Inspection on 17/02/06 for Walm Lane Nursing Home

This inspection was carried out on 17th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walm Lane Nursing Home 17/06/08

Walm Lane Nursing Home 19/06/07

Walm Lane Nursing Home 28/06/06

Walm Lane Nursing Home 29/09/05

Walm Lane Nursing Home 09/03/05

Walm Lane Nursing Home 06/01/05

Similar services:

Ashlong House

Norbury Crescent (30)

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

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

CARE HOME ADULTS 18-65 Walm Lane Nursing Home 141 Walm Lane London NW2 3AU Lead Inspector Sue Mitchell Unannounced Inspection 17th February 2006 09:00 Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Walm Lane Nursing Home Address 141 Walm Lane London NW2 3AU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8450 8832 Ibexbrook Limited Amanoollah K Juhoor Care Home 21 Category(ies) of Past or present alcohol dependence (0), Past or registration, with number present alcohol dependence over 65 years of of places age (0), Past or present drug dependence (0), Past or present drug dependence over 65 years of age (0), Dementia (0), Dementia - over 65 years of age (0), Learning disability (0), Learning disability over 65 years of age (0), Old age, not falling within any other category (0), Physical disability (0), Physical disability over 65 years of age (0), Sensory impairment (0), Sensory Impairment over 65 years of age (0), Terminally ill (0), Terminally ill over 65 years of age (0) Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 21 persons over the age of 18 in need of nursing care. Date of last inspection 29th September 2005 Brief Description of the Service: 141 Walm Lane is a care home, which provides personal care and nursing for up to 21 adults aged from 18 years. The primary care needs of the older adults are nursing and personal care and those of the younger adults are dementia, mental health and alcohol dependency. At the time of this inspection there were only three older people living in the home The home is a large detached building on three floors. At the time of this inspection, the home was in the process of completing major development and renovation work to provide a new laundry area, new smoking room with kitchenette facility and an office. There is also a plan to convert the sluice/bathroom on the ground floor into a shower room. The home currently has 3 bathrooms to service the 21 residents and on the third floor there are 4 bedrooms, no bath and 1 small toilet. There is also a large garden at the back of the house and parking space in the front. The home is located close to Cricklewood Broadway and Willesden districts with good access to a variety of shops and public transport services Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out jointly by a Regulation Manager and a Regulatory Inspector. The inspection started at 8.55 am and finished at 4.15 pm. The Registered Manager and Proprietor were present throughout the inspection. There was one Registered Nurse and four care assistants on duty. A part-time activities person, a cook and a domestic were also on duty. The home was full with one person away with their family and the remainder either in the home or going out into the community either on their own or with staff. A week prior to the inspection a pre-inspection questionnaire was sent to the Proprietor for completion, comment cards were also sent to the service users and visiting professionals. Four completed service users comment cards were returned and two completed visiting professionals comments cards were returned. A tour of the premises was undertaken and a sample of bedrooms viewed. The focus of this inspection was to review the requirements from the last inspection and to follow through other key standards. A sample of service user plans, maintenance records, staff records and health and safety records were viewed. Also at the time of inspection building work was in progress to the new recreation/smoking area. It is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. What the service does well: What has improved since the last inspection? Some requirements from the previous two inspections have been partially addressed. Further work must be undertaken to ensure that requirements are addressed fully. Daily records for service users have improved and these now detail clearly all aspects of service users daily living. This progress must be maintained. Staff have received training in the Protection of Vulnerable Adults. The appointment of a Deputy Manager and the proposed recruitment for an administrator are positive steps for the home. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 6 What they could do better: This inspection found a number of shortfalls within the assessment and care planning standards in relation to improving their collation of information on service users to meet their needs. The manager must ensure that attention is paid to improving risk assessments and care plans particularly in relation to those who have nursing care or medical needs. There were some minor repairs required to a bathroom. It is strongly recommended that the elderly bed bound resident, who is isolated in their room due to their condition, is moved to a more central location near to the staff and the home’s activities to stimulate and protect them. The Manager and Proprietor must ensure that premises risk assessments are carried out regularly and reviewed particularly in relation to service users who use small kitchen appliances as part of their daily living skills. The Proprietor must ensure that fire risk assessments are carried out annually and that fire records are kept up to date. There must be a more formalised health and safety audit of the home with records of checks carried out particularly of hot water temperatures. The proprietor was given a copy of the latest CRB guidance to assist him in improving records of checks carried out. The home must ensure that all recruitment and verification of qualifications is carried out and recorded as per Schedules 2 and 4 of the Care Homes Regulations 2001. A supervision policy is required to be written and the Adult Protection policy must be amended. The Manager must ensure that the requirements and recommendations from the CSCI Pharmacy report (18/10/05) are carried out. The Manager was informed that the CCSI Pharmacy inspector would be making a follow up visit to assess progress to the requirements. There were a number of good practice recommendation made in relation to improving practice and care in the home. These included devising a checklist of pre assessment documentation required about residents, a hospital discharge checklist for reassessment of needs, a staff record checklist and a record of residents dietary needs and preferences. It was recommended that old care file information be archived and that individual care plan folders be made up which contains day-to-day working documents for staff to use. As the manager’s new office is also a fire exit and cannot be locked the proprietor was advised to purchase lockable filing cabinets for storage of confidential information. The manager is advised to contact the LFEPA to ensure the safety of the residents in that area in the event of fire. It was noted by a visiting professional that the home’s décor was not homely and a recommendation has been made for the Proprietor to discuss the colour schemes of individual rooms and communal areas with the service users to improve the presentation of the home. It was recommended that the Proprietor investigate suitable training for the activities coordinator to ensure that appropriate activities are provided within the home for the service users. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 7 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. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users needs must be fully assessed and documented prior to admission to ensure the home can meet their needs EVIDENCE: The home has developed its own assessment documentation, which is used to assess the service user either in their own home or in hospital. For one service user who had been referred by Camden Social Services no Needs Led Assessment had been obtained. It is essential where service users are referred through care management that a full needs led assessment is obtained. The Regulation Manager found that there were inconsistencies in the documentation and the level of detail provided. In some of the more recent admissions records there was good detail and in those of some of the longer term residents there was minimal information. It was recommended that the home develop a checklist of essential documentation that is required. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 Service users individual needs were not always reflected in the plan of care, and this can place service user at risk of not having their needs fully met. EVIDENCE: One Inspector viewed a sample of care plans, two were for service users that had to be nursed in bed and one was for a service user that had recently moved into the home. For one service user who had a Percutaneous Endoscopic Gastrostomy (PEG) tube in place there was no reference to the management of the stoma site. The records indicated that the service user vomited on occasions, however this was not recorded in the care plan. Monthly weights could not be undertaken on this service user, this needed to be recorded in the care plan. Weight charts viewed evidenced some gaps where service users had not been weighed due to absence or hospitalisation. Where this is the case this must be recorded. For a service user that had epilepsy, the care plan did not record this, or how often seizures were taking place, what effect they had on the service user and the medication that was in use. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 11 A PEG feed chart was in place which detailed fluid input and output. Staff generally signed the chart when a feed was started. On some occasions there was no signature. There was a client care plan agreement form, which had been completed on the 5/1/04, the service user had not signed this, nor had any next of kin. Where the service user is not able to sign this must be recorded. Where next of kin are not available to sign, this also must be recorded. Daily logs viewed by one Inspector were completed on each shift and were detailed, signed and dated. Risk assessments in relation to individual service users smoking and alcohol dependency were available. The need to have a clear and consistent assessment and care planning system in place was discussed with both the Registered Manager and the Registered Provider. As the home is registered as a care home, which provides nursing, the records must be maintained in keeping with the NMC Records and Record Keeping Guidance It was also recommended at the time of the inspection that the Registered Manager compile working care plan folders for each service user which should include the care plan, risk assessments, monthly summaries, recent review, daily log, pre-admission assessments, details of any management guidelines regarding service users treatment, behaviour etc. It was also recommended that the Registered Manager archive any old information in order that the files are easier to use. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,17 Social activities are in place but these should be further developed with the service users to ensure that they are in accordance with their wishes and assessed needs. The meals in this home offer choice and variety this should be further developed to include a record of special dietary needs and personal preferences. EVIDENCE: At the time of inspection the part-time activities person was on duty. It was not clear what activities are on offer and how service users are informed of them. The activities organiser was observed undertaking some board games and taking one service user out for a haircut. It was suggested that the Registered Manager investigate suitable training for the activities person in order that activities are provided that would meet the needs of the main service user group. With the new building work there will be a recreation/smoking room for service users to use. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 13 There is a full time cook who prepares the main meal during the week and the home also employs a weekend cook. A four-week rotating menu was in place, which also recorded alternative meals, provided where service users had not eaten the main meal. The menu for the day was displayed on the notice board in the dining area. For one Asian service user the staff had prepared a detailed list of their preferences. This is good practice. It was recommended that this area is further developed to include detailed lists of service users with specialist dietary requirements, i.e. diabetes, vegetarian, culturally appropriate diets. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Shortfalls in the development and implementation of assessment tools do not ensure that the service users physical and emotional needs are fully met. EVIDENCE: Assessments in relation to nutrition, moving and handling, risk of falling and continence assessments were not available for the three service users files viewed. The manager must ensure that these are carried out and recorded. Details of one service user’s moving and handling needs were recorded in the care plan but this did not specify the equipment that was to be used. For another service user that was nursed in bed there was no moving and handling assessment in place. Bed rails were in use for two service users however their was no clear risk assessment as to why these where required. A pressure sore risk assessment for one service user had been completed and was reviewed in January 2006; prior to this the last review had taken place on 31/10/05. There was no evidence that the pressure sore risk assessment had been updated for a service user who had been in hospital and had returned to the home. The Inspector recommended that when a service user is discharged Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 15 from hospital and is returning to the home, it is essential that a full reassessment is undertaken, including tissue viability, moving and handling, risk of falls, nutrition, body mapping and continence. It was also suggested that where a service user is admitted to the home with a pressure sore that the home notifies the Commission through the Regulation 37 notification. For a service user that had been admitted to the home recently the staff were in the process of developing care plans. The care plan viewed on diabetes required more information in relation to hypo and hyperglycaemia, foot care and whether input from the dietician is required. The moving and handling assessment for this service user had not been completed even though the pre admission assessment indicated that this service user had ataxia. Written mental state assessments were not available for service users that had a cognitive impairment due to long-term alcohol abuse. Records indicated that for one service user that oedema had been noted, there was no care plan to evidence this. Pressure relieving equipment was seen in use in the home. This needed to be clearly recorded in each service users care plan. Any visits undertaken by a visiting professional are recorded in the service users notes. Evidence of this was seen on the files viewed this included visits by the community dietician, Social Worker from the Primary Care Trust and the Chiropodist. The Pharmacy Inspector had visited the home on 18th October 2005 and had made a number of requirements and recommendations to improve their medication practices. This inspection did not include a review of whether these had been achieved. The pharmacy inspector has been asked by the inspectors to visit the home to assess whether the requirements set by her have been met. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a clear complaints procedure in place to address any concerns raised by service users and their visitors. The home’s adult protection policies need to be amended and detail Brent POVA’s role. EVIDENCE: The home has a complaints procedure and this is also available in the Service Users Guide. Since the last inspection the home had received one complaint from a service user. The records viewed indicated that this had been appropriately investigated. The Registered Manager informed the Inspectors that the staff had received training in the Protection of Vulnerable Adults (POVA) the day before the inspection. The homes Protection of Vulnerable Adults policy must be amended to include the details of the Brent POVA team and details of other placing authorities. The policy indicated that the CSCI would lead any POVA investigation, this must be removed from the policy and refer to the local authority procedures. It was recommended that the Registered Manager contact the Brent POVA team to access the referral form and to include this in the homes policy. The home must also have copies of the Brent POVA procedures in the policy manual. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 29 The standard of the environment within some areas of this home is institutional and does not provide service users with an attractive and homely place to live. EVIDENCE: At the time of inspection there was an ongoing programme of building work to a smoking/ recreation room and office in progress. A kitchenette was being provided for the service users to make hot drinks and snacks. The Proprietor was advised that a risk assessment on this area must be in place and needed to include details around kettles, hot water etc. The Proprietor stated that he had contacted Environmental health to assess the kitchen following completion of the refurbishment; he had not had a response as yet. He had been advised by the Fire Officer to contact Building Control in Brent to view the new extension. A tour of the premises was undertaken and a sample of bedrooms and all bathrooms were viewed. One bedroom contained a hospital type bedside locker; the proprietor needs to replace this with a more homely cabinet. One resident, who was bedridden, was situated on the top floor of the home away from staff. This person has sensory impairment and is quite elderly. The inspectors discussed their concerns about this person’s isolation and advised Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 18 the Registered Manager to move this person to the ground floor to be near staff and the general activity within the home. The Registered Manager and proprietor agreed to do this. The home was noted to be decorated in a uniform colour scheme in both in the resident’s bedrooms and communal areas. The new extension was also decorated in the same colour. This was discussed in some detail with the proprietor. He was advised to ask the residents if they wished to have a change of décor in their rooms, particularly those who were long standing residents. He was advised to review the colour scheme of the communal areas and ask residents to choose the colour scheme. A response from a visiting professional comment card stated that” the environment is not welcoming in terms of decoration and lay out” Some of the corridors were noted to have paint chipped and dirty marks on the walls. The bathroom door on the mezzanine floor was not closing fully, this must be repaired In the kitchen the door handle to the fridge/freezer was broken and a potential hazard as the broken parts were still attached. This must be addressed. For details regarding specialist equipment please see details under the section Conduct and Management of the Home. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 The home was adequately staffed to meet the needs of the service users. The vetting and recruitment practices were not robust and did not safeguard the service users. EVIDENCE: There had been no changes to the staffing levels since the last inspection. During the morning shift there are two Registered Nurses and four care assistants on duty two ancillary staff. An Activities person is also employed for the morning shift. In the afternoon there is one Registered Nurse and four care assistants on duty, at night there is one Registered Nurse and one Care Assistant on duty. The management are aware of the need to keep staffing levels under review on an ongoing basis to ensure that the changing needs of service users are met. The Registered Manager informed the Inspectors that a Deputy Manager had been recruited and was to commence employment in the home from the 1st April 2006. There are plans to recruit an administrative officer to provide support to the home. This is a positive step, which will provide additional support for the Registered Manager and staff working on the floor. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 20 Two staff employment files were viewed. These did not contain the required information as per Schedule 2 of the Care Homes Regulations 2001. For example start dates were not recorded, there was no verification of Personal Identification Numbers for a Registered Nurse and a telephone reference had been obtained for a member of staff. Current guidance on Criminal Records Bureau checks was given to the Proprietor, this included information on portability and POVA First. It was recommended at the time of inspection that a checklist be formulated and a staffing matrix developed detailing whether all required information had been obtained prior to appointment. There were staff supervision records in their personal files. The home had been required to develop a supervision policy at the March 2005 inspection. this had not been achieved by the time of this inspection. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 & 42 Record keeping practices did not safeguard the service users rights and best interests. The Health and Safety systems in place in the home need to be reviewed to ensure that the safety of the service users, staff and visitors to the home is maintained at all times. EVIDENCE: Once the building work is complete there will be a new office, which will store all records. This room also has a fire exit located within it. The inspectors were concerned about access to confidential information and advised the Proprietor to purchase locked cabinets to secure these records. All certificates and records in relation to the equipment and appliances used in the home were made available for inspection and viewed by the Regulation Manager. Records in relation to the hoists were viewed. The recommendation made on the 5/9/05 in relation to the Oxford hoist was that the hoist should be replaced as the padding needed replacement, castors were not acceptable and Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 22 paint was peeling from the base. The mobile Trixie hoist did not have a record of service. At the time of inspection the proprietor contacted the engineer to arrange a Loler inspection. The inspectors were informed following the inspection that the proprietor had ordered a new hoist. The home has a number of hospital style beds; there was a record of services to this equipment in place. The records in relation to fire safety were out of date. The last fire alarm call bell check was undertaken on the 23/1/06. The fire drill was recorded as being undertaken on the 15/8/05. The Proprietor informed the Regulation Manager that a drill had been undertaken in January 2006 but no record was available. CHUBB fire servicing company had provided a comprehensive fire record folder, the proprietor was advised to use this record and archive all other out of date fire records for ease of record management. The fire risk assessment was dated 31/5/04; no review of this had taken place since then. Fire extinguishers and the fire alarm panel had been serviced The LFEPA visited the premises on the 25/9/05 at the request of the Proprietor; a number of recommendations were made following this visit and had been addressed by the Proprietor. The manager is also advised to contact the LFEPA to ensure the safety of the residents in the new recreation room in terms of the location of the fire exits. PAT testing had been undertaken and these records were up to date. Hot water temperatures were last recorded as being undertaken on 22/1/06. No further tests had been undertaken. In room 22 the sash cord to the sash window was broken and there was no window restrictor. The proprietor informed the Inspector that he would ensure that this would be repaired immediately as the builders were on site. Risk assessments for all safe working practices on the premises had not been formulated. The need to have these in place was discussed with the Registered Manager and Proprietor. Risk assessments in relation to individual service users are detailed under the section “Individual needs and Choices” of this report. Risk assessments need to be formulated in relation to equipment used by service users in their own bedrooms i.e. kettles, fridges etc. There was no evidence that regular health and safety audits were taking place, it was recommended that the Proprietor develop a health and safety audit checklist, which is completed periodically, any shortfalls identified and a record kept of action taken to address shortfalls. Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 1 X X X X X X 1 1 X Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 24 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 YA2 Regulation 14 Requirement Where a service user has been referred via care management a copy of the Needs Led Assessment must be obtained. The service users care plans must be personalised to the individual, be accurate and up to date, and information contained therein must be consistent. The care plan must fully detail the assessed needs and the action required to meet that need. The Manager / key worker must ensure that the client care plan agreement forms are signed either by the service user or next of kin. Where either of these persons is unable to sign, this must be recorded. Prior to their use, risk assessments for the use of bedrails must be carried out and the appropriateness of their use clearly identified. This must be discussed and agreed with the service user, their representative or DS0000022945.V282719.R01.S.doc Timescale for action 30/04/06 2 YA6 15(1), (2) 17(1)(a) 30/04/06 3 YA6 17 30/04/06 4 YA9 13 (4)(c) 13(7) 30/04/06 Walm Lane Nursing Home Version 5.1 Page 25 relevant professional. 5 6 YA9 YA19 13(4)c 15(1), (2), 12(1)a,b Risk assessments on the prevention of falls must be in place for each service user. All assessment tools i.e. Pressure Sore, moving and handling, mental state assessments for those with cognitive impairment and nutritional needs must be in place, reviewed and used as a basis for care planning. Where service users are unable to be weighed or are absent from the home a record of this must be kept. The care plan for a service user that had epilepsy must record this, and must detail how often seizures were taking place, what effect they had on the service user and the medication that was in use. As the home is registered as a care home, which provides nursing, the records must be maintained in keeping with the NMC Records and Record Keeping Guidance. The type of pressure relieving and/or moving and handling equipment provided for individual service users must be recorded on their care plan. The Registered Provider/ Registered Manager must ensure that the requirements and recommendations arising from the CSCI pharmacist inspection on 18/10/05 are carried out in full (Not assessed on this occasion) Continence assessments must DS0000022945.V282719.R01.S.doc 31/03/06 30/04/06 7 YA9 17 31/03/06 8 YA19 14,15 31/03/06 9 YA19 17 31/03/06 10 YA19 13(4)(c)14 31/03/06 11 YA20 13(2) 30/04/06 12 YA19 12(1)a,b, 30/04/06 Page 26 Walm Lane Nursing Home Version 5.1 13(1)b 13 YA23 13(6) be undertaken on service users where continence needs have been identified, these must be recorded, updated regularly or whenever there is a change. Where required the professional advice about the promotion of continence is sought. The homes Protection of 30/04/06 Vulnerable Adults policy must be amended to include the details of the Brent POVA team and details of other placing authorities. The policy indicated that the CSCI would lead any POVA investigation, this must be removed from the policy and refer to the local authority procedures. The home must also have copies of the Brent POVA procedures in the policy manual. The door handle to the fridge/freezer must be replaced The corridors throughout the home must be redecorated to cover marks and chips in the paint work The bathroom door on the mezzanine floor must be repaired to ensure it closes fully. 31/03/06 31/05/06 14 15 YA24 YA24 23(2)(c) 23(2)(d) 16 YA27 23(2)(b) 31/03/06 17 YA28 18 YA34 13(4)(a)(b)(c) The Proprietor/ Manager must 30/04/06 carry out a risk assessment on the new recreation area which needs to include details around kettles, hot water etc. Sch 2, Sch 4 The registered Proprietor and 30/04/06 19 Manager must ensure that they obtain all the required recruitment information as per Schedule 2 of the Care Homes Regulations 2001 and the DS0000022945.V282719.R01.S.doc Version 5.1 Page 27 Walm Lane Nursing Home 19 YA36 18 20 YA42 23(4) most recent CRB guidance prior to staff being appointed. As Walm Lane is a nursing home the Manager must ensure that he obtains verification of Personal Identification Numbers for Registered Nurses. A supervision policy must be in place (Refer to Standard 36 for details of suggested content) The Manager must ensure that records of all tests of the fire alarm call bells, emergency lighting and Dorgards are kept up to date The manager must ensure that fire drills are recorded whether planned or unplanned The fire risk assessment must be reviewed on a yearly basis. 31/05/06 31/03/06 21 22 YA42 YA42 13(4) 13(4) Hot water temperatures records must be recorded regularly Risk assessments for all safe working practices on the premises must be formulated. Risk assessments must be formulated in relation to equipment used by service users in their own bedrooms i.e. kettles, fridges etc. 31/03/06 30/04/06 23 YA42 13(4) 23(1)(2)(b) The Proprietor/Manager must 30/04/06 ensure that regular health and safety audits take place, it was recommended that the Proprietor develop a health and safety audit checklist, which is completed periodically, any shortfalls identified and a record kept of action taken to address DS0000022945.V282719.R01.S.doc Version 5.1 Page 28 Walm Lane Nursing Home shortfalls. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA6 Good Practice Recommendations It is recommended that the home develop a checklist of essential pre admission documentation that is required. It is recommended that the Registered Manager compiles working care plan folders for each service user, which should include the care plan, risk assessments, monthly summaries, recent review, daily log, pre-admission assessments, details of any management guidelines regarding service users treatment, behaviour etc. It is also recommended that the Registered Manager archive any old information in order that the files are easier to use. It was suggested that the Registered Manager investigate suitable training for the activities person in order that activities are provided that would meet the needs of the main service user group. It is recommended that staff make a list of service users with specialist dietary requirements, i.e. diabetes, vegetarian, culturally appropriate diets. It is recommended that when a service user is discharged from hospital and is returning to the home, that a full reassessment is undertaken, including tissue viability, moving and handling, risk of falls, nutrition, body mapping and continence. It was also suggested that where a service user is admitted to the home with a pressure sore that the home notifies the Commission through the Regulation 37 notification. It is recommended that the Registered Manager contact the Brent POVA team to access the POVA referral form and to include this in the homes policy. One bedroom contained a hospital type bedside locker; the proprietor should replace this with a more homely cabinet. DS0000022945.V282719.R01.S.doc Version 5.1 Page 29 3 YA12 4 5 YA17 YA19 6 7 YA23 YA24 Walm Lane Nursing Home 8 YA24 9 YA24 10 11 12 YA34 YA41 YA42 It is strongly recommended that the elderly bed bound resident who is isolated in their room due to their condition is moved to a more central location near to the staff and the home’s activities to stimulate and protect them The Proprietor is advised to ask the residents if they wished to have a change of décor in their rooms, particularly those who were long standing residents. He was advised to review the colour scheme of the communal areas and ask residents to choose the colour scheme. It is recommended that a checklist be formulated and a staffing matrix developed detailing whether all required information had been obtained prior to appointment The inspectors advised the Proprietor to purchase locked cabinets to secure confidential records to be held in the new office area The manager is advised to contact the LFEPA to ensure the safety of the residents in the new recreation room in terms of the location of the fire exits. The proprietor and manager are advised to use the fire record provided by CHUBB and archive all other out of date fire records for ease of record management. 12 YA42 Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Walm Lane Nursing Home DS0000022945.V282719.R01.S.doc Version 5.1 Page 31 - 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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