Inspection on 21/06/05 for Ogilvy Court

This inspection was carried out on 21st June 2005.

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

Ogilvy Court 07/08/07

Ogilvy Court 15/11/06

Ogilvy Court 06/01/06

Ogilvy Court 25/02/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOMES FOR OLDER PEOPLE Ogilvy Court Nursing Home 13-23 The Drive Wembley Park Wembley,London HA9 9EF Lead Inspector Ram Sooriah Announced 21 June 2005, 10:00h00 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 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. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ogilvy Court Nursing Home Address 13-23 The Drive Wembley Park Wembley London HA9 9EF 020 8908 5311 020 8908 5807 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care UK CRH PC Care Home only 57 Category(ies) of DE Dementia 65 years and over both male 15 registration, with number and female 30 of places LD Learning Disability 45 years and over both male and female 12 LD Learning Disability 65 years and over both male and female 12 MD Mental Disoder 65 years and over both male 15 and female 30 Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th February 2005 Brief Description of the Service: Ogilvy Court is a care home, which belongs to Care UK, a national care homes’ provider. It is situated in The Drive, which is a small road off the main busy Forty Lane. It is easily accessible by buses, which pass on the main road and is about 5-10 minutes walk from local shops and local amenities. It is a short bus ride journey to Wembley town centre. It also has a large car park in front of the home easily accommodating about 15 cars. Ogilvy Court is a care home specialising in providing nursing care for elderly service users over the age of 65 years with mental illness and for service users with a learning disability from 45 years of age. It is purpose built and provides accommodation in mostly single rooms with en-suite facilities. It has three double bedrooms also with en-suite facilities. There are three units in the home. Ivy accommodates 12 service users with a learning disability, Dahlia accommodates 15 male elderly service users with mental health needs and Bluebell accommodates 30 mostly female elderly service users also with mental health needs. The home has a manager in place, supported by unit managers. The home provides all the other necessary ancillary services such as laundry and catering. At the time of the inspection, there were 54 service users in the home. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first time that the service is having an announced inspection against the national minimum standards. As a result, this report may contain a substantial number of recommendations and requirements. If so, the number of this should fall significantly at the next inspection, when the provider would have had time to take action to meet the requirements and recommendations. The inspection started on a Tuesday at 1000 and lasted for about 12 hours over two days. During the course of the inspection the inspector spoke to service users, visitors to the home and the manager and his staff. The inspector also inspected the premises and looked at care records, the health and safety records and other home records. The manager completed a preinspection question as part of the inspection process. Fourteen comments cards from relatives/visitors have been received about the service prior to the inspection. They indicated that the relatives/visitors to the home were mostly happy about the standard of care provided by the home. The content of the comments cards have been used in the compilation of this report where possible. Since the last inspection a new manager has been appointed as the previous manager has moved to another home belonging to the same company. There is evidence that the manager has been trying to meet the requirements following the last inspection. The inspector would like to thank the service users, visitors, the manager and his staff for a kind welcome to the home and for their cooperation during the inspection. He would also like to thank all those who have responded with comment cards. What the service does well: What has improved since the last inspection? Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 6 Some areas in the home have been redecorated and the grounds of the home have been made tidier. Staff have been attentive to medicine administration to ensure good practice. Some Health and Safety issues have been addressed such as providing a fire risk assessment and ensuring that fire doors could be easily opened in an emergency. The staffing has improved to ensure that all units are staffed by the appropriate numbers of trained nurses 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. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 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 standard(s) 1-5 The home has a service users’ guide, which is offered to new service users. This document and others, which are provided to service users, could be in formats, which would make them more ‘user friendly’. The home is able to meet the needs of the service users, but more attention must be given to the assessment of the needs of the service users, particularly with regard to the mental health assessment of service users, to ensure that care plans can then be formulated to meet all the identified needs. EVIDENCE: The inspector has been sent an updated service user’s guide (SUG) and statement of purpose (SOP). These were generally appropriate and contain the necessary information as laid down by legislation. The inspector noted that a new service user to the home was offered a copy of the statement of purpose. The units however have a range of service users from learning disability to service users with mental health needs. It is required that the registered person explores other formats to produce the SOP and the SUG, such as easy to read format (e.g. signs and symbols) for service users with learning disability or in large prints for those with poor vision. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 9 The inspector noted that most service user had the terms and conditions made out for them as if they were funded by Brent PCT. However although most of the service users were from Brent PCT and were given the right statement of terms and conditions, others who were funded differently needed individual statement of terms and conditions, which reflected their particular condition. There were pre-inspection assessments of the needs of service users before they were offered a place in the home. These were normally comprehensive. The manager stated that he carries out the assessments together with a unit manager. Once admitted to the home, the needs of service users were further explored by trained nurses on a model based on the activities of daily living (ADL). The model further aimed to bring a holistic approach by looking at the physical, psychological and social aspects of a particular ADL. This assessment was generally well completed but could have benefited from some ‘fine tuning’. For example, the section under communication for one service user addressed speech and hearing but did not address sight; another assessment did not address the person’s ability and disposition to communicate. The section on ‘eat and drink’ did not always clarify the likes and dislikes of service users. However the main deficit of this model is that it does not look at the mental health needs of the service user. There is a mental status questionnaire, which gives information about the cognitive mental state of service users, but this does not give information on the behaviour of service users and about explaining how the mental health needs of the service user manifest itself. As a result the registered person must ensure that service users admitted to the home have a thorough assessment of their needs including their mental health needs. The home was fully staffed on the day of the inspection. There was a relatively stable group of staff, who were familiar with the needs of the service users. There was evidence in care records that although the mental health needs of service users were not always recorded in the assessment, there were at times care plans in place to meet some of these needs. The manager stated that service users are invited to visit the home where possible and that in cases where this is not possible then the relatives and friends are invited to visit the home. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-11 Care plans were comprehensive most of the time. Some progress has been made with regard to involving service users and their relatives in the care planning process, and this process must now be consolidated. The continence assessment did not always clearly demonstrate that the continence needs of service users were being met. Medicines in the home were generally well managed. Although the clothes of service users were clean, these were not always ironed appropriately to ensure that service users were always dressed appropriately and in a dignified manner. EVIDENCE: The care plans of service users were in good condition and were all kept safely in the nurse’s office. The plans of care were generally clear and contained the actions that should be carried out to meet the needs of the service users. Care plans were generally reviewed monthly or more often if required. However in one of the care plans chosen at random, the inspector noted that the night care plan has not been reviewed since 2002. The registered person must ensure that all care plans are reviewed at least monthly. There was evidence that the home has started involving service users or their relatives in drawing care plans and risk assessments. However, some areas in the care plans where the service user or relative should sign to say that they Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 11 have agreed to the care plans were still left blank. Further progress must now be achieved in this area by involving service users or their representatives not only in drawing care plans but also in the review of the care plans. The home uses a pressure sore risk assessment to determine service users at risk of developing pressure sores. There were care plans and equipment in place in cases where service users were identified at risk. The inspector noted that at times the compressors for the air pressure mattresses were not adjusted at the pressure, which corresponded to the weight of the service user and that the equipment in use were not always described in the care records as evidence that appropriate pressure relief equipment were being provided for service users. The registered person must take action to address these points. Service users had incontinence assessment and care plans were in place in cases where problems were identified. Care plans and incontinence assessments did not however clarify the care that service users should receive with regard to the type of pads being used to manage the incontinence and the time for changing the pad. One mentioned use ‘appropriate pads’ and change at ‘appropriate times’ and ‘regular intervals’. There were records of service users being visited by a number of healthcare professionals such as the GP, chiropodist, psychiatrist, dietician and Tissue Viability Nurse. Records were however not always clear to show if service users have had yearly checks by the dentist and by the optician in the period from June 2004-June 2005. Medicines were checked on the bluebell unit. The clinical room was clean and appropriate records were being kept about the temperature of the room and about the medicines fridge. All medicines were signed when administered and there were no empty spaces in the medicines charts. There were sample signatures and initials of the nurses responsible to administer medicines and there was evidence that these nurses have also been assessed by the unit managers about their competencies with regard to medicines administration. There were appropriate records about medicines being returned to the chemist and medicines received in the home. In general the management of medicines was assessed as appropriate at the time of the inspection. The inspector noted that there were some service users who were on anticonvulsants and medicines to control manic depression, which normally requires close monitoring of the blood levels of these medicines. Although a care plan for one service user said to monitor the blood level of the medicine three monthly, there was no evidence that this was being carried out. Some service users were also on diazepam to be administered when they fit. One of them had a clear plan when to administer the diazepam. Others did not have that. It is recommended that there is clear plan/protocol for each service user who is on rectal diazepam with regard to the administration of this medicine and which has been agreed with the GP. All service users wore clean clothes and were appropriately groomed during the inspection. The inspector however noted that at least one service user was Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 12 wearing a shirt which has not been ironed. Cupboard of service users also contained a number or items of clothing, which have not been ironed. The manager stated that he was aware of this problem and is looking at solutions to this problem. This is an issue, which urgently needs to be addressed as it is detracting from the good care that the home otherwise provides. The home has a trolley phone, which normally stays in one area of the home. It is not always possible to use the trolley phone in the bedrooms of service users for them to make or to receive phone calls from the privacy of their bedrooms, because there is no connection for it. This may be particularly relevant if service users are unwell or confined to their beds. Some care plans of service users contained some information about the wishes and instructions of service users about the future and arrangements with regard to death and funeral. This information may not be available on all occasions, and a note should be made when this is not available. The information provided in this section is important as it helps to understand the perspectives of the individual service user/representative about death and to ensure an appropriate outcome. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12-15 Service users are offered a range of activities to satisfy their social and recreational needs. The home provides meals in a congenial and pleasing environment. Staff take the choices of service users into consideration when serving the meals. There were some minor issues on the menu, which needed to be clarified with regard to the nutritional content of the meals. EVIDENCE: Information about the social and recreational needs of service users was in most cases appropriately recorded. The format used by the home for information collection about this aspect of care was very clear and comprehensive. There were one full time activities coordinator and one part time for service users with mental health needs and the same number of activities coordinator for service users with a learning disability. Programme for activities were available on the notice boards. The inspector was informed that service users could go on outings during the weekends in a minibus, which is rented by the home and that other service users could go for walks in the vicinity of the home. There was information about arranging aromatherapy sessions and hand massage. The inspector judged that the home meets this standard. The home has open visiting and the inspector noted a number of visitors to the home. They met the service users in the bedrooms or in one of the empty Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 14 communal areas such as in the dining room, outside mealtimes. The inspector was informed of the involvement of the local church in the home. A number of service users were observed going out in taxis. Some apparently go for meals outside, others go out shopping and some also attend day centres. This normally applies to a larger extent to service users with a learning disability who are of a younger age group than service users with mental health needs and who have attended day centres in the past and now continue to do so. The inspector noted that service users were asked about their choices and about what they wanted to do and that staff took the wishes of the service users into consideration. For example they were asked about the activities that they wanted to do and about their meals. According to the pre-inspection information none of the service users are able to handle their own finance. There are a number of service users without relatives or representatives. The manager stated that he has made contact to arrange for advocates for the service users and that there is a shortage of independent advocates in the area. Inspection of the rooms of service users showed that a number of service users had brought personal possessions into the home to personalise their room and to make them more familiar and homely. The manager stated that the home actively encourages service users/representatives to do that. The inspector observed the lunch being served on Dahlia and the Ivy unit. On one of the day there were tuna pasta bake and the second choice was carrots, peas and potatoes with broccoli cheese. On the second day there were meatballs, cauliflower, sprouts and potatoes and vegetables burgers for the second choice. There were some days however when it was not clear what the source of protein for the second choice was for example on Thursday of week 1 (vegetables provincial), and Thursday of week 2 (ratatouille). The inspector also noted that suppers were not very clear with regard to the source of carbohydrate for example for Wednesday of week 2 (liver sausage and vegetables) and Friday of week 2 (cauliflower cheese and chopped tomatoes). As a result of the above the registered person must consider reviewing the menus with the help of a dietician to ensure that the meals are as nutritious as possible. The inspector observed that a number of aids such as plate guards, deep plates and some adapted drinking receptacles were in use to increase the independence of the service users with their meals. This is commendable. The inspector noted that fruits are sent daily to each unit for service users with lunch. He was also informed that service users receive a snack in the evening before going to bed. The kitchen was clean and tidy. Records were kept about the fridges and freezers temperatures. The inspector however noted that records about the meals cooked in the home were not always kept as per Schedule 4 (13) of the Care Homes Regulations 2001. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16 and 18 The service takes complaints seriously and offers the opportunity for service users or for their representatives to make complaints. The manager ensures that service users are safeguarded as much as possible from abuse by training his staff in relation to abuse issues. EVIDENCE: The complaint procedure was provided to service users in the service users’ guide. A copy was also available in the foyer of the home. Records about complaints were kept in the home and the inspector noted from the preinspection questionnaire that there has been one complaint during the past 12 months. This was partially substantiated. The commission has not received any complaints about the service. The inspector received 14 comments cards from relatives and visitors to the home. None have had to make a complaint about the service. The home now has the full Inter-agency policy and procedures for the Protection of Vulnerable Adults from the London Borough of Brent. The training programme showed that the manager has been arranging training on abuse for staff in the home. The Commission has not been informed of any allegation of abuse in the home. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19-26 Service users live in a generally clean, safe and well-maintained environment. The call bell system in the home needs a complete overhaul. EVIDENCE: The grounds in front of the home were tidy and maintained. The grounds on the sides of the home have also been tidied, but these areas may benefit from a new lawn particularly when service users tend to enjoy sitting outside on the sides of the home when the weather is nice. The building was maintained and was in good condition. A copy of the redecoration plan of the home was available for inspection with an audit of all the different areas of the home. The inspector noted that the home did not have a plan for the renewal of fittings and fixtures in the home. The communal areas were maintained and in general were appropriately decorated. Furniture in the communal areas was domestic in nature and appropriate to meet the needs of the service users. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 17 Bathrooms, showers and communal toilets were generally appropriate for service users except for a shower, which was being decorated on Dahlia unit. All the bedrooms have an en-suite, which consists of a toilet and washbasin. These are fitted with aids including grab handles and are accessible for the use of the hoist. Most of the bedrooms are single except for three double bedrooms. All the bedrooms of service users were appropriately furnished and personalised where appropriate. Some looked like they could do with some redecoration, but the inspector noted that they were already on the redecoration list. An immediate requirement was imposed on the home during the course of the inspection to ensure that the call bell system in the home worked appropriately. The inspector noted that the call bell system on two units was switched off, and the alarm was not very audible. This could have posed a problem if service users were summoning help and if staff were unable to hear the bell for example if they were busy in the bedrooms of other service users or if they were at the end of the corridors, where the call bell was not very audible. The other concerning issue with the call bell system is that if activated, it can apparently be switched off/reset from the lounge or the nursing station without actually visiting the room of the service user. Following the immediate requirement, the system has been repaired but according to the manager the whole system will have to be replaced. The home was generally clean and free of odours. There were sluices in the home for the handling of clinical waste. The laundry was kept clean and the two washing machines and dryers were in good working order. The inspector noted from the individual training profiles of staff and from the training program that a number of staff have not had recent training on infection control (See standard 30). Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The home provides staff in adequate numbers and skills to meet the needs of the service users. The vetting of the references of applicants in the past, has not been as thorough as it should have been to demonstrate that solid recruitment procedures were in place for the protection of service users. EVIDENCE: The home was fully staffed on the day of the inspection. There was a number of support workers in the home including kitchen staff, laundry staff, maintenance staff and activities coordinators. All service users were clean and appeared to be physically well cared for. The inspector also observed support being provided to service users as and necessary in an appropriate manner. As a result he judges that the numbers and skills of staff are appropriate to meet the needs of service users. The manager stated that he was negotiating to have more staff in the laundry to iron the clothes of service users. The inspector looked at five staff records. Staff generally had proof of identity, proof of eligibility to work in the UK, copies of the statement of terms and conditions, job descriptions, and evidence of a CRB check. The inspector however noted that some employees did not have references, which have been requested by the home, but brought in by the employee and were dated prior to the application for employment. Another employee had friends as references and one had a neighbour as a reference. The inspector observed that there were at times small gaps in the employment history as contained in the application forms. As a result the registered person must ensure that Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 19 appropriate references are obtained for all applicants and that all gaps in employment or education are explored before they are offered employment in the home. The manager stated that he was aware of some of these deficits following an audit of the personnel files and that he has started addressing some of the issues identified. There was a health questionnaire in place, but in some cases there was no follow up when for example staff were not fully vaccinated. It is recommended that the service offers some form of occupational service and ensures that staff have had the relevant vaccinations to work safely in a care setting. There was a training plan available for inspection during the last inspection. The new manager has not had the opportunity to update the plan but he has prepared a six-monthly training programme for staff. The inspector noted that a number of staff have had mandatory training in areas such as fire training, manual handling, food hygiene. A number of these training have however been provided on site and the contents and outcomes of these programmes were not clear. For example it is recommended by the Certified Institute of Environmental Health and Royal Institute of Public Health that staff who handle food have the basic certificate in food hygiene which normally requires at least six hours of training while the training provided by the home is a few hours. It is recommended that staff have a foundation certificate in food hygiene and that the short courses are used for updating staff. The inspector also noted an absence of training in clinical areas and in areas such as managing aggressive behaviour, managing confusion and disorientation and restraint. For example when talking to a member of staff, the latter was not very clear about the restraint policy of the home and the home’s views on restraints. The pre-inspection questionnaire showed that 8 of care staff were trained to NVQ level 2 or above and that 25 were in the process of studying for NVQ level 2 qualification in care. If they do finish before 2005, then the home would meet the standard with regard to having 50 of its staff trained to NVQ level 2 by the end of 2005. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36 and 38 Management issues in the home are dealt with appropriately. The service is generally run with service users at the centre of what it does. A few issues were identified which need to be attended to, to ensure the health and safety of service users at all times. EVIDENCE: Since the last inspection, the registered manager at the time has left the home after she had been promoted. CSCI is currently processing the application of the current manager. Comments from service users, visitors and staff in the home were positive about the management of the home. The inspector also noted that a number of issues identified in the last inspection have been addressed or are being addressed appropriately by the manager. The home has a quality assurance procedure and there are quality control methodologies in place. The inspector receives regular reports following Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 21 Regulation 26 visits in the home. These are generally comprehensive. Although the home is not accredited to a quality system, the manager discussed a number of quality issues with the inspector and about a proposal to identify areas for improvement and development. It is recommended that the home develop a system to gauge the level of satisfaction of users of the service by carrying out a satisfaction survey. At the time of the inspection the home did not have an annual development plan based on a systematic cycle of planning-action-review. The manager stated that he would prepare one to include in the business plan of the home. The inspector looked at the management of personal monies of service users in the home. Each service user with money has an individual bank account, which is managed by Head Office. Requests for money is agreed by the administrator and manager and sent to the head office. Once the money is received, it is entered in the home records. Records were generally well kept and receipts were available for inspection. The inspector however noted that a small amount of money from a service user was used for another service user. The inspector was informed that the money is normally refunded. Money for one service user must not be used for another service user, unless there has been permission given by the service user. Staff and the manager confirmed that supervision of staff takes place in the home. From records the inspector noted that these were not always held every 2 months or at least six times a year. The inspector looked at the health and safety records in the home. They showed that equipment in the home was generally being maintained. The inspector did not see a LOLER certificate for the lift and an Electrical Wiring safety certificate. The manager has carried out a health and safety risk assessment and a fire risk assessment. The fire risk assessment was comprehensive, and it is recommended that a third person allocated by the service review the health and safety risk assessment, as the latter will be able to look at the service from a different perspective. Records showed that there have been fire drills in the home, which are held twice yearly. However the records also show that quite a number of staff have not had fire drills. The registered person must ensure that all staff take part in the drills. Once most staff have been on fire drills, the home can then elect to carry out the drills twice yearly. A number of staff have had training in first aid, but these were short in-house courses which did not give an ‘appointed person’ qualification in first aid. According to the pre-inspection questionnaire only one member of staff had a first aid certificate. As a result the registered person must ensure that there is an appointed person for first aid at all times in the home. Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 x 2 2 x 1 Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 23 Yes 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 1 Regulation 4,5 Requirement It is required that the registered person explores other formats to produce the SOP, the SUG and other documents accessible to service users, such as in easy to read format for service users with a learning disability or in large prints for those with poor vision. The registered person must ensure that all service users to the home are offered a statement of terms and conditions which reflect their individual circumstances. The registered person must ensure that all service users have a thorough assessment of their needs including their mental health needs (previous requirement) The registered person must ensure that all care plans are reviewed at least monthly (previous requirement). The registered person must ensure the involvement of service users or their representatives not only in drawing care plans but also in the review of the care plans Timescale for action 31/10/5 2. 2 5(3) 15/9/5 3. 3 14(1,2) 15/9/5 4. OP7 15(2)(b) 15/9/5 5. OP7 15(1) 30/9/5 Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 24 (previous requirement). 6. OP8 12(1) The registered person must ensure by training of staff or otherwise that the compressors for the air pressure mattresses are adjusted at the pressure, which corresponds to the weight of the service users and that the equipment in use are described in the care records as evidence that appropriate pressure relief equipment are being provided for service users. Care plans and incontinence assessments must make clear the type of pads being used to manage the incontinence and the times for changing the pad. The registered person must ensure that all service users are seen by healthcare professionals such as the dentist and optician at the required intervals with records being made about the outcomes of these visits. The registered person must ensure that service users who are on medicines which require blood levels to be monitored have the blood tests at the appropriate intervals with records being kept. The registered person must ensure that the clothes of service users are always ironed appropriately. The home must have a facility to enable service users to make or to receive phone calls from the privacy of their bedrooms, in cases where service users are unwell or confined to their beds. The registered person must ensure that comprehensive information is recorded about the wishes and instructions of service users with regard to 15/9/5 7. OP8 15(1,2) 15/9/5 8. OP8 13(1)(b) 30/9/5 9. OP9 12(1) 15/9/5 10. OP10 12(4)(a) 15/9/5 11. OP10 16(2)(a) 30/9/5 12. OP11 15(1,2) 30/9/5 Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 25 13. OP15 16(2)(i) 14. OP15 17(2), schedule 4 (13) 15. OP19 16(2)(c) 16. OP22 23(1)(a) 17. OP29 19(1) 18. OP30 18(1)(c) 19. OP35 20 20. 21. OP36 OP38 18(2) 13(4,5) death and funeral arrangements, which takes into consideration any rites or cultural aspect of death. The registered person must consider reviewing the menus with the help of a dietician to ensure that the meals are as nutritious as possible. The registered person must ensure that records are kept about all the meals cooked in the home as per Schedule 4 (13) of the Care Homes Regulations 2001. The home must have a plan with regard to the the replacement of fixtures and fittings, with records being kept of areas/issues, which have been addressed. The registered person must ensure that the home has a suitable call bell system in the home. The registered person must ensure that appropriate references are obtained for all applicants and that all gaps in employment or education are explored before they are offered employment in the home. The home must have a comprehensive training plan and must address training such as in infection control, managing aggressive behaviour, on restraint and in other clinical areas. Money for one service user must not be used for another service user, unless there has been permission given by the service user. There must be supervision of staff every two months or at least six times a year. The registered person must ensure that there is a LOLER 15/9/5 15/9/5 30/9/5 15/9/5 15/9/5 30/9/5 15/9/5 30/9/5 15/9/5 Page 26 Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 22. OP38 13(4) 23. OP38 13(4)(c) 24. OP38 23(4) certificate available for the lifts as per the Lifting Operations and Lifting Equipment Regulations 1998. The registered person must 15/9/5 ensure that the home has an electrical wiring certificate available for inspection The registered person must 15/9/5 ensure that there is an appointed person for first aid at all times in the home. The registered person must 15/9/5 arrange for all staff to take part in the fire drills. Once most staff have been on fire drills, the home can then elect to carry out the drills twice yearly. 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 OP9 Good Practice Recommendations It is recommended that there is clear plan/protocol for each service user who is on rectal diazepam with regard to the administration of this medicine and which has been agreed with other healthcare professionals such as the GP. It is recommended that the service offers some form of occupational service and ensures that staff have had the relevant vaccinations to work safely in a care setting. It is recommended that the home develop a system to gauge the level of satisfaction of users of the service by carrying out a satisfaction survey. The home should have an annual development plan based on a systematic cycle of planning-action-review, reflecting the aims and outcomes for service users. It is recommended that a third person allocated by the service review the health and safety risk assessment in the home, as the latter will be able to look at the service from a different perspective. 2. 3. 4. 5. OP29 OP33 OP33 OP38 Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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 Ogilvy Court Nursing Home G62-G11 S59961 Ogilvy Court NH V225142 210605 Stage 4.doc Version 1.30 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!