Inspection on 10/10/07 for Wellington Park Nursing Home

This inspection was carried out on 10th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wellington Park Nursing Home 12/06/06

Wellington Park Nursing Home 12/12/05

Wellington Park Nursing Home 19/05/05

Wellington Park Nursing Home 10/01/05

Wellington Park Nursing Home 19/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Wellington Park Nursing Home 76 Wellington Road Bush Hill Park Enfield Middlesex EN1 2PL Lead Inspector Duncan Paterson Unannounced Inspection 10:00 10 & 17 October 2007 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellington Park Nursing Home Address 76 Wellington Road Bush Hill Park Enfield Middlesex EN1 2PL 020 8360 5977 020 8364 0696 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) www.bupa.co.uk BUPA Care Homes (GL) Ltd Jane Ann Hepton Care Home 33 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (33) of places Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 30 service users may receive nursing care. As agreed on 20th July 2006, one named service user over the age of 65 years, with Dementia, can be accommodated. 12th June 2006 Date of last inspection Brief Description of the Service: Wellington Park Nursing Home is owned by BUPA Care Services providing nursing care. The home is registered to care for thirty three older people. The home is purpose built and is situated in a residential area, approximately one mile from Enfield Town. All bedrooms have en-suite facilities, telephone point and a remote controlled television. One room is currently shared by two people with the rest of the rooms being single occupancy. A number of the bedrooms are double rooms but the policy is for bedrooms to be provided as single unless two people, for example, a couple, wish to share. This means that currently there are 24 residents at the home rather than the registered number of thirty three. The registered manager stated that the current cost of a long stay place in the home is between £544 and £1000 per week depending on the service user’s assessed needs and the type of room occupied. Information about the service is made available to all prospective service users and a copy of the latest CSCI report is kept in reception at the home and the contents fed back to staff when it is received. The home’s stated aim is to provide high quality nursing care for the older people who live there using the company’s health and care knowledge, specialist skills and values to deliver as individual a service as possible to residents. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on 10 and 17 October 2007. The first day of the inspection concentrated on inspecting care plans and talking to people living at the home. The second day focused on staffing, maintenance and health and safety matters. The inspection involved speaking with the people using the service, the staff on duty and the manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was returned to CSCI by the manager. This was taken into consideration. The inspection also involved the case tracking of four people’s care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. Questionnaires were also received from people using the service, their relatives and staff. What the service does well: What has improved since the last inspection? The new QUEST care planning documentation has been introduced with each person using the service having a new care plan. These care plans are detailed and will, over time provide a useful means for planning and proving individual care. Similarly, new staff training and staff files have been introduced which will assist with recording, planning and monitoring staff training and development. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 6 Improvements have also been made to the environment with a room on the ground floor now available for storage of a hoist, the safe keeping of maintenance records and the charging of hoist batteries. 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. The summary of this inspection report can be made available in other formats on request. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 123&4 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are good arrangements in place to provide information, assess needs and to introduce people to the service. Some further equality and diversity development work is needed. EVIDENCE: I used the CSCI case tracking method throughout this inspection to assess the quality of the service. This involved selecting four people using the service and looking in detail at their care plans and other records held in the home. It also involved talking with people using the service about the care provided as well as talking with staff and the manager. This allowed me to reach an overall judgement about the quality of the service provided. There has been no change to the statement of purpose. I read through the current document and could see that it provided a useful guide to the service. I discussed the contract arrangements with the manager and was shown a sample copy of the BUPA terms and conditions of residence as well as copies of Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 9 contracts for two of the people living in the home. The arrangements are clear with relevant information set out simply and clearly. Through my case tracking work I was able to see the assessment information for four of the people using the service. One was funded by a local authority. BUPA has introduced new care planning documentation through the adoption of their QUEST system. This is a corporate care planning system. The assessment information I saw was detailed and provided the opportunity for a comprehensive build up of information about each individual. Staff at the home had clearly worked hard to transfer the information to the new QUEST forms and a good standard had been achieved. I met with six of the people living at the home as well as a visiting relative. I also made observations throughout the inspection. I could see that many of the people using the service have high level needs, often through advanced age, which require a great deal of expertise as well as patience and sensitivity from staff. My observations were that staff were meeting people’s needs well. This was endorsed through discussions with people using the service as well as feedback from relatives via questionnaires. One relative in a questionnaire said, “On the whole the standard of nursing care is excellent”. Some of the people using the service have dementia care needs partly because needs have changed since moving into the home and partly through a planned admission. I had some discussion with the manager, as part of the registration review of the service, about the future plans for the service. It may be necessary for consideration be given to including dementia in the category of registration. This will require a formal application to CSCI should it be decided that it is necessary. I had some discussion with the manager about equalities and diversity as well as some feedback via questionnaires. I was told that referrals were mainly for White British older people and I noted that the profile of the people using the service is mainly White British. The service is well equipped to provide care for such a group. For example, food provision is of a traditional British flavour and activity provision responds well to people’s interests such as music sessions and individual trips out. However, some of the feedback received was that there were sometimes difficulties in communication particularly where English may not be the first language for staff. In turn there was some feedback via staff questionnaires that communication amongst staff could be improved. These matters need to be addressed by the manager and an overall recommendation is given for there to be a review of equalities and diversity at the service. There are other equality and diversity matters which can be covered in the review. For example, consideration of how to make the service attractive to a wider range of people from different ethnic groups given that Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 10 there is a growing percentage of the local elderly population from black and ethnic minority groups. Intermediate care is not provided at this service. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The introduction of new care planning documentation has enhanced the ability of the service to plan and organise health and care provision. The service is good at individual work with people and in providing a caring and warm atmosphere. Attention needs to focus on ensuring that dental and medication records are accurate. EVIDENCE: I inspected the care plans for four people using the service as part of my case tracking. Discussions were held with three of the people as well as staff on duty and the manager. Observations were made during the inspection visit. Each person whose case file I looked at had the new QUEST paperwork. The QUEST documentation provides a comprehensive set of information about the person which is used as the basis for a detailed individual plan of care. I noted that additional assessments had been drawn up such as pressure area care and nutritional assessments. In addition, there were risk assessments. Overall, a good standard had been achieved. There is room for development Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 12 of the care plans as the QUEST forms are new and staff are getting used to them. The overall forms provide a vast amount of information and staff will be able to use them to set out detailed ways in which they are working with people using the service. Having said that I noted that not all areas of the QUEST forms had been completed. For example, the “End of Life” section for two of the individual files I looked at was blank. End of Life care was discussed with the manager who said that nursing staff had attended recent training in this area and that they were working towards the end of life ‘Gold Standard Framework’. This is a recognised procedure followed by many providers to assist their work with people using their services when they may be approaching death. The manager said that the plan was to develop the end of life services at the home and produce plans for the people using the service. I could see, from my inspection of the four individual files, that health care needs were covered. There was a great deal of health related information on the forms and regular review of assessments such as pressure areas and nutritional assessments. I saw that there was a section on the files entitled, “Care and Communication Sheet”, which was a daily record of what care had been provided for people that day. For example, whether a bath had been provided, oral care and help with washing. I noted on one file that there were some periods when the daily oral care had not been recorded. And I noted on another file that the last record of having seen a dentist was 2002. This was discussed with a nurse who advised that dentist appointments had been offered and refused but that the records had not been updated. To safeguard people’s health there is a need for more detailed dentist and daily mouth care recordings. A requirement about this is given. I discussed medication arrangements with the manager. I was advised that there were two arising matters. One, following a recent complaint there had been an internal audit of the medication in use at the home. This was part of the complaint investigation. The complaint is not yet concluded and BUPA are to provide CSCI with details of the outcome. Two, there were plans to change the supplying pharmacy as there had been some difficulties experienced with receipt of medication. The manager was confident that the change of pharmacy would result in improvements in medication arrangements. I inspected the medication storage arrangements and medication administration recordings with the help of one of the nurses. Overall, the arrangements were adequate. However, I found some problems including medication not having been signed as given for in two cases and staff signatures needing to be changed to avoid confusion. To improve medication arrangements for people using the service the manager must ensure that accurate recordings are made. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 13 One of the people’s files I looked at had the “Relatives expectations” section of the QUEST form blank. This was discussed with the manager. It connects with overall care arrangements for the individual which were complex and involved privacy and dignity. There were also issues relating to the overall service and the balance of ensuring safety whilst at the same time assisting people using the service to make choices and lead quality lives. This is a difficult matter and a recommendation about working with the individual is given and further information has been provided in a letter to the manager. The feedback I received from people using the service as well as from relatives was that people were treated with respect and dignity. Many of the people living at the home have high level needs, are frail and require a great deal of care from staff. I saw some excellent examples of good practice as well as individual staff members demonstrating a good understanding of elderly people. For example, included in the staff team is a staff member who provides a “Companion Carer” role. This involves working with individual residents, spending time with them, talking and listening and assisting with such make up and other personal one-to-one tasks. I spoke with the member of staff and could see that she was able to bring experience and skills to the work as well as great enthusiasm. The work was appreciated both by people using the service and other staff who often did not have time to spend long periods with individual residents. I also spoke with the Housekeeper who had a good understanding of elderly people and a determination to provide a good standard. As a result there were good standards in laundry provision, which people using the service told me they appreciated. There were also good standards in cleaning as well as a friendly approach being taken by the Housekeeper and her staff. The relative small size of the home also assisted as staff worked close together and knew all the people using the service well. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Thought, planning and consideration has been invested in the arrangements made for activity and meal provision and how to assist people using the service to choose how to spend each day. The range of activities provided is flexible and provides people with choice. Food provision is good and can be improved further with minor staff changes. . EVIDENCE: Walking through the home I saw a number of well presented notice boards with adverts and details about recent and forthcoming trips and activities. For example, trips to a pub for lunch, a garden centre, a clothes sale and a visit from a musician and singer. The activities organiser was arranging a trip to Arsenal football ground for one of the residents during the inspection and she told me about future activities including the Christmas party. The manager told me that members of religious orders came to the home on a regular basis. I spoke with people living at the home about activities. I could see that there was choice for people about what they did. For example, some people using the service preferred to stay in their bedrooms and they had established a daily routine. Others spent time in the lounge. I could see that staff were Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 15 putting effort into providing a range of activities for people and that there was choice. The trips arranged are usually only for a small number of people as there needs to be a number of staff to help. Not everyone wishes to take part as it can be quite an effort for some of the frailer people to go out of the home. In the questionnaires I received two respondents stated that they could not take part in activities. This could relate to the trips only being available for small numbers at any one time and the manager will need to include these comments when the activities are reviewed. I spoke with one relative who said that he visited the home everyday. People using the service told me that they had regular visitors or that they had good relations with either friends or relatives who looked after their affairs. I discussed the looking after of people’s money with the manager. She told me that they do not look after the money for people using the service. The practice is to invoice relatives or next of kin to cover small everyday purchases. Relatives or representatives look after money for the people using the service. I was able to confirm this through my case tracking which provided details of how money was looked after for people using the service. I sat with people in the dining room just before lunch was served. I observed the meal arrangements and I visited the kitchen to speak with the chef. Overall, the meal arrangements are good. Staff assisted people to eat, were relaxed and unhurried throughout the meal. The tables and meals were well presented and a pleasant atmosphere had been created for people in which to eat. However, I did think that more could have been done to create enjoyment for people when having meals as well as encouragement should people have reluctance to eat. People I spoke with, at their dining room table, did not know what the meal was. I asked staff and they did not know either and had to ask the chef. There was a well presented and attractive menu on display but unfortunately it displayed the food being provided for a different day. A recommendation is given about this so that the manager can make sure that meal provision is a more enjoyable experience for people using the service. Having said that I could see that thought and consideration had been taken in the food arrangements. The chef was able to describe how she worked with planning meals and asking people using the service what they wanted. The chef had a good knowledge of people using the service and their dietary needs and wishes. She was able to provide alternative meals for people when required. I also noted that there was a system for providing snacks for people at night. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints that people using the service or their representatives make are responded to seriously with investigations carried out. The overall complaints arrangements and Safeguarding Adults arrangements are supported by detailed policies and procedures, which, if followed, provide a suitable means of investigating and safeguarding people. EVIDENCE: The manager showed me the complaints records. Monthly returns are filed. There have been two complaints since January 2007. One related to the use of a call bell. This was investigated but not upheld. The second has been referred to earlier in the report. A detailed investigation has been undertaken. BUPA are to provide details to CSCI about the investigation and outcome. There is a corporate BUPA complaints policy and procedure. I was shown the BUPA Safeguarding Adults policy which I noted was last updated on 15 December 2006. The policy is adequate. It makes reference to reporting to local authorities under the government’s “No Secrets” guidance. Also available in the home were the Safeguarding Adults policies for local authorities. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 & 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Good standards are provided in terms of appearance and comfort at the home. Staff have been successful in providing a cared for environment which is clean, inviting and appreciated by the people living there. Despite some design drawbacks staff have worked round these and provide a pleasant attractive home. EVIDENCE: I toured the building with a member of the nursing staff. The tour included the laundry and kitchen as well as the layout of each floor. I later looked at selected parts of the home with the maintenance officer and visited a number of people using the service in their bedrooms. The home is attractive, welcoming and very well presented. There is a good standard of cleanliness and staff have been able to maintain a pleasant and homely building. There are some nice additional touches such as potted plants Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 18 at the front and a colourful and attractive landscaped garden to the rear. Notice boards are clean and tidy and there is an obvious pride taken in the appearance of the home. There are some drawbacks to the building. Although purpose built the design lacks some of the features usual in a modern care home. For example, the lift is relatively small, storage space is limited, the laundry is located on the first floor and deliveries have to go through the front of the building as there is no dedicated side or rear delivery access. Having said that, staff have responded well and managed their work to take account of such matters. For example, there has been a reorganisation of a ground floor room to allow storage of a hoist and an area to charge the hoist batteries. The laundry location allows domestic staff to be more accessible to people using the service than might be the case if their location was on the lower level of the home. There is a large lounge and dining room on the lower ground floor. This is a pleasant area which can be used for a variety of activities. Many of the people using the service spent the afternoon here. The bedrooms I visited were all nicely decorated and furnished to a good standard. People told me they were happy with them. I noted that there was a selection of manual hoists available and I was shown the maintenance certificates for them. There is also an adapted bath as well as a sluice room on each floor. The laundry is well equipped with two washing machines and two dryers. There are sluice facilities on the washing machines. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The numbers of staff scheduled on duty allow time and the mix of skills to meet the needs of people using the service. Staff numbers with NVQ qualifications are growing and new forms being introduced should assist with staff training and induction. Staff are recruited properly. EVIDENCE: In order to assess the staffing standards I spoke with some of the people using the service, staff on duty and the manager. I also took into consideration feedback from the returned questionnaires as well as findings from my inspection of the staff rota and the records of training and recruitment. The staff I met were friendly and helpful taking time out to talk with me and to assist with the inspection. I was shown the staffing rota. I noted that there were sufficient staff scheduled on the rota. There were two qualified nurses throughout the day along with six care staff in the morning and four in the afternoon. In addition, the companion carer worked an 18 hour week. There were also administrative, activities, domestic, catering and maintenance staff. At night there were three care staff and a nurse in charge. I inspected a sample of three staff recruitment files. I could see that the recruitment process followed was robust with all the required checks having been made. CRB checks were kept separately and I inspected all of these. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 20 The manager, through submission of the Annual Quality Assurance Assessment (AQAA) reported that 64 of the total staff (including bank staff) had NVQ qualifications. I did not inspect these records other than to see certificates on the three staff files I looked at. I noted that the staff files had three sections: recruitment, training and supervision / appraisal. I was shown a new document called a “Care Staff Learning Portfolio”, which had recently been introduced for staff to record their induction and training. There were also sections for supervision sessions. I could see that a range of training, including induction training, had been provided for staff and there were also adverts in the home about forthcoming training. Staff I spoke to confirmed that they had received training. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 & 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is experienced. She provides clear and consistent leadership for staff and has been able to make sure that the service is run in line with the aims of the organisation. People using the service and their relatives confirm that the service is providing what is expected. Health and safety and quality assurance arrangements are good but improvement is needed to the frequency of staff supervision. EVIDENCE: The manager has been working at the home for four years and provides consistent and clear leadership for the staff team. Many of the staff have worked at the home for many years, enjoy working at the home and together with newer staff provide a reliable and enthusiastic workforce. The aims of the service are upheld by the work of the staff team. I could see that there was a Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 22 harmonious spirit with staff getting on well with each other. Many positive and appreciative comments were received from both people using the service and relatives about the staff team. A typical comment concluded that the service was the, “next best thing to being at home”. I discussed quality assurance with the manager. I was told that that there were a number of initiatives being followed. One of these was the awards for staff often being triggered by nominations from the people using the service. Another was the use of regular surveys for people using the service and relatives. BUPA also complete an annual satisfaction survey. I concluded that these initiatives met the quality assurance standard. The arrangements for looking after people’s money was discussed earlier in the report. Basically, staff at the home do not look after people’s money. Therefore, my assessment in this area was limited as I took my evidence from the case tracking of four people’s individual files. I saw reference to money arrangements on the files I looked at and did not see any indication that money was not being looked after properly. In order to assess the staff supervision arrangements I looked at nine staff supervision records. I found that the written records varied in frequency. Two staff had records of regular supervision and another two staff had records of supervision approximately three times a year. However, a further three staff had only one record of supervision per year and two new staff had no records of supervision at all. There has been progress with improving the frequency of supervision for staff but the standard has still not been reached despite a previous requirement in this area. It is important that staff receive regular supervision to ensure that staff continue to provide positive outcomes for people using the service. For example, it could cover such matters as ensuring that staff are fully conversant with meal arrangements. The previous requirement is extended with a new timescale given. I spent some time with the maintenance officer who was able to show me records of the servicing of the home’s installations and equipment. He had rearranged the administrative system for the storage of these records and they were all to hand to show me. I could see that all the required checks were taken place regularly and that, for example, the home’s equipment was being regularly serviced. Again, a good standard had been reached in this area. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 2 x 3 Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 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 OP36 Regulation 18(2) Requirement Timescale for action 01/01/08 2 OP8 12(1)(a) 3 OP9 13(2) The registered persons must ensure that staff receive formal and recorded supervision at least once every two months. Previous timescale of 31/03/07 not met. The registered persons must 01/12/07 ensure that records of dental appointments and oral care provided are accurate and kept up-to-date. The registered persons must 01/12/07 ensure that records of medication administered are accurate with reasons given if medication is not administered. 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 OP4 Good Practice Recommendations The registered persons should ensure that there is a review of the overall equality and diversity arrangements. DS0000027825.V350449.R01.S.doc Version 5.2 Page 25 Wellington Park Nursing Home 2 OP10 3 OP15 The registered persons should ensure that the care arrangements for one of the people using the service is clearly set out in writing including any restrictions and details of agreements from relevant persons. The registered person should ensure that consideration is given to ways to meal provision a more enjoyable experience for people using the service. Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wellington Park Nursing Home DS0000027825.V350449.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!