Inspection on 28/01/08 for Westmead Elderly Resource Centre

This inspection was carried out on 28th January 2008.

CSCI found this care home to be providing an Poor service.

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

Westmead Elderly Resource Centre 27/05/08

Westmead Elderly Resource Centre 11/06/07

Westmead Elderly Resource Centre 06/02/07

Westmead Elderly Resource Centre 30/06/06

Westmead Elderly Resource Centre 23/08/05

Westmead Elderly Resource Centre 22/03/05

Westmead Elderly Resource Centre 19/07/04

Westmead Elderly Resource Centre 02/03/04

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Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

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Tudor Lodge

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

CARE HOMES FOR OLDER PEOPLE Westmead Elderly Resource Centre 4 Tavistock Road London W11 1BA Lead Inspector Ffion Simmons & Jane Shaw (Pharmacy Inspector) Key Unannounced Inspection 28th & 29thJanuary 2008 09:50 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 Westmead Elderly Resource Centre DS0000036658.V348981.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. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westmead Elderly Resource Centre Address 4 Tavistock Road London W11 1BA 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 7641 4595 020 7641 5781 Westminster City Council Vacant post Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (42), Old age, not falling within any other category (42) Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on the 5th September 2006, one named service user under the age of 65 years can be accommodated. The CSCI must be advised when the service user no longer resides at the home. 14th August 2007 Date of last inspection Brief Description of the Service: The home is registered to care for up to 42 elderly residents of either gender. The home is registered to care for residents with dementia and for residents with mental health needs. The home is owned and run by Westminster City Council and is situated in the Westbourne Park area with easy access to transport links and local amenities. The home was purpose built in the 1970’s and is a two-storey building. There is a passenger lift fitted in the home making all areas in the home accessible to residents. The home is divided into four units, and each resident has their own bedroom, and there is a range of communal areas within the home. The fees are £528.62 per week. This fee does not include the following items: hairdressing, personal toiletries, clothing, newspapers, cigarettes, alcohol, taxis for shopping and outings, television sets in bedrooms, phone installation and hand sets, pet food and veterinary expenses, transport and storage for own furniture, repair and maintenance of own equipment and furniture, sweets, postage and extra recreation. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This key unannounced inspection took place over two days in January 2008. This was the home’s second key inspection in the inspection year 2007/2008. We spent time talking to the residents and staff. A range of documentation was checked, which included care records and staff files. The care was observed in the home. An audit of medication was carried out in each of the four units by a specialist Pharmacy Inspector to determine whether medication was being administered to residents as prescribed. The Commission received a low return rate (9 ) of the questionnaires sent out to residents, health care professionals and visitors/relatives and or advocates. Some of the comments received have been included in this report. What the service does well: What has improved since the last inspection? The home’s brochure has been updated to include brief details on the distance between the bedrooms and lavatories. Care plans seen were up-to-date and included the advice of the multidisciplinary team. A new weighing scale has been purchased and residents’ weights were being monitored regularly. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 6 The referral process for reporting any issues falling under the safeguarding adults procedure has improved and staff are now clearer on how and when to make a referral. Stronger links have been formed with the safeguarding team and as a result, incidents are being reported promptly to the relevant parties including CSCI. The Interim Manager has provided good leadership during this time and has supported the team to become more autonomous. Although there are still some issues requiring resolution, the team dynamics are improving. Visits on behalf of the Registered Provider are undertaken and the reports are made available for staff reference in the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 7 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. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 8 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 Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 9 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): 1, 3, Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. A full needs assessment is undertaken prior to residents moving in which ensures that the home is suitable to meet their needs. EVIDENCE: The home has a brochure designed to give people an introduction to the home and its facilities. Copies of these packs were available at the home’s main reception area. The information is printed out as needed and contains information on how to make a complaint. The brochure has been updated to include brief details on the distance between the bedrooms and lavatories. The inspector noted that an inspection report from the home’s Key Inspection in February 2007 appeared with the Service user’s guide. As the June 2007 key inspection report is now available, this should be included with the service user’s guide and made available to ensure that residents have the most up-todate information. The brochure given to the inspector on the day did not include the views of residents and should be in available within the pack. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 10 The files of two recently admitted residents were checked during the inspection. This provided the evidence that a full needs assessment had been completed prior to the residents moving in. This enabled the home to assess whether their needs could be met prior to admission and to be used to formulate a plan of care. Westmead Elderly Resource Centre DS0000036658.V348981.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of medication must be further improved to make sure resident’ health care needs are always met safely and that residents receive their medication as prescribed. People have access to health care services both within the home and in the local community. Each resident has a care plan that includes the information necessary to plan the individual’s care but lacked falls risk assessment for two residents. EVIDENCE: Five residents were case tracked during the inspection, this included checking their files. Each resident had an up-to-date care plan on their file. The files demonstrated that where there are concerns about residents’ diet and nutritional needs, a referral had been made to a dietician. Advice given from health professionals had also been incorporated into the care plan as per the requirement of the last random visit. Residents’ weights are normally monitored on a monthly basis and the home has purchased new weighing scales to replace the scales that were not working when we visited in October. A comprehensive risk assessment was in place for one of the residents who had experienced recent falls. There was also evidence on the file that a referral had been made for Physiotherapy input. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 12 A recently admitted resident had been identified as being at risk of falls within their initial assessment, having experienced several falls in recent months. The risk assessment and management plan for this risk area could not be located when at the home. Staff told us that they had seen a risk assessment but when we asked staff to see this risk assessment, it could not be located. This was the case also for another resident who had experienced three falls since our random inspection on the 29th October 2007. The risk assessment was not available on the first day of the inspection but again staff confirmed that a risk assessment had been compiled but could not be located. By the second day of the inspection, a risk assessment had been compiled. It remains a requirement that risk assessments are in place for residents who are at risk of falling and that the risk assessments are available at all times for staff reference and available for inspection. This is to ensure that all staff are made aware of the risks and to implement the management plan so that the risk to residents’ safety is minimised. It is a recommendation that the incidents of falls are regularly monitored/audited. An audit of medication was carried out in each of the four units to determine whether medication was being administered to residents as prescribed. The medication administration records (MAR) were inspected; three discharge letters from hospital and two care plans. The inspection was carried out on the first day of the new cycle and when the MAR sheets were inspected for the previous cycle in one unit it was noted that there were no omissions in recording of receipts, administration or disposal. There was concern expressed at the late checking in of medication for this cycle and the last cycle. The home is not allowing enough time to check medication before the start of the cycle. Medication must be checked thoroughly to ensure that continuous supplies are maintained and any discrepancies are resolved with the GP and the pharmacist in plenty of time. This issue was raised at a previous inspection. It was noted that care workers were not dating receipts of medication. Unless this is done it is not possible to reconcile quantities of medication during the cycle. Because insufficient time had been allowed for checking, several new items such as eye drops had not been carried forward to the new MAR and cycle and therefore administration missed. Two residents prescribed alendronic acid weekly had not received their medication but it had been signed as given. The MAR’s were corrected in these cases at the time of the inspection. Another resident had been given lactulose but no stock could be found. Care workers must be reminded of the homes policy that the MAR is read before administration and checked against the stock and instructions before giving and signing. Several residents had been in hospital or seen consultants and there was good practice of keeping discharge letters and changes in dosage with the MAR for Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 13 reference. There was evidence of review of dose of several anti-psychotic medicines following blood level monitoring and observation of behaviour. Of the greatest concern however, was the lack of supply of warfarin in the medication trolleys for two residents. A supply was eventually located –one was due to be disposed of. For one resident the dose being given for the previous two weeks was incorrect in spite of the new dose being received from the pharmacist at the correct time, and the correct dose and blood level available for reference with the MAR. The home was now holding a stock of controlled drugs. They were stored securely and recorded in a bound register. Balances were correct. There was a significant amount of waste medicine requiring disposal, particularly insulin, laxatives and analagesics. The home should ensure that the GP reviews prescriptions if the latter two are only required on an occasional basis. Otherwise stock was tidy and well organised. Dates of opening were written on packs when opened to prevent them being used past their expiry date and to enable accurate audit. The fridge was inspected and it was noted that the minimum and maximum temperature was no longer being recorded. One resident prescribed citalopram drops was having her dose measured with a syringe designed for use with another medicine. One resident was applying her own creams and the home had written risks assessments to maintain safe administration. Enforcement action has been taken by the Commission to ensure that the arrangements for the recording, handling, storage, administration and disposal of medicines received into the home safeguard the residents. Staff were observed to be respecting residents’ privacy and dignity during the inspection. This was also the feedback received from relatives and professionals visiting the home. Westmead Elderly Resource Centre DS0000036658.V348981.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from an individualised programme of activities based on their individual interests, diverse needs and capabilities. The food in the home is of satisfactory quality, request for more variety, with more fresh fruit and vegetables made available and for vegetables to be fully cooked were received within the feedback. EVIDENCE: The care plans seen contained some information about residents’ interests and religious and cultural needs. It was noted that once per month on a Wednesday, residents are able to take part in the church service, which takes place at the home. The home has an activity co-ordinator who facilitates the programme of activities that includes cross words and quiz games, art and bingo, reading and discussing newspapers and music and movement. Where residents’ interests were different to those activities on the activity programme, it was not clear what steps are taken by staff to maintain these interests. A resident commented when asked how they spent the day, “drinking tea and eating biscuits”. The inspector saw residents for long periods of time not engaged in any activity. Residents would benefit from an individualised programme of activities, based on their own interests and consideration given to their abilities and their individual needs. The lack of sufficient activities and stimulation for residents has been acknowledged by the acting Manager. Work is currently underway in the form of training and Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 15 developing life story books for residents so that staff learn about residents’ life history. Visitors are welcomed into the home. Relatives commented “Westmead has always had a wonderfully relaxing and caring feel about it. A warm reception is always to be found here.” Meals are served from the central kitchen on the units or in residents’ rooms if they prefer. The 4 week rolling menu gives an alternative dish for each main meal, ensuring that a vegetarian option is always available. Soft drinks, water and fruit juices are given to service users throughout the day. Comments received about the food were mixed and included a request for more variety, with more fresh fruit and vegetables made available and for vegetables to be fully cooked. It was noted that food was an item on the agenda for discussion the last residents’ meeting and it is a recommendation that the home continue to obtain feedback from residents about their preferences and consider the feedback when planning the meals. Westmead Elderly Resource Centre DS0000036658.V348981.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. Complaints from individuals are not fully recorded, and do not outline the actions taken to investigate these concerns. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. EVIDENCE: The service user’s guide contains information about how to make a complaint. Since the last inspection, the home has introduced the complaints procedure in a pictorial format and large print to make the procedure more accessible to the residents. A copy of this procedure was seen on display at the main reception area. There is also a book at the reception for residents, relatives and visitors to write in any comments they have on the service. It was noted that the home had received three complements since our last key inspection. The inspector noted from checking daily records that a resident had raised some concerns. The records showed that unit managers/residential managers had been notified but it was unclear what action had been taken to investigate. Staff should record all concerns raised, noting action taken. These concerns should be regularly audited to identify any patterns of concerns/complaints. The Acting Manager has worked hard to improve the referral process for reporting any issues falling under the safeguarding adults procedure. Staff are now clearer on how and when to make a referral. The Acting Manager has also formed stronger links with the safeguarding team and as a result, all incidents are being reported promptly to the relevant parties including CSCI. The Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 17 referral procedure/pathway to the safeguarding adults team was on display in each of the home’s units and in the duty Manager’s office for ease of reference. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 18 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 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. Residents have a single room but no en-suite facilities. The home is comfortable and has a programme to improve the decoration, fixtures and fittings. The home however is not always clean and fresh. EVIDENCE: The home is situated in the Westbourne Park area with easy access to transport links and local amenities. The home is fitted with an intercom monitoring door system and is safe and secure. The home is a purpose built home, which benefits from very well maintained gardens. There are no en-suite bedrooms in the home and some bedrooms are a considerable distance from the lavatories, resulting in a high use of commodes. The information provided about the home now however makes references to this distance. It was noted that the malodour at the front of the home was less than on previous inspections. We however noted a strong odour in two of the four Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 19 units we toured during this inspection including the toilets within one unit. Further work is required to address malodours within the home so that residents’ home environment is fresh and pleasant. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are generally satisfied with the care they receive but the staff team appear to be short in number and under pressure. Permanent staff are dedicated but there is a high reliance on agency staff, which is impacting on the quality of care to residents. The service recognises the importance of training, and tries to delivers a programme relevant to the needs of the residents. EVIDENCE: The staffing rotas were checked during the inspection. Staffing rotas reflected that there are a minimum of six (occasionally seven) staff on duty in the morning shift and a minimum of five staff (occasionally six) on duty in the pm shift and four staff on during the night. The care staff appeared very busy during the two days of the inspection. Staffing was also identified as an issue within feedback from relatives and health professionals. A resident commented that staff don’t spend much time with them and preferred more one-to-one time communicating with them. “Spending time with me makes a difference”. It is a requirement that the staffing levels are reviewed again to ensure that residents’ increasing needs are met. At the home’s last random inspection in October 2007, it was noted that the home’s use of agency was high and agency staff were working long hours. The home has reduced the seven vacant posts to five and has reviewed the long shift and long hours worked by agency staff. Although the five vacant posts are currently covered by regular agency staff, the feedback from staff and relatives was that this high use of agency staff affects the quality of care to residents. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 21 The home’s recruitment procedures were checked by checking the file of a recently recruited member of staff. Staff at the home confirmed that there has only been one new staff recruited since the last inspection. On the file there was record of face-to-face interview having taken place and there was a completed application form on file. Pre-employment checks such as Criminal Records Bureau checks (CRB) and checks against the Protection of Vulnerable Adults List (POVA) of those unsuitable to work with vulnerable adults are completed by the Human Resources Department. There was no evidence from checking the file that the staff member had received satisfactory POVA, CRB and reference checks. This was discussed with the Manager at the time of the inspection. Following the inspection, confirmation was forwarded to the Inspector as evidence that the checks had been completed. This confirmation however should be on file prior to the member of staff commencing work so that the Manager can be assured that the necessary checks have been undertaken and that the new staff are suitable to work with vulnerable adults. The staff training records were checked as part of the inspection process. A new spreadsheet is in place for recording the training that staff have attended and to identify and nominate staff that require updates. The templates demonstrated however that some staff were still in need of updates in their training in safe working practices, which include health and safety, manual handling and food hygiene. The Manager and staff explained that staff have received updates in their training in safe working practices but the training records need to be updated to reflect the recent training. It is a requirement that staff training records must be kept up-to-date to reflect the training undertaken by staff and to identify clearly when staff require the necessary updates and to identify areas of professional development. The inspector was informed that 60 of care staff hold the NVQ level 2 or above in care. The staff team including domestic and catering staff have received training in dementia care developed by the Alzheimer’s Society. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 22 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, 33, 35, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is currently without a permanent full-time Manager in post. The home needs to have a full time and permanent Manager in post to ensure further improvements in the service and to ensure the health, safety and welfare of the residents. Systems are in place for safeguarding residents’ financial interests. EVIDENCE: The home is currently without a Registered Manager in post. Since the 25th June 2007, the home has been managed by an interim manager who is covering two homes. The Interim Manager has provided good leadership during this time and has supported the team to become more autonomous. Although there are still significant issues requiring resolution within the staff team, staff commented positively on the interim Manager’s contribution in improving the team dynamics. The interim manager has made some improvements in the home but there is a need for this to be continued and sustained. The interim manager is the registered manager of another home Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 23 therefore Westminster City Council must ensure that management arrangements for Westmead reflect the needs of the service. An urgent requirement was made at the homes’ random inspection in October 2007 that permanent full time management arrangements are put in place. Westminster City Council is in the process of recruiting a new full time and permanent Manager to manage the home. Enforcement action has been taken by the Commission to make sure that at all times a suitably qualified, competent and experienced person is working at the care home to ensure the health and welfare of service users. The home has a business plan in place. Person in control reports were available for inspection on the day of the inspection. It was noted that a new format has been created for the monthly person in control visits. This format is much improved and reports on the views of residents and staff at the time of the visit and demonstrates areas of the improvement plan being monitored at the time of the visit. It was noted within the report that proposals are in place for introducing a tool for monitoring the health and well being of residents with dementia living in the home. This is very encouraging but staff commented that it is not currently in use so it should be introduced as soon as possible. The inspector was told during the inspection that the home has recently circulated a resident satisfaction questionnaire to gain the view of residents living at the home. As outlined under Standard 1, the results of the service user satisfaction questionnaires must be published in the service user’s guide. Internal audits of how the service is meeting the National Minimum Standards should take place at least annually. The medication audits should be rotated between different managers to identify any issues. The home’s systems for managing and recording residents’ finances were checked during the inspection. Systems are in place for ensuring residents’ money is securely stored in a lockable safe. Transactions are recorded and receipts maintained and signatures obtained. The financial procedures and practices are audited and the inspector was told that a financial audit is due shortly. As discussed previously within this report, it remains a requirement that risk assessments are in place for residents who are at risk of falling and that the risk assessments are available at all times for staff reference and available for inspection. This is to ensure that all staff are made aware of the risks and to implement the management plan so that the risk to residents’ safety is minimised. It is a recommendation that the incidents of falls are regularly monitored/audited. Staff training records should also be kept-up-to date to reflect that staff have received the necessary training in safe working practices. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5 Requirement Timescale for action 01/04/08 2. OP7 OP38 13 3. OP12 16 (2) 4. OP16 22 The Service User’s Guide must include a copy of the most recent inspection report and service users’ views of the home. Original timescales of 01/09/07 not met, this is a repeat requirement. Risk assessments must be in 01/03/08 place for residents who are at risk of falling. The risk assessments must be available at all times for staff reference and available for inspection. Original timescales of 01/12/07 not met, this is a repeat requirement. An individualised programme of 01/04/08 activities, based on residents’ interests should be introduced with consideration given to their abilities and their individual needs. Steps must be taken to ensure 01/04/08 that staff are aware of the procedures for recording complaints/concerns and compliments and that they are effectively documented and investigated. DS0000036658.V348981.R01.S.doc Version 5.2 Westmead Elderly Resource Centre Page 26 5. 6. OP26 OP27 23 18 7. OP27 18 8. OP29 19 & Schedule 2 17, 18 9. OP30 10. OP33 24 Original timescales of 01/08/07 not met, this is a repeat requirement. The home must be kept clean, free from malodours and comfortable. The staffing levels must be reviewed again to ensure that residents’ increasing and changing needs are met. The high use of agency staff must be reviewed. Original timescales of 12/11/07 not met this is a repeat requirement. Confirmation that the necessary pre-employment checks have been completed and are satisfactory, should be on file prior to staff commencing work. Individual training records must be kept up-to-date to reflect training attended and to highlight when training updates are required. The home’s quality assurance systems must be reviewed to include suitable ways for securing the views and experiences of people with dementia living in the home. Original timescales of 01/10/07 not met, this is a repeat requirement. 01/03/08 01/04/08 01/04/08 01/03/08 01/04/08 01/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations That the medication audits are rotated between different managers to identify any issues. DS0000036658.V348981.R01.S.doc Version 5.2 Page 27 Westmead Elderly Resource Centre 2. 3. 4. 5. 6. 7. 8. OP9 OP9 OP9 OP15 OP16 OP33 OP38 That pain relief, laxatives and insulin is reviewed by the GP to reduce waste. That the pharmacist is requested to give clear instructions and/or appropriate measuring devices e.g. for citalopram drops. That a new minimum maximum thermometer is purchased to ensure accurate recording of fridge temperatures. The home continue to obtain regular feedback from residents about their preferences in relation to food and consider the feedback when planning the meals. Concerns raised by residents should be regularly audited to identify any patterns of concerns/complaints. Internal audits of how the service is meeting the National Minimum Standards should take place at least annually. The Manager of the home should produce an annual report containing information and incidents and outbreaks of infection, risk assessment, training and education of staff and infection control audit and the actions taken. Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Westmead Elderly Resource Centre DS0000036658.V348981.R01.S.doc Version 5.2 Page 29 - 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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