Inspection on 30/07/05 for Wellesley Road

This inspection was carried out on 30th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wellesley Road 17/10/07

Wellesley Road 23/08/06

Wellesley Road 14/11/05

Wellesley Road 22/11/04

Wellesley Road 27/05/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

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

CARE HOMES FOR OLDER PEOPLE Wellesley Road 1 Wellesley Road London NW5 4PN Lead Inspector Pippa Treadwell-Smith Unannouced 30 July 2005 09.00 am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wellesley Road Address 1 Wellesley Road, London, NW5 4PN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7267 0856 020 7424 0999 London Borough of Camden Katherine Williams is the manager for the homw Care Home 48 Category(ies) of DE(E) Dementia - over 65, MD(E) Mental registration, with number Disorder -over 65, PD(E) Physical dis - over 65, of places OP Old age Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions Date of last inspection 22nd November 2004 Brief Description of the Service: Wellesley Road is a care home providing personal care for up to 48 older people. The home caters for both male and female service users who are aged 65 years and older. The certificate of registration reflects that the staff are caring for people within the categories of dementia, mental disorder, old age and physical disability.The home not only provides long-term residential care but also three separate units for emergency admissions, respite and interim care. The permanent service users are accommodated on the ground floor and the three other services are on the first floor. The units are self contained and staffed separately. They are organised so as not to impact on the lives of the long stay service users.The owned is operated by Camden Council and has been registered under The Care Standards Act 2000. It is situated with good access to public transport, shops and community facilities.The home was purpose built about thirty years ago therefore not all the rooms sizes and corridor widths meet with the national minimum space standards. All the bedrooms are single occupancy however forty of them are slightly below the national minimum space standard and eight of them measure over twelve square meters. The home is three storeys high although accommodation for service users is on the first two floors only. A shaft lift gives access to the second floor; the third floor is not registered. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one Saturday morning at the end of July 2005. It lasted about 4 hours. A tour of the premises was made and about 10 service users were spoken to. There was a general discussion with3 members of staff, each from a different unit. A variety of records were looked at including care plans, menus and drug administration records. Since the visit a number of comment cards have been received in respect of the home. This was the first inspection to take place within the new inspection schedule. Another visit had been made by a CSCI Pharmacist in response to serious drug administration errors. A letter sent to the manager following this visit can be obtained from the CSCI office. What the service does well: What has improved since the last inspection? It is recognized that much work has gone into improving medication handling in the home over the last few months. Medication policies and procedures have been updated and staff demonstrated an awareness of safety. There has been an improvement in the environment with evidence of new furniture and decoration. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 6 When people move into the home, there is a clear assessment process to identify their wishes and needs. Service users fell confident that Wellesley Road is a suitable home for them. EVIDENCE: The residents spoken to said that they enjoyed living in the home and thought that their needs were being met. One resident has commented, “I am very happy here and well cared for at Wellesley Road. Those staying in the shortterm units said that the care staff are been instrumental in helping them to settle in quickly. This was echoed by a comment from a General Practitioner (GP) who said, “ I have been very impressed by the speed with which new residents settle in”. A selection of care records were examined relating to service users from different units. All contained detailed assessments identifying the needs and wishes of the service users. Those in the short stay units confirmed that they had received information about the service and a visit from a representative of the home prior to the admission. There is dedicated accommodation for service users who require, respite, emergency or interim care. These units are Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 9 self-contained and staff separately therefore they do not impact on the permanent long stay service users. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 There is a clear and consistent care planning system in place that provides staff with the relevant information they need to meet the health, welfare and social care needs of service users. There has been a proactive approach towards improving the systems for the administration of medication so that service users are no longer placed at risk. EVIDENCE: The records for four service users were looked and indicated that for each one there was a current care plan. The plans set out the needs of each person, how they were being met by the home and with evidence that reviews are taking place. The care plan shows regular activities and appointments. Leisure and topics of special interests are also included. Some of the service users were aware of their care plans. A GP visits the home twice a week. A comment received was “I have been very impressed by the positive atmosphere in the home, the obvious team spirit. In addition the staff have been open to news ways of working and embraced changes positively recognising the benefits. Very Impressive.” The GP has found that staff demonstrate a clear understanding of the care needs of the service users and communicate clearly with the surgery in order to work in Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 11 partnership. Care record show referrals to other health care professionals, including the Community Nursing Services. There are policies and procedures relating to the prevention of cross infection, which underpin practice in the home including MRSA. Medications issues have arisen in the past from the emergency admissions’ unit, where service users come into the home with very little notice. The manager had taken the appropriate action and notified the relevant people. In response to these errors a CSCI Pharmacist undertook an inspection. Prior to this inspection, the manager and staff in the home were already being proactive in improving the safety when ordering, storing and administering medication. Discussion with designated staff who were dispensing medication highlighted that they were aware of the changes in policy and procedure. The home is complying with the requirements made by the Pharmacist. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 The staff at Wellesley Road are good at making service users feel at home, comfortable and that they are well looked after. Service users are offered nice food in pleasant surroundings with their individual preferences catered for. EVIDENCE: “Whenever I visit, I have always witnessed kindness and consideration”. This was a comment recorded in a thank you care from a relative. Staff are adept at treating people as individuals examples of this were seen during the inspection as service users were enabled to follow their preferred lifestyle. The home has a programme of activities. Feedback from the last “Resident’s Meeting” showed that the service users liked the activities that were on offer, however they were asked for suggestions. A number of ideas have been put forward and some have already been acted upon. The notice board displays details of regular trips to places of interest. Food was a topic discussed at the last “Residents’ Meeting”. The home offers a four-week menu and choice is extended. Specialist diets are catered for in respect of medical, religious and cultural needs. Although there was a lot of positive feedback from the service users who attended the meeting, they were clear about the changes they wanted to see on the menu. Some of these have already been implemented. An audit of the catering provision has been carried Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 13 out and two of the service users have been approached to be part of future menu planning. Work will be done to make the menu reflect the seasons. A service user has commented that the meals are too close together however staff said that meals can be served according to individual requirements as long as basic food hygiene guidelines are followed. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has an effective complaint’s system. Service users feel that their views are listened to and acted upon. EVIDENCE: Each service user is given a copy of the complaint’s procedure in the service user guide. A guide can be found in each bedroom. There is a copy of the complaint’s procedure on display on the notice board in the main foyer for the benefit of relatives and other visitors. Complaints were discussed at the “Resident’s Meeting”. Service users were informed that raising concerns is a positive way to help staff deliver a better service. Service users felt that they could approach staff or the manager of they were unhappy with any aspect of their care. One service user said, “I feel confident that things would get dealt with in the home”. A service user did raise a concern during the inspection and the staff dealt with it patiently and sensitively. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 The standard of the environment is reasonable and improvements are being made to ensure that service users have a more attractive place and homely place to live. EVIDENCE: The building is in keeping with the local area and it is accessible by public transport. There is level access into the building via a secure entry. Staff commented that the front door cannot be seen from the main office therefore consideration is being given to altering the layout. A tour of the building identified that there is maintenance is carried out however the ceiling in the first floor dining room requires attention and a large crack was noted in one of the stairwells. The carpet in the main foyer has been earmarked for replacement. New furniture has been ordered and some areas are due for redecoration. Service users have been approached about the colour scheme. There is accessible outdoor space for service users to use in good weather. Throughout the inspection the home was found to be clean and hygienic. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 16 Comments from service users and visitors indicated that they considered a very good standard was being achieved in this area. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not inspected. EVIDENCE: Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The home has systems in place to ensure that service users are kept safe and secure whilst living at Wellesley Road EVIDENCE: A wide range of records were looked at, including fire safety and accident reports. These records were detailed, up-to-date and accurate and confirmed that the home is being run responsibly with essential checks being made and acted upon. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 20 No 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 9 Regulation 13(2) Requirement The registered person must forward an action plan to CSCI Camden in response to the three deficiencies recorded on the pharmacy report. The damaged ceiling in the first floor large dining room must be repaired. The crack wall in the stair well must also be repaired Timescale for action 30.09.05 2. 19 23(2)(b) 31.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommened that the home implement the good practice guidaance included in the pharmacy report dated 15th July 2005. Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Centro 4 20-23 Mandela Street London NW1 0DU 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 Wellesley Road G58 s37326 Wellesley Road v210269 300705 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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