Inspection on 13/07/07 for Whitchurch Lodge

This inspection was carried out on 13th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Whitchurch Lodge 09/07/08

Whitchurch Lodge 20/04/06

Whitchurch Lodge 21/06/05

Whitchurch Lodge 06/04/05

Whitchurch Lodge 08/12/04

Whitchurch Lodge 15/06/04

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

CARE HOMES FOR OLDER PEOPLE Whitchurch Lodge 154-160 Whitchurch Lane Edgeware Middlesex HA8 6QL Lead Inspector Diane Roberts Key Unannounced Inspection 13th July 2007 09:30 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 Whitchurch Lodge DS0000017565.V342684.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. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitchurch Lodge Address 154-160 Whitchurch Lane Edgeware Middlesex HA8 6QL 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 8952 5777 020 8952 5777 Finbond Limited Mr Jamnadas Haridas Raithatha, Mr Mahendra Mehta Mrs Beatrice Anne Donlevy Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2006 Brief Description of the Service: Whitchurch Lodge is a care home providing personal care and accommodation for up to 32 older people. The registered provider of services at the home is Finbond Limited, a local organization run mainly by Mr. Raithatha. He visits the home a number of times each week. The home itself has been operating as a care home since 1965. The premises is a two-storey building that was adapted from local houses. It was significantly rebuilt in the mid-1990s. It blends in well with surrounding homes. The home is located within a residential area of Edgware, near Canons Park tube station, within the London Borough of Harrow. It is around five minutes walk from shops and a park, and has a bus stop outside the home for buses on the #186 route between Harrow and Edgware. The home has a driveway that can take about six vehicles. Five of the homes bedrooms are double rooms. All bedrooms are fully furnished. They have either built-in sinks or en-suite toilet facilities. The home has four communal bathrooms and nine communal toilets. Access to the first floor is by stairs or a lift. The home has a large dining room, and a large main lounge that is arranged into two separate areas. The home has a fair-sized open garden, with an extensive patio area and suitable garden furniture. The home has a service user guide available and the current charges range from £450.00 to £575.00. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The manager was available on the fieldwork day of the inspection and the proprietor visited the home during the day. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. The manager completed a very comprehensive quality assurance assessment, which reflected the home quite accurately and demonstrated that the manager has a very open and objective approach. 3 residents, 2 relatives and 4 staff were spoken to during the inspection. Eleven residents and eleven relatives also completed feedback sheets. All these comments were taken into account when writing the report. What the service does well: What has improved since the last inspection? What they could do better: Care plans do not show enough detail to ensure that care is given appropriately to all residents. Residents or relatives need to be involved in Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 6 their care plans and they need to be kept up to date and the care of residents with dementia could be improved upon. Activities for the individual need to be developed further to ensure all residents’ needs are met. Some areas of the home require refurbishment and shortfalls in relation to health and safety must be addressed. The implementation of a robust quality assurance programme would help the management of the home identify potential and actual issues and address them rather than the CSCI identifying them on inspection. 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. Whitchurch Lodge DS0000017565.V342684.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 Whitchurch Lodge DS0000017565.V342684.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): 1 and 3. People using this service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. The home has an assessment system in place that helps to ensure that they can meet the needs of people they admit to the home. Information available to prospective residents could be developed further. EVIDENCE: The manager has a pre-admission assessment system in place. The assessment documentation completed goes on to form part of the care plan. The manager or her deputy undertake all the pre-admission assessments. The assessments of recent admissions to the home were inspected. The assessments were seen to cover all the required areas and had been completed well, giving sufficient detail so that an informed decision could be made. Good detailed information was available on both the physical and social side of care with good family and social history in place. Information on resident’s personal preferences and their daily routines was also available. It is Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 9 clear that time had been taken when completing the assessment and family members as well as the resident were involved. One relative who commented said that ‘when my relative was admitted to the home the service and attention towards us was excellent’. Another said that ‘the manager was quite helpful with regard to information at the time of admission’. A service user guide is available but again needs updating with regard to content and format, in relation to the resident group. This was discussed with the manager who states in her annual quality assurance assessment that she plans to rewrite these over the next few months. Service user guides were not seen to be available around the home and consideration should be given to this. Residents who commented said that they had received a contract and had had sufficient information on admission regarding the home. Records show that residents are able to come to the home and spend time prior to making any decisions about admission. They are able to have a meal and take part in social activities should they so wish. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. Care systems are not sufficient to evidence that the team have a proactive, resident led approach to care provision and ensure needs are met and positive outcomes for residents. EVIDENCE: The team uses an standex care planning system which consists of a full assessment, short and long terms care plans, risk assessments and records sheets for professional visits, daily records etc. Three care plans were reviewed in detail. Whilst the residents had a full assessment in place, which contained personal preferences, some detailed care needs, there were subsequently no real care plans in place. The staff are not using the system in full. Occasionally there were limited care plans in place, on the short term care plan format, but these were seen to be out of date or contained insufficient detail. Residents with identified care needs did not have a care plan in place. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 11 The assessments seen were often two years old and contained out of date information. There is no formal review system in place. Whilst the assessments contained some good personal preferences and evidence of staff’s appreciation of their right to choose, overall the care records were not very person centred and did not evidence that staff appreciate the diversity of the residents in their care. The records did not identify residents’ strengths and abilities and did not contain specialist assessment tools that can be used for residents with dementia or communication difficulties. Good records were provided by keyworkers that evidenced that they have sought feedback from residents as to how they were feeling and if they had any concerns etc. Daily notes were seen to be quite informative and evidenced residents are exercising their right to choose, however, they did not link into any care plan. Overall the care records do not evidence a proactive approach to the care of residents and this can adversely affect outcomes for residents. Care plans also do not show enough detail to ensure that care is given appropriately to all residents. Residents who commented said that their care needs were ‘usually met’. One resident said that the care was ‘uneven and that staff do not always do as they are asked’. This could be a reflection of the limited care planning process in the home. Some staff training in the use of the care planning system, that is in use, would be of value and the manager should be utilising her senior staff who are currently undertaking NVQ level 3. Resident and relative involvement in the care planning process is variable. Some residents confirmed that they had seen their care plan, which is good, but often this was some time ago. Further work needs to be done on this aspect of the care planning. Records show that the staff contact the residents’ doctors proactively and in a timely manner if there are concerns. Residents spoken to were happy with the arrangements for seeing the doctor. A range of risk assessments are in use. Some of these were seen to have been reviewed and kept up to date whilst others were not. One risk assessment had not been reviewed since 2005. Risk assessments that had identified risks did not have an associated care plan outlining the management of the risk. At the time of the visit, there were no residents in the home being cared for in bed and no pressure sores were being managed. On inspection\pressure relieving equipment was seen around the home. The team uses a weekly nomad system for the residents’ medication. This was inspected and found to be well managed with only minor issues noted. The MAR sheets were clear and neatly maintained with items checked in and no missing signatures. The home has the appropriate storage and recording systems for controlled medications and these were checked and found to be in Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 12 order. The home has a specific medication fridge and the staff monitored the temperatures daily to ensure safe storage. The follow was noted. Dates of opening are needed on liquid medications to enable a full audit if required. A significant amount of residents were noted to be taking laxatives and this should be reviewed and linked in with menu planning. This was discussed with the manager. Items without a current prescription should be returned to the pharmacy. Records and care plans evidenced that the visiting doctor had reviewed residents’ medication. Relatives are very happy with the care provided at the home and comments included: ‘staff are very patient when trying to communicate with my relative’, ‘staff keep me informed of any occurrences relating to my relative’, ‘the staff at the home are good at informing me if my relative is unwell’, ‘I think my relatives physical needs are met but I am not sure if her emotional needs are met due to her limited communication’, ‘my relative always looks well cared for’’, ‘ the level of care and support is very good’, ‘the staff are very caring and treat my relative as an individual and are aware of particular needs’, ‘overall we are very impressed by the care of my relative who has come on leaps and bounds since living at the home’ and ‘the home provide excellent care’. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 13 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 and 15. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. The range of activities are not sufficiently developed enough to improve outcomes for residents. The meal service is generally satisfactory but ongoing consultation with residents will improve the experience. EVIDENCE: Further work is needed on the care planning in order to evidence that residents are being consulted about their daily routine, life choices and social activities. Residents who are able do have choice with their daily routine but this is not evident for all residents. At the current time care plans are variable and not always person centred, this is especially important with residents who have dementia. Social activity plans are in place but some are very limited and do not relate to residents interests, which are clear when you chat to them. Family and social histories were in place for some residents and not for others. On discussion staff did know about the residents history and they could have been completed, so all staff are informed and the information linked into the care plan. From discussion and records, it is clear that activities are being provided but this is not always linked to an assessment and resident choice. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 14 Activities include, crafts, quizzes, reminiscence, organised entertainment, birthday parties, games etc. Activities that help residents maintain their skills and independence and that promote self worth should be explored further and this was discussed with the activities officer. The activities officer has been working at the home a short time and residents spoken to and who commented speak very highly of her. She provides many group activities and spends time with residents in their rooms. One resident said that ‘She comes every day during the week and I miss her if she does not come’. The activities officer works 11.30 – pm. Monday to Friday. She is steadily developing a programme and on discussion is very aware of resident mood and changes activities accordingly. She is building up her resources but needs to have a greater understanding of the assessment and social care plan side of the work, which she is gradually addressing. From discussion she knows the residents well and her records need to reflect this. In order for a good activities programme to be in place that meets individual and group needs, the care staff also need to work with the activities officer to move this forward. Relatives who commented said that ‘Care staff could socialise with residents more, especially when the activities officer is not working’ and ‘the person who deals with the activities is a real asset to the home’. Other comments included ‘ the activities lady does sterling work but cannot work seven days a week. During the weekend she is sorely missed and the residents sit around staring at the walls’ and ‘ entertainment is provided weekdays by a very caring and lovely lady, it would be good if there was an occasional outing and some activity on the weekends, which are only broken by mealtimes’. The activities officer has a very open approach and from discussion is obviously very keen to provide a good service to the residents. Residents are limited with regard to outings away from the home at the current time and the activities officer is working on developing this. The manager reiterates the need for more outings in her annual quality assurance assessment. Residents who commented said that the activities programme ‘usually met their needs’. Residents’ friends and family are encouraged to visit the home and are invited to specific events. The home was about to put on a bring and buy sale the following day and this was clearly advertised outside the home. Relatives spoken to and who commented said that they were made welcome, had taken meals with their relative and that ‘Staff are pleasant to relatives’. Lunch was observed to be a calm affair with some residents using specialist aids and being sensitively assisted by care staff. Residents are encouraged to eat in the dining room but do have choice as to where they eat. This was confirmed through observation. From discussion with the chef and review of records, the menu shows a limited variation and the same meals are repeated very regularly. This needs addressing and on discussion with the manager she stated that residents had been consulted and new Summer and Winter menus Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 15 were being introduced with more variety. Records show that individual meals are provided apart from the menu choice and a few specialist meals are prepared for specific residents. Although the home has residents of differing faiths, that often require specific foods, the staff in the kitchen stated that these residents were not practising their faith and were happy with the food provided. Other staff in the home also confirmed this. Fresh fruit and vegetables were seen in the kitchen and food stocks were suitable. Comments from residents and relatives included ‘My relative enjoys their meals and the food seems nice’, ‘my dietary needs are taken into account’, ‘I would like marmalade in the mornings’, ‘The food is wholesome and appetising’ and ‘Supper could be improved by giving more variation and better quality items’. Consideration should be given to replacing the brightly coloured plastic beakers to those more appropriate to adults. Whitchurch Lodge DS0000017565.V342684.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 and 18. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. Whilst there are systems in place to listen to peoples concerns, shortfalls in relation to adult protection could undermine this and negatively affect outcomes for residents. EVIDENCE: The manager has a satisfactory complaints procedure in place. Consideration should be given to the format in relation to the resident group. The procedure is available within the residents’ contract and service users guide but is not displayed around the home. Consideration should be given to this. Nearly all residents and relatives who commented said that they knew about the complaints procedure and who to speak to if they had a concern. Relatives who commented felt that the staff and the manager make sure everyone is relaxed and therefore able to express himself or herself. Some relatives stated that the manager and staff are always very helpful and the manager has always responded to any queries promptly. The manager maintains records of all complaints however minor. Detailed records are kept, especially by manager and she is aware of need to list all complaints. Records show that issues are dealt with promptly and efficiently. One resident said that ‘It has occasionally been necessary to repeatedly request information or action before things have been done’, whilst other Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 17 residents said that ‘I am happy here because if I have a complaint it is sorted out’. The home has received compliments, which include ‘wonderful care and patience with my relative’, and ‘especially liked the open welcome at Whitchurch Lodge’. The manager does have information on local advocacy services but needs to make this available to residents and relatives. At the current time no residents in the home are using advocacy services. The home has an adult protection policy in place. The manager demonstrates a good understanding of adult protection and the procedures to be followed. The manager does not have copies of local adult protection guidance issued by local authorities and was advised to get appropriate copies from placing councils. Staff training records submitted to the CSCI show that 16 staff have received training in adult protection in 2005 and 17 staff have not had any adult protection training in the home. Some staff may have completed aspect of this training within NVQ course, but there is still a significant shortfall and a possible need for update training. The manager needs to review this and ensure that the training provision is sufficient to help ensure residents are protected through staff awareness. Whitchurch Lodge DS0000017565.V342684.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 and 26. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. A homely environment is generally provided for residents but this is let down by maintenance, updating and décor in some areas of the home, giving variable outcomes for residents and in some instances safety risks. EVIDENCE: A partial tour of the home was undertaken with the manager. First impressions of the home are not good as the reception area is dark and requires redecoration and the main lounge is also dark and in need of decoration. The management have managed to secure a local authority grant and plan to redecorate the main lounge. It is hoped that chairs will also be replaced and the home are trying to purchase a piano. Several relatives who commented felt that the lounge carpet needs replacing. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 19 The lighting in the lounge and in some of the corridors require assessment to ensure that there is enough lux, as they may not provide enough light to read by and pose a health and safety risk. Obsolete zimmer frames are stored in the lounge and these need to be disposed of. On inspection it was noted that two of the nurse call units were not working in toilets located close to the lounge and on further inspection, others were noted not to be working around the home. This was addressed on the day of the inspection but the management must have systems in place whereby such battery operated units are checked regularly to ensure resident safety. This was discussed with the manager. Bedrooms were seen to be in good decorative order although some of the furniture required attention/replacement. One relative said that ‘The furniture in my relative’s room could be better and the room could be cleaner’. Bed linen and pillows on some of the beds were seen to be poor and needing replacement. On review of stock there was plenty of acceptable bed linen but old stock is not being removed and staff are still using it. This needs to be addressed and management quality monitoring systems need to be in place. Residents spoken to were quite happy with their rooms and The home has a large secure garden to the rear with plenty of patio areas for seating. The garden faces south and is quite hot to sit out in. A further patio and path is planned so residents can sit in a part of the garden that gives more shade. The front of the home looks a bit unkempt and needs attention. The home was seen to be clean and no odours were noted. Relatives commented that ‘Sometimes there is an unpleasant smell’ and ‘possibly some of the carpets need changing’. The carpet in the lounge is poor. The laundry rooms were inspected and noted to be open and have COSHH hazards, namely a glass of bleach up on a shelf. This was dealt with immediately and the member of staff spoken to by the manager. Suitable storage for COSHH products is needed in these rooms and training for staff regarding inappropriate handling of chemicals. Despite the home having a registration to take residents with dementia, the premises have not been altered to accommodate their needs. For example, there is no signage on the doors or methods to help them find their way around the home. It was also noted that the corridors were quite stark with no pictures or homely touches. This was discussed with the manager. Window restrictors had been fitted in the upstairs bedrooms but in some rooms they were noted to have been removed. The manager needs to address this. The manager has infection control policies in place. Training records show that only a few staff have received infection control training in the past and this should be addressed. Fire safety arrangements in the home were reviewed and maintenance checks and safety certification were in order. An external company has just completed a fire safety risk assessment and the manager is to action the points raised in the report. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 20 The maintenance man at the home does check hot water temperatures and values are in place. Records show that he is not checking all the outlets that residents have access to and this should be addressed. This was discussed with the manager. Random sampling of safety and maintenance certification for fixtures and equipment in the home showed that these were up to date and in good order. The manager is to action points raised on the recent electrical wiring inspection. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 21 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 and 30. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. The home has a stable staff team, which should benefit residents but a significant lack of training could be putting residents at risk and adversely affecting the quality of care they receive. EVIDENCE: The home has a stable staff team and the turnover of care staff is very low. There is no agency staff use at this home. This should provide consistency for residents and allow for significant positive development of the staff team and services in the home. At the current time the staff rota shows that in the mornings there are seven care staff, in the afternoon five care staff and at night three. In addition to this are the manager’s hours and ancillary staff. Deployment is arranged so that staff care for resident who have differing levels of dependency. The manager also tries to ensure that there is a male carer on each shift to accommodate residents’ preferences with regard to the provision of care. Examination of the staff rota confirms this. On reviewing current dependency levels from the annual quality assurance assessment submitted by the manager, the levels are satisfactory to meet the needs of residents. However, relatives had the following comments. ‘By and large the staff are very warm hearted and considerate but whether it is because they have too much to do or there is inadequate deployment, I feel that they are seldom Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 22 there when they are needed’ and ‘Often as not I am having to take my relative to the toilet because there is no assistance available’ and ‘Staff are not always in the lounge when residents are in there’. In light of this the manager should review the deployment in the home with specific attention given to covering communal areas and at busy visiting times. Other comments on the staff team from relatives included ‘staff are very good and caring’ and ‘We have been impressed by the staff when we visit’. Residents who commented on the availability of staff said that they were generally available and made no adverse comments. The manager encourages NVQ qualifications and the home now has 50 of its care staff with NVQ level 2 or above. A further seven staff are currently undertaking this qualification. Staff turnover at the home is low and no new care staff have been employed since before the last inspection. Staff files were reviewed and this included new ancillary staff. Staff files were found to be in good order with all the required checks and documentation in place. It is recommended that interview records are maintained in order to evidence the recruitment process and equal opportunities. New ancillary staff had started induction programmes but records showed that they were not advanced, as they should be in relation to the time working in the home. The manager has yet to start Skills for Care inductions and this should be addressed. The manager is not aware whether the current purchased system meets the Skills for Care requirements. The manager does have a staff supervision system in place. By her own admission she stated that this system ‘had slipped’ and required work to get it back on track. Training records for staff working at the home were submitted to the CSCI for inspection. It was of concern to note that with such as stable staff team there are significant shortfalls in relation to the training provision at the home. The records reflect that there is not a systematic or needs led approach to the organisation of training for staff. Records show that some staff have not received manual handling training for, 2, 3 or 4 yrs. In one case a member of staff was trained to be a manual-handling trainer and then had no subsequent training for 6 years. No health and safety training has been provided although a few staff have attended in house COSHH training. Fire safety training also shows significant shortfalls with the majority of staff last having training two years ago. Some fire safety training is booked for September this year. Records show that over the past few years the training input at the home has been limited. Despite a registration to care for people with dementia, the number of staff with training in this subject is low. Overall only standard training subjects are provided and no additional training has been undertaken that would enhance the knowledge of staff to care for residents with specific needs, such as diabetes, Parkinson’s disease etc. One resident who commented said that ‘the staff had a limited understanding of their condition’. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 23 It was also noted that staff dispensing medication had not received training since 2003/4 and this should be addressed. The management of the home need to review the training provision at the home and ensure that staff have the correct statutory training in place along with additional training that will promote positive outcomes for residents. The manager, in her annual quality assurance assessment, states that they would like a ‘wider training budget’ and ‘to develop a better staff training format’. The manager also states that ‘ training is our biggest target for improvement over the next 12 months’. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 24 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 and 38. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. A robust quality assurance system in the home would benefit the residents, by acting on their views more and reducing health and safety shortfalls. EVIDENCE: The manager has worked in the home many years. She is currently undertaking the registered managers award and hopes to complete this in the near future. The deputy manager is also undertaking this qualification. The manager has a very open approach and is keen to address any issues raised. Residents, relatives and staff speak positively about her. Relatives who commented feel that the home is very well run. Comments included ‘the manager is very warm hearted and a sincere lady who I have great confidence Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 25 in’ and ‘she welcomes input from relatives of the residents’. The manager holds staff meetings but has yet to develop regular residents or relatives meetings. This was discussed in relation to quality assurance and obtaining feedback from people. Minutes of staff meetings were available and showed that she meets with the day staff and the night staff in the evenings. A wide range of subjects were discussed which related to staffing, deployment, premises, menus and training. The proprietor of the home visits several times a week and completes a comprehensive monthly report. These include resident comments and good open information about the home. The manager has a quality assurance system in place that consists of a checklist, completed by the deputy manager every month and a range of satisfaction questionnaires. The checklist is a very limited system that primarily shows that documents are in place but does not comment on the quality of those documents. It also states that the premises is fine but gives no detail as to what this comment is based upon. This needs work and was discussed with the manager. Quality audit systems needs to be in place that give valuable information and that would identify shortfalls, as noted during the inspection, for example, COSHH hazards, poor bed linen, call bell not working etc. The range of satisfaction questionnaires was seen to be quite good for residents, relatives and staff. These had been completed but were not dated and there was no evidence that the results had been analysed and an action plan drawn up where appropriate. At the current time the home does not have feedback sheets for visiting professionals and this should be considered. All these points were discussed with the manager. Consideration should also be given on different ways to obtain feedback, especially with residents who have diagnosed dementia. The manager states in her annual quality assurance assessment that she plans to ‘completely revamp our quality assurance programme’ and think of new ways to obtain feedback rather than just questionnaires. The manager does hold some monies on behalf of some of the residents in the home. These were checked at random and found to be well managed with a double signing system in place, neat records and receipts available. The home has a health and safety policy in place. Training records show that no staff have had training on this subject. This must be addressed. Accident records were reviewed and found to be completed fully and followed up where required. An external company has carried out a health and safety audit in June 2007. Actions points have been raised and the manager is address the issues noted. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 26 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 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes. 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 The registered person must provide a service users guide, that is kept under reviewed and consideration must be given to the format in order to make it accessible to residents. The registered person must ensure that residents have an up to date care plan in place that outlines their current needs. This must be kept under review and where possible involves them or their relative in the process. Where risk assessments are completed for residents, the registered person must ensure that these outline the current risk and subsequent management and be kept under regular review. The registered person must ensure that residents care plans reflect their individual preferences and choices regarding their care and be more person centred to evidence that staff appreciate the diversity of individual residents. The registered person, through DS0000017565.V342684.R01.S.doc Timescale for action 30/09/07 2 OP7 12 and 15 30/09/07 3 OP8 12 and 13 30/09/07 4 OP10 OP14 12 30/09/07 5 OP12 16 14/09/07 Page 28 Whitchurch Lodge Version 5.2 6 OP18 13 and 18 7 OP19 23 8 OP19 23 and 13 9 OP19 23 and 13 10 OP19 23 11 OP30 18 assessment and consultation, the team at the home must ensure that residents’ individual social care needs are met and that their independence and self worth is promoted. The registered person must ensure that all staff receive training in the protection of service users from abuse and obtain the relevant local guidance from social services. The registered person must ensure that the home is kept in good decorative order with regard to the lounge decor, carpets, bedroom furniture, hallways and the reception area. The registered person must undertake a risk assessment to ensure that the lux of the lighting in the lounge and hallways is sufficient for reading and health and safety. The registered person must introduce a quality assurance system that monitors the battery operated nurse call system to ensure that it is working at all call points for resident and staff use. The registered person must ensure that the home develops with the specialist needs of residents with dementia and communication difficulties in mind, for example, door signage. The registered person must ensure that all staff receive essential (statutory) training within a suitable timescale. This includes food hygiene, fire safety, manual handling, health and safety and protection from abuse. Specialist training in relation to the registration of the home and care needs of residents must DS0000017565.V342684.R01.S.doc 30/09/07 31/10/07 30/09/07 31/08/07 30/09/07 31/10/07 Whitchurch Lodge Version 5.2 Page 29 12 OP33 24 13 OP36 12, 18 also be provided to ensure that residents needs can be met. A training programme must be put in place. The registered person must ensure that a robust quality assurance system is in place that obtains feedback from residents, relatives and visiting professionals and is backed up by an internal audit system. The registered person must ensure that staff supervision must be provided at least six times a year for all care staff. (Previous timescales of 01/06/06 and 31/03/07 partially met) The registered person must undertake a risk assessment in relation to the provision of window restrictors on upstairs windows and the appropriate action taken. The registered person must ensure that COSHH items are stored in lockable cupboards or rooms and not decanted into unlabelled containers. Staff must be appropriately trained. 31/10/07 31/10/07 14 OP38 13 31/08/07 15 OP38 13 14/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP7 OP9 Good Practice Recommendations Consideration should be given to developing a more person centred approach to care planning. Consideration should be given to providing care staff with training in the completion of care plans. A review of laxative use in the home for residents should DS0000017565.V342684.R01.S.doc Version 5.2 Page 30 Whitchurch Lodge 4 5 OP9 OP15 6 7 8 9 10 11 12 OP16 OP16 OP19 OP19 OP26 OP27 OP29 be undertaken linking in with healthy eating on the new menus being introduced. Old medications must be returned to the supplying pharmacy and dates of opening should be recorded on liquid medications. Ongoing consultation regarding the meal provision at the home should continue and consideration should be given to replacing the bright plastic beakers with ones more appropriate to adults. The complaints procedure should be displayed in the home Information regarding local advocacy services should be made available to residents and relatives. The redundant zimmer frames in the lounge should be disposed of. Regular quality checks must be made on the bed linen and pillows supplied in the home. More staff should undertaken infection control training. Staff deployment should be reviewed to ensure that all areas of the home are covered. Interview records should be kept to evidence a thorough recruitment process. Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London 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 Whitchurch Lodge DS0000017565.V342684.R01.S.doc Version 5.2 Page 32 - 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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