Inspection on 12/01/06 for Lewis W Hammerson Memorial Home

This inspection was carried out on 12th January 2006.

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

Lewis W Hammerson Memorial Home 10/11/08

Lewis W Hammerson Memorial Home 30/11/06

Lewis W Hammerson Memorial Home 06/07/05

Lewis W Hammerson Memorial Home 01/02/05

Lewis W Hammerson Memorial Home 21/09/04

Lewis W Hammerson Memorial Home 11/12/03

Lewis W Hammerson Memorial Home 21/07/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lewis W Hammerson Memorial Home 50a The Bishops Avenue East Finchley London N2 0BE Lead Inspector Tola Akinde-Hummel Unannounced Inspection 12th January 2006 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 Lewis W Hammerson Memorial Home DS0000010430.V269922.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. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lewis W Hammerson Memorial Home Address 50a The Bishops Avenue East Finchley London N2 0BE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8458 4523 020 8458 2537 The Lewis W Hammerson Memorial Home Mrs Celia Collier-Bawden Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68) of places Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 68 adults of either gender over the age of 65 years, 15 of whom have nursing needs. 6th July 2005 Date of last inspection Brief Description of the Service: Hammerson House Memorial Home is registered to care for up to sixty eight people over the age of sixty five who are Jewish. The home is owned and operated by a charitable trust on behalf of the Hammerson family and has been registered since 1985. The home is situated in a residential area of North London and is served by public transport. The home is decorated to a high standard and well maintained. There are three floors, with the nursing unit on the ground floor. There is a lift to all floors. There are twenty- two sheltered housing units within the home and these are integrated within the residential home. The home has its own physiotherapy facilities and is run by qualified staff. The kitchen facilities have been contracted to a company who also provide serving staff in the dining room. The aims of the home are That all service users shall live in a safe and clean environment and be treated with respect and sensitivity to their individual needs and abilities. Staff are responsive to the individual needs of service users and will provide the appropriate degree of care to ensure the highest possible quality of life within the home. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one and a half days. Ms Bethenie Salik the locality Performance Information Manager CSCI accompanied the inspector. The inspector received 16 service user comment cards in total. Thirteen were from the nursing and residential side, and three from the sheltered housing service. One relative comment card and one placing officers card was received. The inspector also received a completed pre inspection questionnaire and additional information about the home from the Matron. The chief executive Mr Andrew Leigh and the Matron, Ms Celia Collier- Bawden, were available throughout the inspection. Twelve service users and three relatives were spoken to. Four care staff were formerly interviewed. Two housekeeping staff, the head chef and three nurses were also spoken to during the inspection. A tour of the building was completed. The medication storage, handling and recording was inspected. Seven care plans; five staff files, policies and procedures were also examined during the inspection. What the service does well: What has improved since the last inspection? Hammerson House have met eight of the nine requirements stated from the previous inspection. The outstanding multi disciplinary assessment for one service user and the need for large print on the self- medication form have been met. The five medication requirements have all been met and are having an impact in the safe handling of medication in the home. The requirement to Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 6 ensure the freezer is cleaned has been met and the home has consulted with the crime prevention officer. 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. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3,4 and 5 were examined at the previous inspection and assessed as met. The home does not provide an intermediate care service. EVIDENCE: Lewis W Hammerson Memorial Home DS0000010430.V269922.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): 7,9 The quality and consistency of recording in service users care plans has deteriorated. This could result in service users needs not being met. The home has improved its recording, storage and administration of medication. EVIDENCE: Twelve service users were spoken to during the inspection. In addition, the care plans of seven service user were also examined. The care plans showed that there has been a drop in the quality of recording of information. Only one care plan was up to date in terms of the monthly review. One service user had an incomplete multi disciplinary assessment and there is evidence that service users weight is not being recorded on a monthly basis. Some of the service users are very elderly and no longer wish to be weighed. However this is also not recorded in the plans. Where staff does record information, this is detailed and helpful. Unfortunately, staff are not consistently placing information in the correct section of the file making care plans difficult to follow. The requirement made at the previous inspection to ensure a service user had a completed multi disciplinary assessment has been met. The medication recording and storage was examined. The home has addressed all the requirements made in relation to medication. The medicines policy now includes a section on Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 10 disguised medication and there is a new system in the home for monitoring medication received into the home. The manager and chief executive now check the recording of all medication on Friday mornings. This was checked as part of the inspection and is satisfactory. The gaps in medication records were examined. All non- administration is properly recorded, with more detailed explanations on the back of the medication sheet. The temperature of the medication room is recorded daily and has been maintained below 25oC. The home has arranged for staff to attend the Primary Care Trust training on medicine management. Trained nurses and care staff will attend separate training. There will also be building work undertaken in the near future to increase the space in the medication room. Lewis W Hammerson Memorial Home DS0000010430.V269922.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): 12,13,15 Hammerson House provides a wide range of activities for service users ensuring they are both mentally and physically stimulated. EVIDENCE: Twelve service users were spoken to during the inspection. All service users stated that they are supported in the home by kind, friendly staff. Hammerson House is a home that provides care for Jewish people. All service users are able to embrace their culture and religion. This is understood and respected by non-Jewish care staff. Service users have a wide variety of activities that they are able to participate in. Service users receive a weekly programme of activities and posters are displayed throughout the home reminding service users of what is available. One service users told the inspector, “ The stimulation we get in here is very good” One service users stated “I like the exercise to music sessions as it keeps me active as I have problems walking”. Another service user commented, “ I take part in many of the activities and I a doing things like painting, making jewellery and painting on silk. I had never done things with my hands before”. The paintings made in the home are displayed and exhibitions of work are also displayed for purchase twice a year. The home also organises varied and interesting trips outside the home. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 12 Three relatives advised the inspector that they are pleased with the home and their relatives have appropriate levels of the choice in the home. Relative state that they are made to feel welcome in the home and any issues raised are quickly resolved. Service users have mixed feelings about the food provided although the overall opinion is that it is sufficient in quantity and quality. Nine service users who returned comment cards liked the food, five stated they enjoyed the food sometimes and the remaining three live in sheltered housing so prepare their own meals. The food served is Kosher. Service users inform staff when they are less than satisfied with the food. Kitchen staff work continually to maintain a consistently high standard of food offered. Service users stated that there is a constant supply of fresh fruit, which is available at all times. Lewis W Hammerson Memorial Home DS0000010430.V269922.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): 16,18 Service users and their relatives are familiar with the complaints procedure, which is made accessible to them. EVIDENCE: Service users and relatives spoken to were all clear about how to make a complaint. One relative stated that they have made complaints and were very happy with the way these were dealt with. All sixteen service user comment cards confirmed that they knew whom to make a complaint to. All service users stated that the matron is always around and is very approachable. This was evident during the inspection. Four staff interviewed at the time of inspection clearly outlined different forms of abuse and what action to take should abuse be suspected. Staff are also aware of the need to keep accurate records. The homes abuse policy was revised in July 2005, is very clear and easy for staff to follow. A number of thefts occurred in the home prior to the previous inspection. A recommendation to access the advice of the local crime prevention officer has been met. The officer was able to speak to service users to explain what measures they could adopt to reduce the risk of becoming victims of crime. The home was also advised on added security measures in and around the building to minimise the risk of further occurrences. Lewis W Hammerson Memorial Home DS0000010430.V269922.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): 19,23,26 Hammerson House is a well maintained home. This enables service users to feel comfortable in the communal areas and in their own private space. EVIDENCE: Hammerson House is a well looked after home. The housekeeping team make every effort to ensure that personal and communal spaces are clean and hygienic. A tour of the building noted that some work had been undertaken to replace windowsills in the hallways. There is a larger maintenance and redecoration programme due to start in the next two months. Service users told the inspector that they are very happy with their environment. Bedrooms are furnished according to service users tastes. The home is warm and welcoming with ample communal space and places to entertain visitors. Fourteen service users whom returned comment cards stated that they like living in the home. All twelve service users spoken to during the inspection supported this. Two service users commented that they like living in the home sometimes. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 15 Lewis W Hammerson Memorial Home DS0000010430.V269922.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): 28, 29. 30 Hammerson House encourage staff to undertake training and promote good practice. Thereby improving care delivered to service users. Required recruitment information in the home is incomplete. This must be addressed in relation to staff and volunteers. EVIDENCE: Hammerson House has 12 trained nurses and 37 care assistants. There are adequate numbers of staff in the home to provide assistance for service users and the manger regularly reviews the staffing ratio. The home has met the 50 ratio of staff trained at NVQ level 2 and above and four carers are near completion. The NVQ training is ongoing and the home is committed to continue to train staff. Four staff members informed the inspector that they receive on going training. This is formal and also organised as study days. Staff confirmed that they have received training including moving and handling, fire safety, medication, pressure sores and depression in older people. The personnel files of five staff members were examined. Whilst these were well organised, there were gaps. Two files did not include recent photographs. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 17 One did not have details of an up to date PIN of file and a further file did not have an up to date home office work permit. The manager assured the inspector that these were all up to date and will send the relevant information to the commission. The record of volunteers revealed that not all had up to date criminal records bureau checks. This is essential when having contact with service users to minimise any risk of inappropriate appointments. Lewis W Hammerson Memorial Home DS0000010430.V269922.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): 32, 35,36,37, 38 An effective management team runs the home. This gives service users the confidence that their requirements are understood and where possible are met. Supervision of staff in the home is not sufficient and care plans are not maintained in good order. EVIDENCE: Hammerson House in managed by the Matron Ms Celia Collier –Bawden and Mr Andrew Leigh, Chief Executive. The differing roles ensures that the care side and business side of the home is attended to whilst all staff and service users recognise that work is undertaken in partnership. The vast majority of service users in the home manage their own finances. Those who do not are supported to do so by relatives. The manager does not act as appointee for any service users. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 19 An inspection of supervision records revealed that whilst there has been improvement, there is still a significant shortfall in the amount of supervisions being completed. This is due to a variety of valid reasons. The manager is well aware of this and in her supervision with senior staff has set deadlines for supervisions to be completed. Care plans in the home must be reviewed to ensure information is correctly filed to promote ease of use. The manager is aware that staff are not filing information correctly despite numerous reminders of how the care plans should be presented. On further discussion the chief executive agreed to consider randomly selecting and monitoring care plans as part of the quality assurance process. The home has a responsible maintenance officer who ensures that all safety certificates are up to date and comply with Health and Safety legislation. A tour of the building found some areas that require more attention. Plants obstructed one fire alarm on the first floor hallway. A wheelchair obstructed another hallway. A sink no longer in use had not been safely disconnected to avoid injury to service users unaware that it can no longer be used. However all these issues were resolved during the inspection. The kitchen area was inspected in the company of the head Chef and the chief executive. The milk and meat kitchens were inspected and a previous requirement to clean the grill had been met. The cold storage area does not have all items labelled and the large cereal and flour containers require cleaning. The large fridge is not stacked properly to ensure contents in the fridge can be easily identified and avoid injury to staff when removing items. The previous requirement ensuring that the freezer is cleaned has been met. Lewis W Hammerson Memorial Home DS0000010430.V269922.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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 X 2 2 Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14, (1), (a), 2 (a) Requirement The registered person must ensure that multi- disciplinary assessments are completed for service users entering the home. Staff must sign these. The registered person must ensure that all plans are reviewed on a monthly basis. The registered person must ensure that any changes to the plan, (such as a decision to longer weigh a service user) is properly consulted upon and recorded in service users records. The registered person must ensure staff members have valid PIN numbers recorded on personnel files. The registered person must ensure that staff have valid work permits on personnel files The registered person must ensure that all staff have recent photograph ID on personnel files The registered person must ensure that all volunteers who have direct contact with service users have a valid criminal DS0000010430.V269922.R01.S.doc Timescale for action 28/02/06 2. 3. OP7 OP7 15, (2), (b) 12, (3), 15, (1) 28/02/06 28/02/06 4. OP29 19, Schedule 2 19, Schedule 2 19, Schedule 2 19, Schedule 2 28/02/06 5. 6. 7. OP29 OP29 OP29 28/02/06 28/02/06 28/04/06 Lewis W Hammerson Memorial Home Version 5.0 Page 22 8. OP36 18, (2) 9. 10. OP38 OP38 13(4), (c) 13, (4), (c) 11. OP38 18 (1) (c) (ii) records bureau check. The registered person must ensure that all staff receives supervision at least six times per year. The registered person must ensure that fire alarms and hallways are not obstructed. The registered person must ensure that all food is labelled and that the large containers in the cold storage area are cleaned regularly. The registered person must ensure that food in the fridge is properly stored to reduce any risk of injury to staff 29/12/06 13/01/06 28/02/06 28/02/06 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. 2. Refer to Standard OP7 OP33 Good Practice Recommendations The registered person should consider a review of care plans during supervision of staff to ensure these are up to date and overdue information can be completed. The chief executive with the matron should consider sampling care plans as part of the quality assurance process. Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Lewis W Hammerson Memorial Home DS0000010430.V269922.R01.S.doc Version 5.0 Page 24 - 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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