 10 The home is able to manage service user incontinence, but when necessary refers to the continence adviser. During the inspection it was noted that care staff spoke to the service users with respect and dignity. Carers were seen to knock on bedroom doors before entering. Service users are given the choice of staying in the privacy of their own room during the day or sitting in the communal areas. The service users are addressed by their preferred name, which is recorded in the care plans. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users have access to a variety of religious, social and cultural activities. Family and friends are encouraged to visit the home. Where possible, service users exercise choice over their lives. Service users are offered a varied and nutritious diet. EVIDENCE: The home employs an activities co-ordinator during the working week. The activities co-ordinator was present during the day of inspection and talked with the inspector. The inspector viewed the activities programme, which was extensive and varied. Activities included board games, reading the newspaper, memory work, music and watching DVDs, Bingo, Dominoes, family fellowship or massage. Activities away from the home such as going to the theatre, shopping, exhibitions and shows such as “time of your life” are popular amongst service users. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 12 Service users have the opportunity to be taken to their places of worship; however, representatives of a variety of churches visit the home regularly. The manager told the inspector that family and friends are encouraged to visit the home at any time. Service users are given control of their own activities of daily living where possible. They can decide when to get up and go to bed, whether to sit in their room or the communal area, how often they have a bath and whether or not to participate in the activities. Service users can specify the type of food they want to eat. The inspector toured the kitchen area and spoke with the two chefs. The kitchen was clean and tidy. Food items were labelled both in the fridge/freezer and out on the shelves. Food that had been opened had the date of opening recorded. Food temperatures and the fridge/freezer temperatures had been recorded daily. The cleaning roster was inspected and showed that all aspects of the kitchen and food storage areas were kept clean at all times. The food menu was varied and nutritious. The manager informed the inspector that all but three of the service users have their money handled by their family. Three service users have their finances organised by the management of the home. The inspector viewed the financial documentation for one of the service users. A ledger sheet for money in and out is kept along with the petty cash in the home’s safe. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home has a solid complaints procedure, which is made accessible to staff, family and service users. Service users rights are protected and the home has a robust protection of vulnerable adults policy. EVIDENCE: The home has a complaints procedure that is given to prospective service users and their families. The procedure is kept in the policy and procedure manual for staff to access and a copy is in each bedroom. The inspector viewed the procedure during the inspection. There is a comments folder in the entry hall of the home for any suggestions. There have been no complaints since the last inspection. All of the service users who were spoken to by the inspector said that they had no complaints. The manager of the home told the inspector that she is pursuing access to advocacy services for all service users who do not have a formal representative. The home has a robust protection of vulnerable adult policy in place. This is kept in the policy and procedure manual. All staff have a copy and have all attended the Protection of Vulnerable Adult training. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,25,26 Service users live in a safe, well-maintained environment with comfortable bedrooms. Service users have sufficient toilets and washing facilities. The home is clean, pleasant and hygienic. EVIDENCE: The inspector toured the home. The layout was suitable for the needs of the service user. There is an on-going programme of redecoration and maintenance. Since the last inspection some of the bedrooms had been re painted, re carpeted and re papered. Five bedrooms will be redecorated in the near future. The home has a full time handyman. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 15 The inspector found that the home was free from odour and was well ventilated. Inspection of records showed that the building complied with the requirements of the local fire service and environmental health department. All but two of the bedrooms had en-suite toilet facilities with a hand basin. There was a bathroom on each of the floors with a bath and shower. These were clean and tidy and free from clutter. Service users have the opportunity to specify how often they wish to have a bath or a shower. The inspector viewed a roster on display in the bathroom specifying those who are to have a bath or shower each day. The inspector noted that each of the service user bedrooms were furnished and equipped to assure comfort and privacy. Eight of the beds were adjustable and all beds had pressure-relieving mattresses. The service user had bedside lighting as well as overhead lighting, a mirror, wardrobe and drawers for their clothes. All of the bedrooms inspected had carpeted floors. All bedrooms have locks and service users are given a key. Rooms are all individually and naturally ventilated and have central heating with fireguards. Furniture and fittings are domestic in nature. Water is stored at a temperature of at least 60 degrees and distributed at 50 degrees C minimum. Legionella inspection was performed on 4th July, 2005. Laundry facilities are sited so that soiled articles are not carried through food storage areas. When inspected the laundry was clean and a system of keeping service users clothes separate was in view. The washing machine and dryer were commercial and met regulations. The policy and procedure for control of infection is kept in the procedure manual. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The number and skill mix of staff that are trained and competent to do their jobs meets Service users needs. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. EVIDENCE: During the inspection there were five carers and one registered nurse on duty. The manager is also a registered nurse. The inspector was informed that the evening shift has four carers and one registered nurse and there are two carers and one registered nurse at night. There are currently 25 service users. The home employs one full time domestic staff and has two chefs working during the day. There is a full time handyman, activities co-ordinator and administration staff. The registered manager has completed NVQ level 4. Seven care staff have completed NVQ level 2 and four or them are now doing level 3. Four are doing NVQ 2. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 17 The inspector viewed the staff-training programme. Topics covered are Manual Handling, Protection of Vulnerable Adults, Fire awareness, Health and Safety, Food Hygiene, Coshh and First Aid. The manager is currently organising training for Infection Control. The inspector viewed the personnel file of the most recently employed staff member. This met with standards, had a current CRB check and two recent references. She had been given a statement of terms and conditions of employment. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,38 Service users live in a home run by a competent manager. Service users benefit from the philosophy of the home. Health and safety of the service users is promoted by the homes good practices. EVIDENCE: The manager of the home is a registered nurse with many years of experience. She also holds a Diploma in Social Studies, an honours degree in Social Anthropology, a Certificate in Supervisory Management and a Certificate in Counselling. She is currently studying “Mentoring in the Work Place”. Since she has taken over the management of the home the staff report that the standard of the home has greatly improved. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 19 During the inspection it was noted that staff treated the manager with great respect. There is a clear line of leadership but the staff reported feeling able to approach the manager. The registered manager ensures good health, safety and welfare standards with staff attending all core training as list on page 18. Safe storage and disposal of hazardous substances meet requirements. premises are secure. The Records inspected were Gas and central heating certificate. This is due for renewal on 8th November, 2005. Water temperature certificate awarded 8th February 2005, Hoist check 9th November, 2005, Legionella check 4th July, 2005, Fire Inspection 4th April, 2005, Fire Precautions 5th August, 2005, PATS 7th October, 2005, Aqua treat Chlorination 4th July, 2005, Hazardous Waste Removal 29th July, 2005, Electricity check 29th April, 2005 and Stannah Lift Services check 26th August 2005. Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 3 18 3 3 X 3 X X 3 3 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 3 X X X X X 3 Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 7 (6) Regulation 15 Requirement Care plans and monthly reviews must show evidence of service user input and agreement signed by the service user or their representative. Timescale for action 31/12/05 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 Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Craven Park Nursing Home DS0000022925.V259061.R01.S.doc Version 5.0 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. 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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