Inspection on 20/04/06 for Whitchurch Lodge

This inspection was carried out on 20th April 2006.

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 13/07/07

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 Clive Heidrich Unannounced Inspection 20th April 2006 9:45 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.V290469.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V290469.R01.S.doc Version 5.1 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.V290469.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August, 2005 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. There were seven vacancies in the home at the time of the inspection. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place across one and a half days in mid-April. It lasted eleven hours and twenty minutes. Its focus was on inspecting all of the key standards, and with checking on compliance with requirements from the last inspection report. The inspection process involved meeting with nine service users individually to discuss the services provided in the home. The inspector also discussed aspects of the service with a few visitors present during the visits, with staff who were working during the visits, and with the deputy in the manager’s absence through planned leave. Additionally, care practices were observed across the first day, aspects of the environment were checked on, and a number of records were sampled. Consequently, the inspector spoke with the manager by phone, to clarify issues and to provide feedback. An urgent action letter was also sent to the registered people, as discussed further under the ‘what they could do better’ heading below. A few months prior to the inspection, the manager was requested to send out comment cards to involved people, and to complete an inspection questionnaire. Consequently information from six service users’, six friends/relatives/visitors’, and two health & social care professionals’ comment cards have been included in this report. Feedback was mainly positive. Judgements in this report, about outcome areas (groups of standards), have been made using the available evidence to the CSCI. This evidence particularly includes the inspection visits. The inspector thanks all involved in the home for the patience and helpfulness before, during, and after the inspection. What the service does well: The majority of verbal and written feedback about the home was positive. All relatives reported being satisfied with the care provided, and most service users stated that they like the home overall. One relative commented, about the home’s services, that their relative was quite ill on admission, but has since put on weight and has recovered. A placing officer commented that the home showed a great deal of empathy and commitment for caring for their client. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 6 The home has good standards of considering whether its service can meet the needs of prospective service users, and of aiming to meet the needs of those admitted. Interactions of staff with service users were seen to be respectful and service user led. Good relationships were observed and fedback about. Service users also experience good standards of making decisions about their lifestyles within the home, and visitors are made welcome. The building has a reasonable, homely environment. Good emphasis is put towards cleanliness. What has improved since the last inspection? What they could do better: Improvements need to be made in a number of areas, including in some cases within areas previously identified. Most importantly, as outlined in an urgent action letter to the registered people that was sent at the end of the inspection, is for sufficient recruitment checks of prospective staff to take place. In particular, Criminal Record Bureau (CRB) checks must be through the organisation, and staff must not work unsupervised unless the POVA-First component of the CRB has been suitably returned. Failure to do this could put service users at risk of having unsuitable staff supporting them. The manager has provided a suitable written plan to address these issues. Other necessary improvements include for: • New staff to promptly receive formal training in key areas such as with protecting service users from abuse, manual handling, and food hygiene. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 7 • • • Service users to be provided with consistently varied and appetising choices of meals. Monthly formal reviews of each service user to capture, and aim to address, all changed needs. Ensuring that when service users are supported in wheelchairs, footplates are always used unless identified as a specific care need. Additionally, there are some necessary improvements that have not been addressed since the previous inspection. These include: • For there to be clear and individual continence support plans for applicable service users. • For care staff to receive formal supervision sessions at least every other month. • For at least half of the staff team to be qualified at NVQ level 2 or equivalent. Progress was however evident in respect of these areas. 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. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4. Quality in this outcome area is good overall. Service users’ needs are assessed in suitable detail, and placements are only offered where the manager is confident that the home can meet the service user’s needs. Improvements are only needed with making the service user guide more accessible. EVIDENCE: The manager confirmed that the service user guide, whilst being used, remained in need of work to ensure it contains all necessary information. The guide was seen to be available in one service user’s bedroom. During the inspection, the inspector had concerns about whether the home could meet the needs of some recently-admitted service users. This arose from pre-admission assessment documentation that included significant information about some of the needs of these service users being outside of the home’s category of registration. This could risk the home not being able to meet these needs. These concerns were put to the registered people by urgent action letter at the end of the inspection. The manager’s detailed response showed that due Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 10 consideration about each of these service users’ needs had however been made. Appropriate external professional support was additionally found to be in place. There were no other concerns with the assessment processes used by the home. The manager or the deputy visits prospective service users and their representatives in advance of offering a placement in the home. Records of this were seen. There was useful documentation available on file from social services in respect of individual placements. There was also evidence, from feedback and observations, about newly-admitted people’s needs being addressed, for instance with acquiring a GP assessment within a day of moving in. It was confirmed by management that they do not admit people whose needs are too great, such as with nursing needs. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate overall. Strengths are with providing detailed overall information about service users’ individual needs, accessing health professional support, and treating service users respectfully. Improvements are needed to keep care plans up-to-date, and to use health assessments effectively. EVIDENCE: The home uses the Standex system of care planning and recording. Checks of a sample of these files found that: • Plans of care are set up for new service users usually within a few days of them moving in, and that these plans correlate well with admission assessments. • Plans of care usually provide detailed and relevant information about the service user’s needs. In some cases, details about the support that staff should consequently provide are however poor. For instance, where a service user has identified diet-controlled diabetes, there is no guidance to staff about what this means in practice. Where a service user has continence needs, there is no statement about how to provide appropriate and individual support. Sometimes these issues are addressed within the ‘short-term’ care plan, but the lack of guidance for Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 12 • • • • some of the key needs of some service users puts them as risk of receiving inappropriate care. The manager must ensure that care files are audited and that all key support needs are clearly stated and planned for. The system of reviewing and updating care plans is not fully capturing changed needs. Many service users have received only one care review since July 2005, despite this standard expecting monthly reviews. Accident records are not prompting for reviews so as to prevent repeated falls. Health professional advice is not being incorporated into care plans, but is only recorded within care files. This again puts service users at risk of receiving inappropriate care, which the manager must ensure is addressed. It is recommended that monthly reviews record any significant events for the service user since the previous review, and that short-terms plans are then adjusted based on this. Reasonable standards of daily recording and individual risk assessing are in place. Dependency profiles and nutritional assessments that are updated regularly are in place. Close analysis of these however identified that some are filled in incorrectly. For instance, with rating a service user as low risk with eating and drinking when they have recorded swallowing difficulties elsewhere in their file. Another person’s dependency assessment showed no change in scoring across many months despite clear deterioration between inspections. This puts service users at risk of not having changing or concerning needs identified and addressed, which the manager must look into and change procedures for as needed. There were no concerns with the ongoing monthly weight checks of those service users’ files sampled. Observations found no concerns with how staff provide dependent service users with toileting support. Records of providing support, as per a specific section of each care file, were however intermittent. This has the potential for concerns with a service users’ toileting support to be missed, which the manager must address. It is recommended that the actual times of providing the support be recorded as part of this process. It was encouraging that the appropriate support of continence was discussed and clarified at a recent staff meeting. Feedback, records and observations showed that service users are generally receiving timely support from health professionals. One GP commented that service users are believed to be well-cared for and that they are contacted appropriately most of the time. All other GP comments were also positive. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 13 Most service users fedback positively about the staff, using comments such as good and hardworking. One service user said that staff pop in for chats if they are staying in their room. It was also evident, from feedback and observations, that staff listen to and respond to service users. Relatives fedback very positively about staff, all noting that privacy is provided as needed. One visitor commented that staff treat service users with respect and are truly devoted to their work. There was reasonable manual handling support observed overall, of service users by staff. One relative confirmed this, noting that staff use appropriate grips. Service users were seen to be generally well-presented, which shows that staff provide appropriate personal support where needed. Staff were also observed to talk to service users before supporting them to adjust clothing, which shows appropriate respect for the service user. The local CSCI pharmacy inspector undertook an audit of the home’s medication procedures. A report of her visit has been sent to the home separately, and is available from the CSCI on request. The report contained four requirements relating to appropriate recording and storage equipment. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Quality in this outcome area is adequate overall. Strengths are with service users having freedom of choice around the home, the home welcoming visitors, and improved provision of activities. Improvements are needed to ensure that the food provided is varied, nutritious, appetising, and reflects service users’ preferences, as there were shortfalls in all of these areas. EVIDENCE: Service user feedback about activities includes comments such as that there are no activities but that is fine as none are needed. This was a typcial reaction. Comment cards found that all service users however found the home providing suitable activities. Only one service user referred to there being an activites worker, despite this person clearly interacting with small groups of service users throughout the day. It is recommended that further discussions and audits take place around what service users as a whole, and individually, would like in terms of activities and occupation, and that a clear plan to address this is developed. There was evidence, from feedback and records, of some service users occasionally being supported by staff for local trips out individually, and of visits from representatives of local places of worship. All relatives commented that they are welcomed into the home at any time. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 15 Most service users commented that they do not wish to be more involved in decision-making in the home. Service users were seen to have the freedom of communal areas of the home, including short trips into the garden independently where appropriate. Service users provided varied feedback about the food. Many like it but a significant amount had reservations, and no-one praised it significantly. Issues highlighted by more than one service user are about poor taste and quality of the food, about not generally being asked about food preferences and choices, and about a lack of variety of meals. There was evidence, from records, observations, and tasting the food, in support of the above concerns. For instance, the previous week’s record of meals listed the main course as roast or casserole with potatoes, cabbage and carrotts, or else the latter aspect as vegetables, for six days of that week. The carrots and cabbage were found to be of a weak and watery taste when tasted, while the potatoes tasted and appeared tinned. There were however also positive aspects noted with the food. For example, service users received slices of an appetising, home-cooked fruit cake with afternoon tea. Service users received tea-trays where possible, and staff know what service users’ preferences around drinks are. Staff attended to service users conscientiously during meals, providing support and encouragement as needed. One service user noted that they receive a designated vegeteraian/fish menu that a few other service users also enjoy on occasions. There was also a plentiful supply of food within the home. Following consequent discussions with the manager after the inspection, the following improvements must be made: • Service users must be consistently consulted about their meal choices and preferences, and about the overall menu. This must include regular audits of their satisfaction with meal provision. It is recommended that this include group discussions about the meals and about what meals service users would like, and occasional sampling and taster sessions for different foods and meals. • Service users must be consistently provided with varied, appetising and nutritious food. This applies for main meals, desserts, and evening meals. Management must undertake and report on audits in this respect. It is also recommended that these themes be part of the abovementioned auditing of service users opinions. • Menus for the day must be on display in advance of the meals. It is recommended that this include a pictorial format if there are service users who can no longer work effectively with the written format. • There must be no plastic items for service users’ use with food and drink, such as with the plastic mugs and trays seen, except where specifically identified as necessary for an individual service user’s needs. Plastic items devalue service users as they are not homely in appearance. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 16 • The majority of dining tables were found to be inherently sticky. This causes discomfort whilst eating, and so must be addressed. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate overall. Strengths are that the home has improved its complaints processes to enable complaints to be more easily recognised, that most complaints are appropriately addressed, and that most staff have had training in the protection of service users from abuse. Improvements must be made to enable new staff to receive this training promptly, and for ensuring that all complaints made are captured in writing and appropriately addressed. EVIDENCE: Service user feedback about making complaints was mostly that staff and management listen and address issues. One person noted that staff are approachable in this respect, whilst another said that they go to the office if there is an issue. Two service users however made complaints during the inspection, about environmental and food issues. These were passed onto management. Consequently, the proprietor noted that the environmental issues would be addressed, whilst the food issues were being considered. One complaint was also made to the CSCI since the last inspection, by a visitor of a service user, with respect to medication issues. It was agreed that this would be passed to the home’s management for investigation, which resulted in the no further action needing to be taken. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 18 Relatives’ and visitors’ comment cards to the CSCI found that five out of six are not aware of the home’s complaints procedure. The manager agreed to address this through further efforts at raising awareness of the procedure. There were eight entries in complaint book since the last inspection, from both service users and visitors. Recorded responses generally showed prompt and reasonable actions, with the majority of complaints being upheld and addressed. Importantly, it gave evidence that staff do pass on complaints to management. However, the inspector was aware of two complaints that had not been recorded about, which the manager must address, to ensure that all complaints from service users and visitors are both passed onto management and that appropriate records of them are made. Feedback from service users and visitors about protection from abuse found that all service users reported feeling safe in the home, and that one relative said that when service users are aggressive, staff remain calm. The proprietor stated that all staff undertook training in understanding and managing challenging and aggressive behaviour, and in protection of service users from abuse, during the summer of 2005. Records and other feedback confirmed this for individuals. However, it was found from records that there needs to be training in this respect for staff employed since those training sessions took place, so that they can be aware of expectations in these areas. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, and 26. Quality in this outcome area is adequate overall. Strengths are that the home has new seating in the lounge, that the home is kept clean and hygienic, and that service users are satisfied with the environment. Improvements must be made to stop doors banging, to address air quality issues from service users who smoke, and ensure that all wheelchairs have footplates when used. EVIDENCE: Service users generally commented positively about the home’s environment, noting for instance that it is kept warm enough. Two service users however noted that improvements are needed, in respect of doors banging and air quality respectively. In the former case, the service user noted that a number of doors bang shut loudly. This was found to be the case with some doors throughout the building, which impinges on the quality of life of service users. The proprietor agreed to check and address this where needed. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 20 In the latter case, the comment about air quality was in respect of the dining room having passive smoke, from those service users who smoke, clearly noticeable as service users sat down for lunch. This was discussed with the manager, who agreed that an alternative area for cigarette smoking must be sought. Some improvements in the environment since the last inspection are noted. The garden was attractive, tidy and safe. This was noted to be through the acquisition of a new gardener. Lounge chairs have been replaced with new, comfortable, hard-wearing seats. There was also feedback from staff that they had been shopping with the proprietor to buy replacement equipment such as a fridge, a food trolley, and floor-tiling. It was previously required for the extractor fans in the main toilets near the lounge to be fixed. Whilst this was reported to have been addressed, they were found on this occasion to again not be working, which can cause health and safety concerns. They were consequently reported to have been replaced. Management must ensure that they remain operational. A short tour of the premises raised only one concern with areas used by service users. It was found that some bedroom doors are being propped open, as per some service users’ choices. This however puts them at unnecessary risk should a fire happen, as the door will not shut automatically. It was agreed with management that, with the consent of the local fire authority, fire-alarm release mechanisms must be fitted to doors where service users would otherwise regularly have their doors propped open. Service users were seen to have equipment to help them manoeuvre around the house. This includes sticks and frames for independent use, and wheelchairs, hoists and lifts where needed. All bedrooms have staff-call bells. These were seen to be placed within reach of dependent service users who were using their rooms, as is appropriate. There were a couple of occasions where wheelchairs were seen to lack footplates. In one case, the service user was moved around with the wheelchair tipped back, which was both undignified and a health & safety risk. The manager must ensure that all wheelchairs have footplates in place, unless there are individual reasons for this. It is recommended that weekly checks of wheelchairs and hoists are recorded, so that any concerns with the equipment can be identified and addressed. Feedback from staff found that ten to fifteen of them have recently completed a distance-learning course on infection control. This includes housekeepers. Staff demonstrated how this has improved standards of cleanliness in the home. There were no concerns observed or raised in this respect, from service users and visitors, and from observations. The inspector came across no offensive odours during the visit. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Quality in this outcome area is poor overall. Strengths are that the home has a staff team who are committed to service users’ care, that improvements have been made to the provision of training for staff, and that staffing numbers are generally sufficient. Improvements however must be made to ensure that recruitment checks are sufficient to reasonably protect service users, and that new staff are provided with sufficient training promptly. EVIDENCE: Checks of the roster, and the record of who worked when, found that the planned staffing ratio in respect of reduced service user numbers, of six morning and five afternoon care staff, is mostly adhered to. The manager was aware of the need to review staffing levels when service user numbers or needs increase. The manager must ensure that the list of who actually worked is always recorded in the deputy handover book, as this is the only accurate system of showing who was present, and it did not always show this. Service users’ comments about staff were almost entirely positive. They all noted that staff treat them well. Relatives and visitors all said that there are enough staff working in the home. One visitor said that staff treat service users with respect and are truly devoted to their work. The manager noted that there are a few staff who have qualified at NVQ level 2 or 3 in care. A number of other staff have enrolled through the organization Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 22 to undertake such courses locally. She stated that the home will have achieved the expected standard, of 50 of staff being NVQ qualified, once this latter group achieve the qualifications. This will ensure that service users are supported by a staff team that is appropriately qualified and knowledgeable. The inspector undertook an audit of the training records and certificates of four staff who had started working in the home since the last inspection. Most had undertaken emergency first aid training, but gaps were identified with other standard courses such as for food hygiene, fire safety, manual handling, and protection from abuse. The lack of formal training for new staff puts service users at risk of poor support, which the manager must address. There were additionally no induction training records, despite staff stating that they had received the training including three weeks as supernumerary in one case. The manager must ensure that these are available for viewing as proof of providing a sufficient and timely induction into the work at this home. Checks of the training received by the cook and the activity worker found little in the way of training that directly related to their job roles. There was however evidence of planning in this respect. So as to develop the roles further, such training must be acquired. The inspector undertook an audit of the recruitment records of four staff who had started working in the home since the last inspection. Application forms, identification checks, work permits, and two written references were generally suitably in place. However, shortfalls in specific cases were found, which could put service users at risk of having unsuitable staff supporting them. This is also the case with the Criminal Record Bureau (CRB) disclosures, as these were insufficient in all four cases. Two were CRBs from previous jobs, whilst there were no CRBs in place of the other two staff. The improvements must be made: • For all current staff, a CRB disclosure that relates to employment with the organisation must be promptly acquired unless already in place. • POVA-First checks through the organisation must be in place for any new staff before they commence supervised employment in the home. CRB checks through the employer must be in place for staff to start work unsupervised. • Copies of the POVA-First checks in the cases of three named staff members, and any other applicable staff, must be promptly forwarded to the CSCI, to show that these staff members are not on the POVA list. • There must be records of the exploration by management of reasons for gaps in any applicant’s employment history, and that reasons for leaving employment are recorded on the application form or within interview records. There were shortfalls within the checks made. • Written references must always include a reference from the last carework employer of three or more months’ duration. This was not the case for one staff member. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 23 The requirements relating to CRBs and POVA-First checks were put to the registered people within an urgent action letter at the end of the inspection. Suitable plans have been supplied by the manager in response, at the time of drafting this report. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37 and 38. Quality in this outcome area is adequate overall. Strengths are that management are experienced and are attending relevant NVQ training, and that quality-auditing processes have improved so as to better audit service users’ views. Improvements must be made to ensure that all staff receive appropriate supervision, and that professional health and safety checks are brought up-to-date. EVIDENCE: The manager has many years’ experience of running this care home. She stated that she has been working towards the NVQ level four qualification since December 2005. There was evidence, through feedback and records, of appropriate management of the home. For instance, staff meeting records showed clear direction of expectations of staff, five out of six relatives’ comment cards stated that they are kept informed of issues affecting their relative, and Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 25 feedback from staff was positive about management support. There is additionally now a deputy manager who is also working towards the NVQ qualification. It was found that there have been only two supervision sessions with individual staff across the last year. Staff feedback indicated that they would like to receive supervision more often, as it is helpful with raising issues alongside other avenues for this. Supervision of staff was previously required, on a twomonthly basis, so as to also enable reviews of the staff member’s practices and to clarify training needs. The manager must ensure that this is addressed. Those service users asked reported that they are not ordinarily asked their views about the care in the home. The home conducted an audit of service users and relatives’ views in the summer of 2005, and the proprietor reports that he undertakes formal monthly reports on the care in the home as well as visiting it most days. Reports are usually sent to the CSCI. He noted that service users do raise issues with him. Management also noted that they had recently held a service users’ meeting, with more being planned for. The inspector judges that the home is overall undertaking suitable quality monitoring. In terms of records, it was established that the deaths of two service users, and an incident involving another service user, had not been reported to the CSCI promptly. The shortest gap was of two months. The manager must ensure that this is promptly addressed. She noted that the fax does not always work properly. It is recommended that this be addressed. There was some written evidence of suitable health and safety checks. For instance, water temperatures are monitored monthly. Professional checks of portable electrical appliances, and of the water against legionella, were up-todate. Professional checks of the fire extinguishers, the electrical wiring, the gas systems, the passenger lift, and the mobile hoists were all out-of-date according to records. The manager noted that some of these have recently been addressed, and agreed to provide paperwork as needed. Close inspection of the garden found many old lounge chairs lined up at the side exit awaiting disposal. There was also a sodden mattress near the exit on the other side. One back gate had come off its hinges. There was also extensive amounts of rubbish awaiting refuse collection, including bags on the ground that had been broken into by wildlife. Management explained that extensive refuse was due to a missed collection. All of these issues cause health and safety concerns, and so must be both addressed and prevented from reoccurrence. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 2 2 Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 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 service user guide must be filled in on key pages (e.g. pages 48, 61, and 124) to reflect the specifics of the home. It must include a copy of the standard contract used between your company and any service user (or representative), and must include a summary of the last inspection report. Timescale for action 01/08/06 2 OP7 15 3 OP7 15 4 OP7 15(2) Previous timescale of 1/11/05 not met. The manager must ensure that 15/06/06 care files are audited and that key support needs are clearly stated. Care files must include sufficient 15/06/06 guidance to staff about how to support service users with key needs in the areas of toileting (where needed). Previous timescale of 1/10/05 met met. The manager must ensure that 15/07/06 the system of reviewing and updating each service user’s care plan captures and aims to address all changed needs. DS0000017565.V290469.R01.S.doc Version 5.1 Page 28 Whitchurch Lodge 5 OP8 18(1)(a) 6 OP8 12, 17(1a) s3 pt 3m 13(2) 7 OP9 8 OP15 12, 24 9 OP15 12, 16(2)(i), 24 10 11 OP15 OP15 12 12(4), 16(2)(g) 12 OP15 13(3), 16(2)(g) 13 OP16 22 The manager must ensure that service users’ individual dependency profiles and nutritional audits are filled in correctly throughout. The manager must ensure that records of providing applicable service users with toileting support are kept up-to-date. The manager must ensure that the requirements of the CSCI pharmacy inspector’s report are addressed within the timescales provided. Service users must be consistently consulted about their meal choices and preferences, and about the overall menu. This must include regular audits of their satisfaction with meal provision. Service users must be consistently provided with varied, appetising and nutritious food. This applies for main meals, desserts, and evening meals. Management must undertake and report on audits in this respect. Menus for the day must be on display in advance of the meals. There must ordinarily be no plastic items for service users’ use with food and drink, such as with the plastic mugs and trays seen, unless where specifically identified as necessary for an individual service user’s needs. The majority of dining tables were found to be inherently sticky. This causes discomfort whilst eating, and so must be addressed. The manager must ensure that all complaints made about the home are captured in writing and are hence investigated. DS0000017565.V290469.R01.S.doc 01/06/06 01/06/06 01/06/06 15/06/06 15/06/06 01/06/06 15/06/06 15/06/06 15/06/06 Whitchurch Lodge Version 5.1 Page 29 14 OP18 13(6), 18(1)(c) 15 OP19 12(4), 23(2)(e) 16 OP19 12, 23(2)(a, e, g) 17 OP19 23(2)(b) The manager must ensure that new staff receive training in the protection of service users from abuse within a reasonable timescale after starting work in the home. The registered people must ensure that all doors in the building are checked, and that those that slam are altered to prevent the slamming. Arrangements must be made with service users who smoke cigarettes, to ensure that service users using the dining room for meals are not affected by passive smoking. Extractor fans in the toilets near the lounge there must automatically work. Previous timescales of 1/2/05 and 15/6/05 partially addressed. Fire-alarm release mechanisms must, with the consent of the local fire authority, be fitted to doors where service users would otherwise regularly have their doors propped open. The manager must ensure that all wheelchairs have footplates in place, unless there are individual reasons for this. The manager must keep a clear and up-to-date record of the shifts that were worked by staff in the home. Previous timescales of 11/7/05 and 1/10/05 partially met. The registered people must ensure that at least 50 of care staff become qualified in NVQ level-2 in care. Previous timescale of 31/12/05 partially met. DS0000017565.V290469.R01.S.doc 01/07/06 01/06/06 01/07/06 01/06/06 18 OP19 23(4) 01/08/06 19 OP22 23(2)(c) 01/06/06 20 OP27 17(2) s4 pt 7 01/06/06 21 OP28 10(1), 18(1) 01/10/06 Whitchurch Lodge Version 5.1 Page 30 22 OP29 Misc amnd regs 2(9) 23 OP29 Msc amd rgs 2(9, 11) 24 OP29 17(2) s4 pt6(f) 25 OP29 19 s2 pts 4 and 6 26 OP29 19 s2 pt 3 27 28 OP30 OP30 17(3)(b) 18(1), (2) For all current staff, the manager must ensure that a Criminal Record Bureau (CRB) disclosure that relates to employment with the organisation is promptly acquired unless already in place. POVA-First checks through the organisation must be in place for any new staff before they commence supervised employment in the home. CRB checks through the employer must be in place for staff to start work unsupervised. Copies of the POVA-First checks in the cases of three named staff members, and any other applicable staff, must be promptly forwarded to the CSCI, to show that these staff members are not on the POVA list. There must be records of the exploration by management of reasons for gaps in any applicant’s employment history, and that the reasons for leaving previous employment are recorded on the application form or within interview records. Written references for staff must now always include a reference from the last care-work employer of three or more months’ duration. The manager must ensure that induction training records are always available for viewing. The manager must ensure that new staff always receive essential (statutory) training within a suitable timescale. This will include for food hygiene, fire safety, manual handling, and protection from abuse. 01/06/06 01/06/06 01/06/06 01/06/06 01/06/06 01/07/06 01/09/06 Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 31 29 OP30 18(1)(c) 30 OP36 12, 18 The registered people must ensure that cooks and the activity worker receive formal training that directly relates to their job roles. Supervision must be provided at least six times a year for all care staff. Previous timescales of 31/7/03 partially met. The manager must ensure that all notifiable incidents within the service are always promptly reported to the CSCI. The manager must ensure that professional checks are up-todate and suitable in respect of: • Fire extinguishers; • Electrical wiring; • Gas systems; • The passenger lift; and • Mobile hoists. The registered people must ensure that all the items awaiting disposal in the garden are promptly disposed of, and that there is no undue delay in future disposal of similar items. 01/10/06 01/06/06 31 OP37 37 01/06/06 32 OP38 10(1), 13(4), 23(2c) 01/08/06 33 OP38 23(2)(o) 01/06/06 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 OP7 Good Practice Recommendations It is recommended that monthly reviews of each service user’s individual care plan record any significant events for the service user since the previous review, and that shortterms plans are then adjusted based on this. It is recommended that the actual times of providing each applicable service user with toileting support be recorded within their care file, so as to help ensure that suitable DS0000017565.V290469.R01.S.doc Version 5.1 Page 32 2 OP8 Whitchurch Lodge 3 OP12 4 OP15 5 6 7 8 9 10 OP15 OP15 OP16 OP22 OP37 OP38 toileting support is provided. It is recommended that further discussions and audits take place around what service users as a whole, and individually, would like in terms of activities and occupation, and that a clear plan to address this is developed. It is recommended that there be group discussions, involving service users and key staff, about the meals provided, about what meals service users would like, and with occasional sampling and taster sessions for different foods and meals. It is recommended that these themes above be part of the any formal auditing of service users’ opinions. It is recommended that menu displays include a pictorial format if there are service users who can no longer work effectively with the written format. It is recommended that complaint procedures be clarified with relatives and visitors based on poor feedback of awareness from comment cards. It is recommended that weekly checks of wheelchairs and hoists are recorded, so that any concerns with the equipment can be identified and addressed. It is recommended that the fax be fixed or updated if not working properly. The manager is recommended to audit and update the risk assessments about general hazards to people in the home. Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 33 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitchurch Lodge DS0000017565.V290469.R01.S.doc Version 5.1 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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