Inspection on 29/01/04 for St David`s Nursing Home For Disabled Ex-servicemen and Women

Care Home For Older PeopleSt David`s Nursing Home For Disabled Ex-servicemen and WomenCastlebar Hill Ealing London W5 1TEUnannounced Inspection29th January 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment St David`s Nursing Home For Disabled Ex-servicemen and Women Address Castlebar Hill, Ealing, London, W5 1TE Tel No: 020 8997 5121 Fax No: 020 8997 2447Email Address Name of registered provider/Company (if applicable) St David`s Nursing Home for the Disabled Ex-Servicemen and Women Name of registered manager (if applicable) Mr Barrie Taylor Type of registration Care Home No. of places registered (if applicable) 40Category(ies) of registration, with (number of places) Old age, not falling within any other category (0), Physical disability (0), Physical disability over 65 years of age (0) Registration number G100000199 Date First registered Date of latest registration certificate 30th July 2002 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspection 15th January 2004 YES YES 18/08/03 If Yes Refer to Part CSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector 129th January 2004 09:00 am Mrs Clare Henderson Roe Mrs Jane ShawID Code074866Name of Inspector 2 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionNot present Not required Mr Barrie Taylor, Registered ManagerSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of St David`s Nursing Home For Disabled Ex-servicemen and Women. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. St Davids Nursing Home is situated in spacious grounds in a residential area of Ealing. The home is accessible by bus and the nearest underground and mainline station is Ealing Broadway. The home has a central courtyard that provides a pleasant area in which service users and their visitors can sit. The home provides nursing care for 40 ex-service personnel and has been registered to accommodate female as well as male service users since July 2003. The female service users are accommodated in a designated area of the home at the present time. The Registered Manager is Mr Barrie Taylor and the Registered Individual is Father Abbott Martin Shiperlee.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was a very positive inspection. The Registered Manager and his staff had worked hard to address the requirements from the last inspection report and it was clear that they had a good understanding of the standards that the home was required to achieve. Staff commented that the Registered Manager was approachable and clear in his aims for the home. There was a happy and content atmosphere in the home. Choice of Home (Standards 1-6) Both of the 2 standards assessed were met plus one did not apply to this service. The pre-admission assessment documentation had been updated and was comprehensive. Staff have the skills and experience to meet the needs of the service users. Training in dementia care for staff would be beneficial. Health and Personal Care (Standards 7-11) 2 of the 3 standards assessed were met. The Inspector viewed three service user plans. These were comprehensive and up to date and showed that a lot of hard work had been put into reviewing and updating the documentation to meet the standards. The medications were inspected by the NCSC pharmacy Inspector and requirements were set in line with her findings. Daily Life and Social Activities (Standards 12-15) The one standard assessed was met. The food provision is good in the home and action had been taken to provide chef cover for all meals. One shift was still to be covered but this was being addressed. The menu choice is varied and the chef is involved with the serving of the meals as well as the preparation. Complaints and Protection (Standards 16-18) The one standard assessed was met. The home follows the Ealing Multi-Agency Adult Protection policy and procedures documentation and staff were clear on the action they must take in the event of any protection of vulnerable adult issues. Environment (Standards 19-26) 5 of the 6 standards assessed were met. The home has a maintenance redecoration and refurbishment programme and there was evidence of ongoing work in these areas. The home was clean and tidy and the equipment and assisted toilet, bathing and shower facilities meet the service users needs. The home is spacious and well maintained. The Registered Manager was to check that the home fully complies with the Water Supply (Water Fittings) Regulations 1999.Staffing (Standards 27-30) 2 of the 4 standards assessed were met. St David`s Nursing Home For Disabled Ex-servicemen and Women Page 6 The staffing of the home met the needs of the service users. Additional staff are rostered when needed and service users looked well cared for. The major shortfall at this inspection was the lack of required information available on the the staff files viewed by the Inspector. This is a recurring shortfall and was discussed with the Registered Manager who agreed to address the findings as a priority. Management and Administration (Standards 31-38) 3 of the 5 standards assessed were met. The Registered Manager has an open attitude and staff spoken with said that he was approachable. Work is being done to ensure that staff receive all the training they require and a foundation programme is to be introduced. Some staff have undergone NVQ level 2 training in care and more staff are to commence this. Formal supervision for care staff was still to be commenced and had been done with the registered nurses and heads of department. Generally the maintenance and training records were up to date and some of the risk assessments were still to be completed.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 2 13(4) OP38 19 OP29 Schedule 2 Staff records must contain the information 01/11/03 required by the Care Homes Regulations 2001. Risk assessments must be carried out for premises, equipment and safe working practices and action taken to minimise any risks identified.01/11/03Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Service users to include 40 service users over the age of 40 yearsMet (Yes / No) YESSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action Records of medicines received on the MAR 1 13(2) OP9 require a signature of the person checking 09/03/04 and receiving. The date of opening needs to be written on all 2 13(2) OP9 liquid medications including eye drops and 09/03/04 insulin. 3 13(2) OP9 Two loose oxygen cylinders require securing either to the wall or in a trolley in the clinical room. 09/03/04413(2)OP9To record the minimum and maximum temperature of the fridge on the purchase of a 31/03/04 minimum/maximum thermometer To obtain a bulk prescription for lactulose or ensure that one service users lactulose is not used for another. To update medicines policies to reflect the new pharmacist supplier. There must be evidence that the home fully complies with the Water Supply (Water Fittings) Regulations 1999. Staff records must contain the information required by the Care Homes Regulations 2001. This is restated from previous inspections. 15/03/04 01/06/04 31/03/045 6 713(2) 13(2) 13(3)OP9 OP9 OP26819 OP29 Schedule 231/03/04St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 9 918OP30Induction and foundation training programmes must be based on a TOPSScertified training programme which meet the NTO workforce training targets. A foundation training programme must be formulated and implemented. All care staff must receive formal supervision a minimum of 6 times per year and this must be commenced. Risk assessments must be carried out for premises, equipment and safe working practices and action taken to minimise any risks identified. Up to date Health and Safety Law posters must be on display in the home.01/05/041018(2)OP3631/03/041113(4)OP3801/04/041218OP3831/03/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 2 OP4 OP9 Staff should undergo recognised training in the care of service users with dementia. To include new policies on managing service users with swallowing difficulties and the use of medicines in specialist procedures.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES NO NA YES YES YES NO NO YES YES YES NO YES YES NO NO NO YES NO YES 5 3 X NO YES YES NO 25 9 29/01/04 09.00 8.75St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 11 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 374 To (£) 600Any charges for extras If yes, please state what the extras are:YES CHIROPODY, NEWSPAPERS, PERSONAL REQUIREMENTS 0 Standard met?Key findings/Evidence This Standard was not assessed at this inspection.Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 13 Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The homes pre-admission assessment has been reviewed and is comprehensive and meets this Standard. Those viewed were very clear and there were also copies of Social Services needs led assessments. The lead nurse from Ealing Primary Care Trust does the assessment of service users for NHS nursing care funding and continuing care funding. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Staff have received training to include service users social interest needs. Three registered nurses have completed the NVQ assessors course and one is undergoing the NVQ verifiers course. There is ongoing NVQ in care training for care staff. The Inspector recommended that staff receive training in the care of service users with dementia, so that any service users who develop these care needs can be cared for as long as their placement in the home remains appropriate. Staff are available to communicate with service users for whom English is a second language, for example, those from Poland. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not provide intermediate care.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 14 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The Inspector viewed three service user plans. These were comprehensive and up to date. Care plans had been formulated to address each identified need. Risk assessments for the prevention of falls were available and these had been updated following any falls. A personal profile and `what you expect from the service sheet had been completed by the service users or their representative and gave a clear picture of the service user and their expectations of the home. Service users feedback sheets had also been completed in one of the service user plans viewed. The service user plans had been reviewed and updated monthly.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 15 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)17 13 Key findings/Evidence Standard met? The service user with pressure sores had been recently admitted and was in hospital at the time of admission. Care plans had been formulated for personal and oral hygiene. Assessments for pressure sore prevention had been carried out and were being reviewed monthly. Pressure relieving equipment was seen in use in the home. Continence and moving and handling assessments were available. Nutritional assessments had been carried out pre-admission, and the Inspector recommended that these documents be used following admission. The Registered Manager said that the service users psychological health is monitored and service users can be referred to the Community Psychiatric Nurse and on for psychiatric assessment if necessary. The Registered Manager said that he was advertising for a private physiotherapist and currently service users are referred by the GP and a physiotherapist from Clayponds Hospital comes to assess and advise. The GP carries out weekly visits and also attends when necessary. The service users have access to healthcare services to include chiropody, tissue viability, dietician, optical and hearing services. The Registered Manager said that service users are made aware on admission of their entitlements to NHS Services, nursing care payments and relevant allowances. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Policies and procedures were in place for good medicines management. Updates are required to reflect the new pharmacist supplier. Additional policies are required to cover the special procedures of Peg Feeding, insulin and diabetic management and for any service users who may experience swallowing difficulties. All medicines received into the home were recorded but a signature of the person receiving the medicines is required for audit purposes. Medicine administration records were completed for each s/user .The disposal book used with the previous pharmacist supplier is to continue for recording medicines no longer required. All medicines were stored securely and safely including Controlled drugs. Two oxygen cylinders require securing in the clinical room. One bottle of viscotears had expired and also modecate injection. The minimum and maximum temperature needs recording for the fridge rather than just the actual temperature. Policies were in place for self-administration but no service users were self-medicating at the time of the inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 16 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The chef serves up the meals and is present to speak with service users. The Inspector sampled the food which was tasty and well presented. The chef follows up nutritional assessments to ensure that service users receive appropriate diets as necessary. No service users required specialist diets for religious or cultural reasons and the Registered Manager said that he would ensure that the needs of any prospective service users in this area could be met. One service user enjoys Thai food and this is provided. The menu was viewed and offers a good choice of meals. Mealtimes were unhurried and staff are available to assist service users. A good choice was is available at all meals to include breakfast.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 18 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence This Standard was not assessed at this inspection. 0 X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 19 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The home had copies of the updated Ealing Multi-Agency Adult Protection documentation and the Registered Manager said that this is followed by the home. Staff spoken with said that they would report any concerns regarding adult protection issues. The homes own policies for whistle blowing and POVA needed updating and these have been faxed to the Inspector since the inspection. The Registered Manager takes prompt action to follow up any concerns. The home has up to date policies and procedures for management of service user aggression and for managing service users finances, and £1000 per service user insurance cover for losses.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 20 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home has a comprehensive programme of routine maintenance and renewal of the fabric and decoration of the premises and maintains a list when jobs are complete. The garden was tidy. A fire risk assessment had been carried out and automatic door closures are in place on all doors where service users wish to keep their door open. Environmental requirements from the last inspection report had been addressed. There was still a problem with damp patches on one wall in the dining area and this was being addressed. There was evidence of redecoration and carpeting in areas of the home and generally the home was well maintained. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Suitable locks had been fitted to all the toilet, bathing and shower facilities. This was the only shortfall in this standard at the last inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 21 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The home has a passenger lift and ramps where required. Grab rails were seen in corridors, toilets and bathing facilities. The home has five mobile hoists, two parker baths and three assisted showers. Most of the toilet facilities are spacious for wheelchair access. The corridors and doorways are wide throughout the home. The home does not have a loop system at present but the Manager Designate said that this would be provided if required. Toilet, bath and shower facilities are clearly identified. There is a call bell system throughout the home and the Inspector heard these being answered promptly at the time of inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 22 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This Standard was not assessed at this inspection. NO YES NO 32 2 4 0 Standard met? 0 32 0X X 4 0St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 23 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The furnishings are of good quality and met this standard. Service users can bring in their own furniture in line with fire regulations. The home has 39 electronic adjustable beds plus one divan at the request of a service user who is mobile. Suitable locks were being fitted to all the bedroom doors, with three more to be fitted at the time of inspection. The Registered Manager said that all service users had been offered a key to their doors and none had taken up this option. This was to be recorded in the service user plans. Lockable spaces are provided in the furniture in the new rooms and existing rooms are being refurbished as new admissions are made to the home. In the meantime the Registered Manager agreed to ask all service users if they required a lockable facility and fit where wanted. Screening is provided in double rooms. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The home was warm and well ventilated at the time of inspection. The views out of the bedroom windows are generally good. All radiators have either low temperature surfaces or are guarded. Rooms are centrally heated and all radiators have individual temperature controls. Emergency lighting is provided throughout the home and is checked and serviced regularly. Water storage and hot water outlet temperatures are recorded and were within range. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? The cleaning records were up to date for the laundry and kitchen areas. The laundry was clean and tidy at the time of inspection. Up to date infection control policies and procedures, safety data sheets for the products being used and good laundry practice information were available in the laundry. Information and washing programmes to ensure that foul laundry is washed at the correct temperature were available. The washing machines were fitted in 2000. The need to ensure that all relevant areas of the home to include the shower head attachments, meet the Water Supply (Water Fittings) Regulations 1999, was discussed with the Registered Manager who said that he would address this. Some of the soap dispensers were broken and bottles of liquid soap had been provided until these were repaired.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 24 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X9 25 93 Key findings/Evidence Standard met? There are 15 full time and 10 bank care staff. The home uses agency staff when required and do request for continuity of attendance from the same agency staff so that they are known to the service users. Additional staff are rostered for escorts for clinic appointments, outings, functions and also to meet service users needs. At the time of inspection an additional registered nurse was rostered on some nights to assist with the management of paperwork. Service users looked well cared for and staff addressed them in a courteous and friendly manner. The home was clean and tidy at the time of inspection and appropriate numbers of ancillary staff are employed. One service user expressed concerns regarding staff continuity and was advised to discuss this with the Registered Manager. St David`s Nursing Home For Disabled Ex-servicemen and Women Page 25 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 8 40 3 Key findings/Evidence Standard met? The Registered Manager is aware of the requirement for 50 of all care staff to have NVQ in care level 2 or equivalent by 2005. The Registered Manager said that some of the agency staff used also have an NVQ qualification. NVQ training is ongoing for care staff at the home. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? The Inspector viewed three sets of staff records. No copies of birth certificates were seen in two files. In two cases there were no copies of passports. No photographs were seen. The health check questionnaire was not seen in one file. No written references were seen in one file. No CRB check was seen in one file. This is an ongoing finding from previous inspections and the Inspector expressed her concern that this issue had not been addressed. Action must be taken to update all the staff files with the information as required under the Care Homes Regulations 2001. This was the only major shortfall identified at this inspection and must be addressed as a matter of priority. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? The Registered Manager said that he had not yet checked to ensure that the homes induction programme meets the TOPSS and National Training Organisation standards. All staff receive induction training and work for three days in a supernumerary capacity. The home is still to introduce a foundation programme and it is recognised that staff do go on to undertake NVQ training. The Registered Manager said that all staff receive a minimum of three paid days training per year. An action plan for 2004-06 for staff training had been drawn up.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 26 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The Registered Manager is a first level registered nurse with general and mental health qualifications and 10 years experience of senior management. He has a BA honours in Healthcare Management. He is responsible for one home only. He has undertaken a four day first aid course and stated that he would complete his mandatory training for the year 2003/04 by the end of March 2004. The Registered Manager and staff are familiar with the conditions and diseases associated with old age. The Registered Manager said that his job description enabled him to take responsibility for fulfilling his role. There are clear lines of accountability within the home. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Staff spoken with had a clear picture of the management structure of the home and knew who to discuss any concerns with. The Registered Manager communicates a clear sense of direction and leadership. The management structure now includes two senior nursing Sisters, in the roles of Deputy Matron and Assistant Matron. New job descriptions have been agreed and they are given autonomy within their job remits. The management planning and practice strives to provide creativity and development in line with the service users abilities and aspirations. The qualified staff abide by the Nursing and Midwifery Council Code of Professional Conduct. The Registered Manager said that he would access copies of the General Social Care Council Code of Practices for the care staff.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 27 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The annual development plan for quality assurance was in place up to 31/03/04 and the Registered Manager said that this was being revised for the next year. The Registered Manager said that a recognised quality assurance model was used to formulate the plan. Service user meetings are held every 1-2 months. A generic survey was being conducted and the results were to be collated and incorporated in the Service Users Guide. The home has a computer in the activities room and the Registered Manager said that he had plans to develop the computer links in the home in the future so that more service users had direct computer access. The views of family, friends and stakeholders were to be sought and a questionnaire developed for this. The homes policies and procedures had been reviewed in 2003 and were generally up to date. Some have been updated since the inspection. The Registered Manager and his staff had worked hard to meet the timescales for the requirements set in the last inspection report. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 5 0 00 Key findings/Evidence Standard met? The Inspector was not able to view the financial records at the time of inspection. The Registered Manager said that interest was being apportioned to service users with monies in the `patients account. This Standard will be viewed in detail at the next inspection.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 28 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? The Registered Manager said that he was currently carrying out appraisals with all staff. Formal supervision had been commenced with the registered nurses and heads of department. Formal supervision was still to be commenced with the care staff. The documentation for staff supervision and development was comprehensive. The home has one long term volunteer and it was agreed that basic mandatory training such as fire safety training would be carried out with them. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? All staff receive mandatory training and this includes fire safety, moving and handling, food hygiene and infection control. The deputy matron was responsible for ensuring all staff completed their annual updates by 31/03/04. There were 5 staff, who had undergone the four-day training in first aid and the Registered Manager said that he was to look into appointed persons training. The COSHH storage cupboards were locked and there were no issues noted. The fire log was up to date. Fire drills are carried out every 3 months for day staff. The need to carry out 3 monthly fire drills for night staff was discussed. The Inspector viewed at random some servicing and maintenance records and these were up to date. A copy of the Landlords Gas Certificate was to be obtained following servicing of the boilers in January 2004. The emergency lighting service was due. The maintaining of in house records was discussed to ensure that the forms are fully completed each time a check is undertaken and also completed in pen, not pencil. The Registered Manager said that he ensured compliance with all relevant legislation. The homes health and safety policy was last updated in August 2003. A full fire risk assessment was in place and this is updated every three months. The Registered Manager said that the COSHH risk assessments had been started and that he had applied for the safety data sheets for all products in use in the home. Risk assessments for safe working practices, equipment and the external of the building were still to be done. Action was being taken to address the findings from the security assessment that had taken place. A copy of the new Health and Safety Law poster was required by the home.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 29 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance Service users to include 40 service users over the age of 40 years CommentsYESLead Inspector Second Inspector Locality Manager DateSignature Signature SignaturePART DLAY ASSESSORS SUMMARY(where applicable) A lay assessor was not present at this inspection. Lay Assessor Date Public reports It should be noted that all NCSC inspection reports are public documents. SignatureSt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 30 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 29th January 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible An Action Plan has been received and is available at the West London Record Management Unit.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 31 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESN/AN/ANote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESN/AN/AOther: enter details here N/ASt David`s Nursing Home For Disabled Ex-servicemen and WomenPage 32 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Father Abbot Martin Shiperlee of St Davids Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Father Abbot Martin Shiperlee of St Davids Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Martin Shipperlee U.S.B Martin Shiperlee U.S.B (Signed) Chairman of Trustees 19/03/2004Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.St David`s Nursing Home For Disabled Ex-servicemen and WomenPage 33 - 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. 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