Inspection on 18/12/07 for Kenbrook

This inspection was carried out on 18th December 2007.

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

Kenbrook 14/11/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kenbrook Kenbrook 100 Forty Avenue Wembley Middx HA9 9PF Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 18th December 2007 10:00 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 DS0000070923.V356784.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. DS0000070923.V356784.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenbrook Address Kenbrook 100 Forty Avenue Wembley Middx HA9 9PF 01332 296200 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) home.fxg@mha.org.uk Methodist Homes for the Aged Marian Frances O`Hara Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places DS0000070923.V356784.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. 3. 4. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 52 A maximum of 27 places for people in need of general nursing care A maximum of 25 places for people requiring personal care only. Date of last inspection 17th September 2006 Brief Description of the Service: Kenbrook was built in the 1960s and used to be a rest home for retired British Transport employees. It used to be run by the Willow Care, part of the Willow Group, as a care home. Willow Care has been taken over by Methodist Housing Association from the 5th December 2007. The home is found on Forty Avenue and is easily accessible by car and by public transport. There is a bus service, which passes in front of the home. The nearest underground station is Wembley Park. There are shops at about five minutes walking distance from the home and one can catch a bus into Wembley for a wider variety of shops and for local amenities. The building is spread over a relatively large area and consists of two floors. There are maintained gardens on all sides of the homes and there is a car park in front of the home. The living accommodation is found on two floors along long corridors with rooms on either side. Each resident has a room, with a washbasin and a small area for personal care. Toilets and bathrooms are communal and are found on each floor. The home is run as a main unit, but the DS0000070923.V356784.R01.S.doc Version 5.2 Page 5 number of residents is divided into three groups, each of which is looked after by a team of care staff supervised by the nursing staff. The fees charged by the home for personal care is £545 and for nursing care is £650-£750. At the time of the inspection there were 47 residents in the home. DS0000070923.V356784.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started on Tuesday 18th December at 10:00-17:00 and continued on 20th December 10:15-13:45. It was unannounced and is the first key inspection for the period 2007-2008. Since the last inspection Willow Care has been taken over by Methodist Housing Association (MHA). Willow care was part of Willow Housing and had four homes. Prior to the change, the management of Willow Housing consulted with residents of the care homes about their preferred provider. As a result an organisation was chosen, with the involvement of residents, which closely matched the ethos of Willow Housing and which was considered most beneficial to the future of the homes. As the take over of the home happened in the beginning of December, the home is still at the initial stage of transferring over to MHA policies and procedures and systems of work. If this report contains a significant number of requirements it is expected that these will significantly decrease once the home becomes more involved with MHA and when the policies and procedures of MHA are implemented. During this inspection I was able to talk to residents, visitors to the home, the manager and some members of staff. I was able to observe care practices, inspect a sample of records and toured some of the premises. The manager provided an Annual Quality Assurance Assessment (AQAA), which was completed to a good standard and positively reflects the time and effort that she has put into completing the AQAA. The content of the AQAA has been used in this report where possible. I would like to thank all residents and visitors who spoke to me and the manager and all her staff for their cooperation and support during the inspection. What the service does well: There are good systems in place to enable residents, their relatives and staff contribute to the running the home. There are a number of forums such as the monthly residents’ meetings and staff meetings. There is evidence from talking to residents and their relatives and from the care records that the residents are consulted and are provided with the opportunity to make choices in their daily life. The healthcare needs of residents are generally met. The home has close contact with the GP and other healthcare professionals, which are called upon DS0000070923.V356784.R01.S.doc Version 5.2 Page 7 as required. The standard of pressure area care is generally good and residents are provided with pressure relief equipment as required. The standard of personal care is also good. All residents presented as appropriately dressed, clean and looked well cared for. Residents’ clothes are laundered and ironed to a good standard. The wardrobes and cupboards of residents are kept tidy. The bedrooms of residents and the home in general are personalised to a good standard. Residents and their relatives are encouraged to bring items of personal possessions to make the bedrooms homely. The standard of maintenance and decoration of the home is on the whole good. The management of the home is stable and provides a clear direction for staff to follow. The manager and her deputy are approachable and visible on the floors. Feedback from residents and their relatives suggests that members of staff are also approachable and supportive. Staffing levels in the home are suitable to meet the needs of the residents and members of staff receive appropriate training to make sure that they are able to care for the residents. What has improved since the last inspection? There has been an improvement in the involvement of residents and their relatives in drawing up and reviewing care plans and risk assessments. Most care plans and risk assessments were signed by residents or their relatives, demonstrating their involvement in this process. Other areas where there has been an improvement include the input of residents/relatives in collecting information about the arrangements that have been made about residents’ funeral to manage these situations appropriately should these arise. All residents including those who are admitted for respite care now receive a contract/statement of the terms and conditions to inform them of their rights and responsibilities. This is good practice. The quality of the care records has improved. The computer system used for care records has been updated and it was noted that the updated formats also looked more comprehensive and detailed. The care plans and risk assessments were more comprehensive and were reviewed at least monthly. There seems to be a more serious approach to the provision of activities and there are many arrangements in place to make sure that residents are provided with the opportunities to engage in activities, which are suitable to their needs. In the past complaints were divided into ‘minor’ and ‘other’ with different approaches to these. There were no clear definition of what was a ‘minor’ or major complaint and the approaches were not made that clear in the complaints procedure. Now the home has one complaints procedure, which is followed for all complaints. DS0000070923.V356784.R01.S.doc Version 5.2 Page 8 The carpet in the home was mostly clean and no stains were noted when touring the premises. What they could do better: The care records need further development to make sure that they accurately describe the care that residents receive. The assessments of needs of residents need to be more comprehensive and detailed. Information should also be available about the social and recreational needs of residents and residents’ fears and expectations for the future to make sure that all the needs of the residents are clearly identified. The assessment of residents’ needs also lacks information about the psychological needs of residents such as about behaviour and mood. Without identifying all the needs of residents it is not possible to accurately plan the care that should be provided to them. The home is registered to care for people whose care needs are primarily general nursing care and personal care needs. It is not registered to care for people with primary dementia care needs. The home should therefore make sure that people who are admitted do not have primary dementia care needs, as it has not been assessed as fit to provide this service. The healthcare needs of residents are mostly met although records could have been more comprehensive to demonstrate that. The provision of pressure area care is generally good, but there must be greater clarity with regards to the repositioning of residents, for the home to demonstrate that it does everything possible to make sure that residents do not develop pressure ulcers. Medicines management is in the main carried out to an adequate standard. It is necessary that staff administering medicines comply with the appropriate Nurses and Midwifery Council’s guidance. Medicines must not be left unattended and nurses should only sign the medicines chart after the medicines have been administered. Staff who administer medicines must also be vigilant that they do not administer medicines which have passed their expiry dates. The home must be able to demonstrate that it is able to provide end of life care according to the expectations of the residents and relatives while taking the religious and cultural backgrounds of residents into consideration. Provision of meals to residents should also reflect the cultural backgrounds of residents according to their individual likes and dislikes. To make sure that residents are protected, the home must comply with good recruitment practices as per legislation and national minimum standards. All members of staff must have all the records, including a full work history, two references and evidence of permission to work in the UK. Training records showed that the home provides a range of training that is provided to DS0000070923.V356784.R01.S.doc Version 5.2 Page 9 members of staff, but the home does not yet use the common induction standards for new members of staff as per Skills for Care. The manager and her staff are aware of the need to ensure sustained improvement of the service. As a result a satisfaction survey is carried out yearly to gain information from stakeholders about the quality of the service provided but the home does not yet have a quality control system based on a system of audits. To ensure a high standard of cleanliness, all areas, including those that are not immediately obvious must be cleaned regularly to prevent the accumulation of dust. The provider must also ensure that all items of equipment are maintained as required and that the relevant safety certificates are available for inspection. 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. DS0000070923.V356784.R01.S.doc Version 5.2 Page 10 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 DS0000070923.V356784.R01.S.doc Version 5.2 Page 11 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): 1-4 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and their relatives enough information to help them decide if they want to move into the home. The home did not always admit residents who fit the category of registration of the home. There is therefore a possibility that the needs of these residents may not be met in the home. EVIDENCE: The home has recently been taken over by MHA. The statement of purpose and the service users’ guide have not yet been updated to reflect the recent change of owners. The formats used for these documents by MHA were seen in the home and the manager stated that she has recently received these documents from the head office, that she would amend as required to reflect Kenbrook. DS0000070923.V356784.R01.S.doc Version 5.2 Page 12 The home admits residents for long-term care and there were a few who are admitted for respite care. In the past the long-term care residents have always receive a contract/statement of the terms and conditions of the placement but the short-term residents have not always receive these. The files of two residents who have been admitted recently were inspected. Both residents had copies of contracts/statement of terms and conditions of the home. There were also copies of the agreements of the home with the placing authority. This is good practice. As part of the inspection I looked at the care files of five residents. They all have had a preadmission assessment of their needs prior to them being admitted. The assessments of residents’ needs or care plans by the placing authority were also available on file. There was however a resident who has been identified for residential dementia placement as per the assessment of the local authority. It was clear from that assessment, that the residents’ primary care needs were dementia care needs. The home however is not registered for dementia and the environment has not been fully assessed as suitable to care for residents with primary dementia care needs. I noted on one occasion how staff brought the resident out of the kitchen after she had walked into that area. Therefore although staff seem able to care for residents with dementia care needs, the home must be fully assessed for the provision of dementia care if it wants to admit residents with dementia care needs to make sure that these residents are safe at all times. DS0000070923.V356784.R01.S.doc Version 5.2 Page 13 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): 7-11 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care records of residents need further improvement to make sure that the needs of residents are assessed comprehensively to provide a guarantee that these are being addressed. The home is able to demonstrate that the healthcare needs of residents are being met. Medicines’ management was not robust enough to make sure that residents are safe at all times. While the home has started to address the arrangements in place to manage the funeral of residents, more progress is required with regards to addressing the end of life care of residents and issues about resuscitation. EVIDENCE: The home uses a computerised format for the care plans and also keeps hard copies of the care plans. The printer has apparently not been working for about a month and therefore the care plan in hard copy has not been fully updated. It was noted that the format of the care plans on the computer has also been recently updated to make these more comprehensive. New residents’ needs DS0000070923.V356784.R01.S.doc Version 5.2 Page 14 were assessed using the new format but the needs of other residents were assessed using the old format. As described in the inspection report dated 27th September 2006, the format for the assessment of needs was not that comprehensive and as a result the needs of residents were not comprehensively addressed. The assessment section was mostly of a tick box format and did not adequately describe the needs of residents. Aspects of activities of daily living such as sexuality of residents were not always addressed and basic information about the likes and dislikes of residents were also not always present. It was also noted that the old computerised format as well as the new computerised format of the needs’ assessment do not yet contain an assessment of the psychological aspects of the care of residents including the assessment of behaviour and dementia care needs. Inspection of the care records showed that the assessment of the needs of residents and care plans do not always address the cultural, religious and ethnic aspects of the care of residents. The home accommodates a number of residents from ethnic minorities and the needs of residents with regards to these aspects were not always apparent when reading the care plans of the residents. I saw that the care plans and risk assessments were reviewed at least monthly. The care records contain a number of risk assessments including falls risk assessment, pressure ulcers risk assessment, nutritional risk assessment and a manual handling risk assessment. It was noted that the manual handling risk assessment and associated care plan generally contain information about the hoist to use but did not always contain information about the size of the sling to use with the hoist and the manoeuvres and equipment to use to move the resident in bed. The standard of pressure ulcer management in the home is good. There was one resident in the home with a pressure ulcer. I noted that a care plan, photographs and wound progress notes were in place. The home also has a number of items of equipment for people at risk of pressure ulcers. These were documented in the care records, although not always in the same place. It was noted that the repositioning regime for the residents were not always identified. The repositioning regime is individually tailored according to the residents’ circumstances and would contain information about the frequency of changing position in bed as well as when the resident is seated, and the time to get up and go to bed. Turning charts kept, showed that residents’ position was being changed but the time intervals varied on some occasions from 2-5 hours, as there was no clear repositioning regime. It was therefore not always clear what was the indicated frequency for turning residents and how they were being repositioned when seated during the day. DS0000070923.V356784.R01.S.doc Version 5.2 Page 15 There has been progress with the involvement of residents or of their relatives in drawing up care plan and risk assessments. The printed care plans are discussed with residents and/or their relatives and they are able to sign these. One resident said that ‘the staff are very good and they have shown me all the papers and discuss everything with me’. All residents presented as clean and appropriately dressed. The male residents were shaved appropriately and residents’ hair appeared clean and appropriately groomed. The standard of laundry was good and residents’ clothes were ironed appropriately and placed in the wardrobes and cupboards of residents in a tidy manner. Personal care was offered to residents in the privacy of their bedrooms or in the bathrooms. The home kept good records when residents were seen by healthcare professionals such as the GP, dentist, optician and chiropodist and about the outcomes of these visits. One resident was recently seen by the GP as she had been ill and she had been placed on a new medicine. The care records however did not contain a care plan to address the short-term need of the resident. Medicines management was inspected. Controlled medicines were managed to a good standard and all records were kept as required. The temperature of the clinical room was kept constant by air-conditioning and there were records to show that the temperature of the medicines’ fridge was monitored regularly. There were records of the dates of opening on eye medicines and on liquid medicines. One eye drop was noted to be still in use more than 28 days after it was opened. A newly opened and dated container for the medicine was not available. There were a few instances when the amount of medicines administered was not always recorded in cases where a variable dose has been prescribed. During the tour of the home I noted that a resident had one tablet on her table. She was left the tablet to take but had obviously not taken the tablet. Good practice dictates that the nurse should make sure that the resident has taken the tablet before leaving the resident and signing for the medicine. The home has made attempts to ensure that information with regards to arrangements that have been made for residents’ funerals, were contained in the care records. There were forms that have been completed by residents/relatives in the care records, which contained this information. There was however still a lacking with regards to addressing end of life care of residents. Issues such as the resident’s views and perceptions about their future and their wishes and instructions with regards to end of life care and managing death were not always addressed with consideration of the residents’ cultural and religious background. There was also a lack of instructions with regards to residents’ or their relatives’ wishes/instructions regarding resuscitation. DS0000070923.V356784.R01.S.doc Version 5.2 Page 16 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): 12-15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents generally benefit from pre-arranged social and recreational activities, but less attention seems to be provided to people who are more dependent and are less likely to interact. The meals provided to residents are nutritious but could have been more varied to suit the taste of all people who live in the home. EVIDENCE: The needs’ assessment section of the care records contains a small section about the social background of residents. While there is some information about the individual resident, this section does not fully describe the social and recreational needs of residents. This has been identified in the report following the last inspection of the home, but unfortunately this aspect of care has not yet been fully addressed in the care records. The home does not yet have an activities coordinator and care staff are responsible for carrying out activities. A programme of activities was noted in the home. Residents can take part in activities such as art classes, bingo sessions, exercise sessions including tai-chi and one-to-one interactions. There are visiting entertainers to the home, which are booked for special occasions and once a month when there is a social evening for the residents. DS0000070923.V356784.R01.S.doc Version 5.2 Page 17 On the first day of the inspection there was a residents’ meeting in the morning and an art session in the afternoon. Some residents attended the art sessions which was arranged in another part of the building, but a number of residents remained in the lounges as they did no want to attend the session or the art classes were not suitable for their needs. I noted that there was little in place for those residents who remained in the lounges. There were some members of staff in the lounge but there was little engagement between residents and staff. Engagement was also limited when staff interacted with residents such as when offering them drinks. During the afternoon the TV was playing in one area of the lounge with no sound on and the radio was also playing. In the morning a resident was noted seated next to the TV, which was playing with the sound on, and although she could hear the TV, she could not see the pictures as she was sitting next to the TV. The satisfaction survey conducted by the home in October/September 2007 identified this area as one area where people are less satisfied as compared to other areas. The home has an open visiting policy. I was able to observe a number of visitors in the home who met residents in their bedrooms or in the communal areas. I was informed that a number of residents have the opportunity to go out every weekend in a mini bus. Previously they used the bus which belonged to Network Housing, but as the organisation has now changed, the home did no longer have access to that bus and the manager was making arrangement to access a bus for the weekend to take residents out. The home also encourages and assists relatives and friends to take the residents out. During the inspection I met some representatives from the local Roman Catholic Church visiting residents to offer them communion. I was informed that representatives from other churches also visit the home on a regular basis. Lunch time on the first day of the inspection was observed. Lunch was mostly served in the main dining area and residents were encouraged to use that area. Some residents preferred to have their meals in their bedrooms. Lunch consisted of chicken casserole, potatoes, beans and cauliflower. Residents were also offered alternatives such as omelettes if they wanted to. Kosher meals were also provided to one resident. Residents choose their meals one day before when a member of staff takes an updated menu list for the day and asks residents to choose from the list. The home accommodates residents from ethnic minorities, but it seems that they do not receive culturally appropriate meals. One resident from an ethnic minority said that ‘the food is not really to my taste’. She clarified that she ate the meals that were provided to her because there was no culturally appropriate alternative that she would have preferred. The manager explained DS0000070923.V356784.R01.S.doc Version 5.2 Page 18 that currently catering and other hotel services are contracted to an organisation called Caterplus, and that the home was in the process of bringing the provision of catering and hotel services ‘in-house’. As a result this has caused some disruption to the catering service that the home hopes to rectify when it takes over the provision of this service. DS0000070923.V356784.R01.S.doc Version 5.2 Page 19 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 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager and her staff take all complaints and allegations or suspicions of abuse seriously and deal with these to make sure that residents’ interests are safeguarded. EVIDENCE: The complaint register was inspected. There have been 10 entries since the 1st January 2007. These included all complaints as all complaints are now appropriately recorded. Previously there were some discrepancies because complaints were labelled as ‘minor’ and ‘other’ complaints and were entered in different records. The records showed that complaints were acknowledged as required and dealt with appropriately. The complaints procedure is available in the service users’ guide and in the foyer of the home. This of course will have to be changed to reflect the new owners of the home. Residents and visitors said that they have approached the manager or the deputy manager when they were dissatisfied about the standard of service that they received. They said that management is approachable and that ‘they are very good at listening’. Training records showed that nursing and care staff receive training on abuse as part of the induction and later as part of their personal development. They were on the whole familiar with the procedure to follow if allegations and DS0000070923.V356784.R01.S.doc Version 5.2 Page 20 suspicions of abuse are reported to them or if they have suspicions of abuse that they come across while caring for residents. Since the last inspection there have been two matters, which were referred to Brent safeguarding Adult Team. One was looked into and the other was not accepted as a referral and was left to the home to address. None were substantiated. As areas for future improvement, the manager has identified that senior staff need in depth training in understanding Mental Capacity and exploring the possibility of acquiring Independent Mental Capacity Advocates for those residents who need support in this area. DS0000070923.V356784.R01.S.doc Version 5.2 Page 21 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): 19,24 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a homely, personalised and safe environment for people who live there. EVIDENCE: The grounds and the car park areas of the home were maintained. The trees, flowerbeds, shrubs and lawns were appropriate for this time of the year. There was a skip in the parking area that was awaiting disposal. The home was warm, bright and free from malodours. Corridors and the reception area were in a good decorative order and maintained. There has not been much decoration in the past year but there was major redecoration of the home in 2004. The manager has identified the development of an activities room, purchase of new dining chairs, replacement of some carpet and replacement of the sliding doors in the dining room as plans for improvement in the next 12 months. DS0000070923.V356784.R01.S.doc Version 5.2 Page 22 While touring the premises I noted that the call bell system had only one bell on the ground floor, which is activated when a person rings the call bell for help. There are display panels on the first and the ground floors, but on the day of the inspection I could not hear the bell from the first floor when it was activated. Although the bell is on the ground floor it is not particularly loud to enable a person hear it from the first floor unless the person is standing right by the stairs. This raises concerns as to whether staff would be able to hear the call bell should it be activated at a busy time such as at night when there is less staff and when staff may be in the bedrooms of residents attending to them. As a result it is required that the call bell system be reviewed to make sure that staff are alerted when the call bell is activated so that staff are able to attend to residents who have called for help as soon as possible. The communal areas were on the whole tidy and were appropriately furnished. I noted that residents were able to use both lounges in the home and other seating areas that were found near the lifts on the ground and the first floors. Residents were encouraged to use these areas and were provided with appropriate seating facilities if they were assessed as not able to use normal armchairs. The bathrooms and showers were in good order and were clean and tidy, ready for residents to use. Residents have a small area with a washbasin for washing in their rooms. All toilets facilities are communal. The sluice was also in good order but would benefit from shelves to store bedpans which were kept on the floor. The bedrooms of residents continued to be personalised to a high standard. There were personal photographs, items of decorations, pictures, soft toys and pleasant personal touches such as duvets covers, pillow covers and blankets. These were kept tidy and clean except for the frames of the beds and shelves that needed dusting. Residents are offered keys to their rooms and some use this option to maintain their privacy. They are able to lock their rooms from the outside and the inside of their rooms with their keys. Residents have the option of putting a chain on the door from the inside to maintain their privacy when inside the room, but it remains a risk that if one resident locks the door from the inside and leaves the key in the keyhole it will not be possible for someone else to open the door from the outside in an emergency unless the door is broken down. Risk assessment should be in place to manage this situation. DS0000070923.V356784.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): 27-30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a fairly stable team of staff who are appropriately trained to care for the residents. Recruitment procedures are not always strictly followed to make sure that residents are safe. EVIDENCE: There were 47 residents in the home at the time of the inspection. The manager and the deputy manager were supernumerary. The staff team consisted of 2 trained nurses and 8 care workers in the morning, 2 trained nurses and 6 care workers in the afternoon and 2 trained nurses and 3 care workers at night. There has not been any significant change in staffing since the last inspection. Residents were satisfied with the support that they receive from staff. One resident said that ‘they would do anything for you’. The home is responsible for the recruitment of care staff and Caterplus the organisation, which provides support staff, carries out recruitment of its own staff according to similar procedures to the home’s, to make sure that the home is complying to care homes’ legislation. Three personnel files of care staff were inspected. It was noted that all the records as required by legislation were in place except for a full work history. There were two references, proof of identity, evidence of CRB check and evidence of eligibility to work in the UK. DS0000070923.V356784.R01.S.doc Version 5.2 Page 24 Two personnel files for support staff recruited by Caterplus were inspected. One person had all the necessary records and one person had one reference and there was no evidence of that person’s eligibility to work in the UK. The requirement to ensure the safety of residents by following robust recruitment procedures rest with the registered persons for the home. As a result the registered persons must ensure compliance with the recruitment procedures and must make sure that a full employment history of applicants is available as part of the recruitment procedure. New members of staff receive an induction when they join the staff team. This consisted of a number of days when staff are supernumerary and when they are closely mentored to make sure that they are well able to care for the residents. It was noted that new members of the care staff did not complete the common induction standards as per Skills for Care, the training organisation for the social care sector. There was however evidence that most members of staff have received training in the statutory areas including manual handling, fire, health and safety food hygiene, safeguarding adults and infection control. Information contained in the AQAA suggested that the home has 24 out of 30 care staff already trained to NVQ level 2 or above (80 ). Training records of staff showed that staff were receiving supervision. The deputy manager said that the aim was for all staff to receive supervision at a minimum of six times a year. DS0000070923.V356784.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): 31,33,35 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home benefits from an experienced management team to make sure that the aims and objectives of the service are being met. The management of residents’ money is carried out to a good standard to prevent financial abuse as far as possible. The home does not yet have a fully effective quality control system in place to measure the quality of the service. Health and safety issues are normally addressed appropriately to demonstrate the home’s commitment to maintaining the health and safety of people who use the premises. EVIDENCE: The home as mentioned previously has recently changed owners. The manager remains in post and has now been managing the home for at least 6 years. DS0000070923.V356784.R01.S.doc Version 5.2 Page 26 She is supported by her deputy and has line management support of an operations manager. She has a qualification in management and in nursing. Residents who were able to talk to me said that they knew the manager and the deputy manager well. They said that they would go to the manager or the deputy manager if they felt that their concerns were not being addressed by staff or if they needed to go directly to the manager. They had the confidence that the management would listen to them and would support them. One resident said that ‘the office is always opened and the manager is always available’. The manager runs the home in an open and transparent manner and makes every attempt to involve residents and staff in running the home. There are monthly residents’ meetings (a programme is in place for the whole year), quarterly relatives’ meetings, general staff meetings and team meetings. So there are many opportunities for residents and staff to express their views about the service. The home manages the personal money of some residents. A few residents’ benefits are received by the local authority and passed on to the home to manage. There is a main bank account for the management of residents’ money. The home keeps a small amount of money for each resident, which are toped up as required by residents’ next of kin or by the head office if residents have money in the residents’ bank account. Any requests to head office for the top-up of residents’ personal money are made by the manager and administrator. Records kept about financial transactions were seen and were judged to be appropriate. The management of two residents’ personal money was seen. There was evidence that receipts were given to residents’ next of kin when money was received for residents’ personal expenditures. The records were up to date, and there were receipts for expenditures that were made on behalf of the residents except for toiletries that were bought in bulk. It is recommended that some form of receipts be kept with regards to this matter. The home has an annual open day and carries out a satisfaction survey of stakeholders around the same time. The results of a survey were available for inspection. The home had sent a considerable amount of questionnaires to stakeholders but unfortunately there has been a poor response to the survey. The manager informed me that now that MHA has taken over the home the quality assurance procedure of the new organisation would be implemented. Previously the quality assurance procedure of Network Housing was used but that was mostly geared to the housing association and apart from the customer satisfaction survey, there was no discernible impact of that quality system on the service. The manager added that the quality assurance procedure of MHA involves a series of audits based on standards that have been set. DS0000070923.V356784.R01.S.doc Version 5.2 Page 27 The home had most of the safety certificates and maintenance certificates to demonstrate that items of equipment were being maintained as required. For example there were up to date gas safety, electrical wiring and PAT certificates. An up to date fire risk assessment was also available but it was noted that the health and safety risk assessment has not been recently reviewed and a specific fire emergency plan was not available in the home, although there was a general major disaster plan. The London Fire Brigade says that there must be an emergency fire plan for premises where an employer has five or more employees which must contain information about the warning if there is a fire; calling the fire brigade; evacuation of the premises including those particularly at risk; power/process isolation; places of assembly and roll call; liaison with emergency services; identification of key escape routes; the fire fighting equipment provided; specific responsibilities in the event of a fire; training required; and provision of information to relevant persons (http:/www.londonfire.gov.uk/fire_safety/at_work/the_emergency_plan.asp ). It was also noted that while there were fire emergency lights checks, fire detector checks and fire drills there were no regular in-house checks on fire exits and fire fighting equipment to make sure that these are always in good condition and fit for purpose. LOLER certificates for the hoists and for the lift were available for inspection. There was regular water temperature monitoring in place for the prevention of legionella disease, and to prevent scalding. A number of residents are wheelchair users, and some of them have inherited wheelchairs from the home while others were provided wheelchairs by the wheelchair service. The deputy manager stated that nursing and care staff regularly check the wheelchairs, particularly the ones provided by the home, but there were no records that this was taking place. DS0000070923.V356784.R01.S.doc Version 5.2 Page 28 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 2 3 3 2 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 DS0000070923.V356784.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 5 Requirement The home must have an updated statement of purpose and service users’ guide as soon as possible to reflect the recent changes in ownership as well as to clarify the ethos, philosophy of care and aims and objectives of the new organisation. That the home only admits residents within its category of registration to ensure that it can meet all the needs of residents who are admitted. To provide a guarantee that the needs of residents will be met, all residents must have a comprehensive assessment of their needs, including a psychological assessment. The cultural, ethnic and religious aspects of the life of the individual resident must be part of this assessment. The manual handling risk assessment and the associated care plan must be clear about all the manual handling manoeuvres and the equipment required for all moving of DS0000070923.V356784.R01.S.doc Timescale for action 28/02/08 2 OP4 14(1,2) 31/01/08 3 OP7 14(1) 31/03/08 4 OP7 13(5) 31/01/08 Version 5.2 Page 30 5 OP8 15(1,2) 6 OP8 17(1)(a) 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 OP11 15(1,2) residents, including moving them when they are in bed. The registered person must ensure that service users with short-term problems have care plans in place addressing these needs (Repeated requirement-timescale 30/11/06 not met). That the care plans of residents who have pressure ulcers or who are at high risk of developing pressure ulcers address the repositioning of residents not only when they are in bed but also when they are seated (Repeated requirementtimescale 15/11/06 not met). The procedure for the administration of medicines must be adhered to and nurses must make sure that residents’ take all their medicines according to the procedure and that medicines are not left unattended The amount of medicines administered must be clarified in cases where a variable dose of the medicine has been prescribed To make sure that residents do not receive medicines that have expired, staff must make sure that they promptly discard all medicines that have passed their expiry dates. The registered person must ensure that the wishes and instructions of service users or that of the representatives with regard to end of life care and death of the service user are recorded, as far as possible (Repeated requirementtimescale 31/12/06 not fully met). DS0000070923.V356784.R01.S.doc 31/01/08 31/01/08 31/01/08 31/01/08 31/01/08 31/03/08 Version 5.2 Page 31 11 OP12 16 (2)(m)(n) The resuscitation status of residents taking into consideration the views of the residents and their relatives must be an integral part of care planning. The registered person must ensure a comprehensive assessment of the social and recreational needs of residents and must ensure that appropriate recreational and leisure activities are provided to residents (Repeated requirement-timescale 30/11/06 not met). To make sure that needs of residents from ethnic minorities are being met the registered person must provide culturally appropriate meals to ethnic residents as far as possible. It is required that the call bell system be reviewed to make sure that staff are alerted when the call bell is activated so that staff are able to attend to residents who have called for help as soon as possible. To ensure a high standard of hygiene there must be a high standard of cleanliness in the home. Bed frames and shelves must be dusted as required. The registered person must ensure that all staff employed in the home have the records as detailed in schedule 2 of the Care Homes Regulations 2001. Applications forms must be fully completed and all gaps must be explored at the time of the interview with records kept as required (Repeated requirement-timescale 30/11/06 not met) To make sure that new members DS0000070923.V356784.R01.S.doc 31/03/08 12 OP15 23(2)(i,j) 31/01/08 13 OP19 23(2)(n) 31/03/08 14 OP26 23(2)(d) 31/01/08 15 OP29 19 31/01/08 16 OP30 18(1)(c) 28/02/08 Page 32 Version 5.2 17 OP33 24 18 OP38 13(4) of staff are fully aware of their responsibilities and are appropriately inducted, they must have an induction based on the common induction standards as per skills for care. The quality assurance procedure of MHA must be implemented as soon as possible to ensure not only compliance with legislation but to use it as a way of improving the quality of the service. The home must have an up to date health and safety risk assessment to demonstrate that health and safety issues are being attended to as required. 31/03/08 28/02/08 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 OP12 Good Practice Recommendations The home should look at ways to enhance the lifestyles of the more dependent residents who are unable to take part in some of the activities that are arranged by the home such as the art classes and tai-chi sessions. That shelves are placed in the sluice for the storage of the bedpans, instead of them being stored on the floor. It is recommended that some form of receipt be kept for each resident when toiletries are bought for residents in bulk. That wheelchair checks are carried out at least monthly by a person competent to do so, and that records are kept to demonstrate that the checks are being carried out. A specific emergency fire plan should be available for inspection. Checks of the fire fighting equipment and fire exits should be carried out at regular intervals and recorded. 2 3 4 5 OP26 OP35 OP38 OP38 DS0000070923.V356784.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. 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