Inspection on 23/11/06 for Wilhelmina House

This inspection was carried out on 23rd November 2006.

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

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

Other inspections for this house

Wilhelmina House 07/05/07

Wilhelmina House 09/12/05

Wilhelmina House 08/07/05

Wilhelmina House 16/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Wilhelmina House 21 Parkhill Rise Croydon Surrey CR0 5JF Lead Inspector David Halliwell Key Unannounced Inspection 27th November 2006 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 Wilhelmina House DS0000025870.V321384.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. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilhelmina House Address 21 Parkhill Rise Croydon Surrey CR0 5JF 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 8760 0933 020 8760 0933 NO EMAIL The Dutch Home for the Elderly Limited Deborah Pearson Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th December 2005 Brief Description of the Service: Wilhelmina House was established as a registered charity by the Dutch church in London and aims to provide a sheltered environment for elderly men and women who no longer wish to live independently. It is not a nursing home and is primarily intended for people in reasonably good health. The home was opened in 1984 as a purpose built unit and is registered to provide residential care for up to twenty-one older people. Wilhelmina House is situated in a primarily residential area close to East Croydon station, Lloyd Park and other community facilities. On the day of the inspection there were twenty service users living at the home. Each service user has a bed sitting room with an en suite toilet and wash hand basin. The home has spacious communal areas on the ground floor consisting of a lounge, dining area and a large conservatory, the kitchen and laundry areas are clean and well equipped. Sufficient numbers of baths/ showers wash hand basins and lavatories are available throughout the home. There is a large well-maintained garden to the rear of the property and ample parking space. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit undertaken by the new Inspector responsible for Wilhelmina House. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 3 staff and the Registered Manager. 4 service users were spoken with formally and more informal interviews were conducted with 6 other Service Users as a part of the tour of the home. A member of the Committee was present on the day of the inspection and she is to be thanked for her assistance with the inspection. 3 new requirements have been made as a result of this inspection, all of the previous requirements have since the last inspection been met. 2 new recommendations have been made and the previous 2 recommendations remain in place as they have not yet been met. Feedback on these requirements and recommendations was given verbally to the Manager and to the Committee member who was present at the end of the inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was impressed by the commitment and enthusiasm of the Manager and of the staff group. The Manager informed the Inspector that the standard fees for a standard residential placement at this home are £415 per week. What the service does well: The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their relatives and friends are able to visit and to assess the quality, facilities and suitability of the home. The health care needs of service users are being well met. Service users are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Service users generally presented as well settled in their environment, and very satisfied with the communal and personal facilities provided. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 6 The home is being managed the home in an open, professional and competent manner by Deborah Pearson. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 & 6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be assured that they will have their needs assessed and that these needs will be met. EVIDENCE: Standard 3 - As a part of the inspection the Inspector examined 4 service user files of the 40 residents living at Wilhelmina House. In each of these files a comprehensive needs assessment was seen. The Manager told the Inspector that the referring authorities will usually provide an assessment of the prospective residents needs prior to admission. The Manager of the home then undertakes a thorough in house assessment of all prospective service users needs prior to a decision being taken regarding admission. This includes an Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 10 assessment of the person’s health, risk factors, mobility and the compatibility of the person to ‘fit in’ with the current service users. The assessment is completed with the service user, his/her relative or representative and with the relevant professionals that have been associated with the referral. Religious and cultural needs are a part of the needs assessments seen in the resident’s files and all care plans are based on the information contained in the needs assessments. Standard 6 - Intermediate care is not provided for at Wilhelmina House so this Standard has not been assessed. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their health, personal and social care needs will be the central focus of their care plans and that these plans will be appropriately reviewed as and when required. Service users can also be assured that their healthcare needs will also be met at Wilhelmina House. Medication administration is being appropriately managed and properly recorded and stored, and residents are being protected by the home’s policies and procedures for dealing with medicines. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 12 EVIDENCE: Standard 7 – As indicated above the Inspector examined 4 residents’ files and found that on each file appropriate needs assessments had been drawn up. Service user plans / care plans had been constructed from these needs assessments and the Inspector was impressed with the detail covered in these plans. All the care plans inspected were seen to be reviewed monthly, the date of the review being recorded on file. It was clear from the care plan records held on the files that all the appropriate people are usually involved in the care plan reviews including the resident and their relatives where appropriate or their representatives. The Inspector spoke to 2 relatives of 2 of the residents who also confirmed that their parents care plans are reviewed and that they are normally involved in the process. The Manager informed the Inspector that after the initial placement of a new resident an intermediate care plan is now being drawn up before the 6-week review. After the 6-week review, the care plan is revised and then reviewed monthly. At the last inspection a requirement was made to ensure that interim care plans are in place for newly placed service users and this requirement has now been met. All the documents required under Schedule 3 were seen on the residents files inspected. Standard 8 – This standard is concerning the healthcare of each of the service users. The Registered Manager informed the Inspector that all the service users do have access to a GP. The Registered Manager also told the Inspector that all residents have access to the following health care professionals who visit Wilhelmina House on a regular basis. The optician visits every 3 months and at the time of this inspection Healthcall, the opticians were visiting the home. The dentist visits once every 6 months and the chiropodist also visits on regular basis every 6 weeks. This information was supported by the 6 residents who the Inspector spoke to over the course of this inspection. Dietary needs are assessed for each service user at the time of their admission and then re-assessed as required this includes a nutritional assessment. Evidence of this was seen by the Inspector on the service users files and staff formally interviewed also said that this was the usual practice as a part of the assessment process for service users. Standard 9 – The Inspector was provided with the agencies policies and procedures manual by the Registered Manager and this file included an appropriate medication policy for the unit. The Registered Manager told the Inspector that the usual practice for the administration of medicines at Wilhelmina House is for staff to give the residents their medication. All staff receive appropriate training to ensure that this is done safely and the residents Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 13 are protected by safe and appropriate practices. Training records were presented to the Inspector for the care staff and it was clear that regular training is provided every year on the safe handling of medicines. The last training was held on 13th April and 7 staff attended this training course. A further member of the care staff attended training in September and another in October of this year. Appropriate records (MAR sheets) were seen to have been completed properly for the administration of medicines to service users. Standard 10 - The Inspector spoke with 9 of the 20 residents at Wilhelmena House about the quality of the care they receive to meet their needs. The Inspector was impressed with the positive remarks made by service users about the care and support that they receive from staff at Wilhelmina House. The Inspector was also impressed by the commitment of the 3 staff, formally interviewed by the Inspector, to maintaining the dignity and privacy of the residents wherever possible. All the residents receive personal care and some are helped with washing and bathing, dressing and toileting. Care staff interviewed showed the Inspector by their responses their caring attitude towards the residents and service users in their comments about staff also reflected this. All of the bedrooms have en suite toilet and bathing facilities and this also helps residents to maintain a level of privacy that they welcome. All residents have their laundry done individually by their key workers and this systematic method ensures that residents are able to wear their own clothes when they like. The staff induction programme which all new staff has to work through covers the core standards of privacy, dignity, independence, civil rights, fulfilment and choice. Evidence seen by the Inspector on the staffing files showed that all new staff has received this training. Standard 11 – At the last inspection a requirement was made with regards to the views and wishes of the service user, regarding the arrangements concerning their illness and death and that wherever possible information regarding this should be obtained and recorded on the service user’s file. The Inspector was told by the Manager that since that requirement was made the home has been recording this information for all new residents admitted to Wilhelmena House. Inspection of the files confirmed that this has been done as stated so the previous requirement has now been met. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users / residents are likely to find that the lifestyle they experience at Wilhelmena House matches their expectations and their preferences and satisfies their social, cultural, religious and recreational interests. Residents are encouraged to maintain contacts with their friends and families and service users are helped to exercise choice and control in their lives wherever possible. The meals and food provided to residents is well balanced, healthy and varied. EVIDENCE: Standard 12 - During the course of this inspection the Inspector saw the programme of entertainment and events, which are provided for the service users and residents. The Manager informed the Inspector that the home Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 15 employs an activities officer who works every week at Wilhelmena House from Tuesdays to Fridays and who organises a varied and interesting social calendar for the residents including exercises and appropriate activities. The Inspector noted that a computer has been provided for the resident’s use and some training is provided to enable them to use this opportunity. 4 residents told the Inspector that they really enjoy this facility and one resident gave the Inspector a copy of the bi-monthly news sheet that is produced from contributions made by the residents. The Inspector spoke to 10 of the residents and asked them all whether they enjoyed the different forms of entertainment offered to them. All the residents said that they do enjoy what is offered. The Manager informed the Inspector that the resident’s religious and cultural needs are assessed as a part of their initial assessment and placement at Wilhelmena House. Residents are encouraged to attend church if they wish to and staff will assist them to do so. Standard 13 – The Inspector was told by the Manager and the staff that there are no specific visiting hours and that as long as a resident wishes to see a relative then visitors are welcome at most times of the day. A record of visitors was seen and visitors can be entertained in communal areas as well as the resident’s own bedrooms where relatives, families and friends can be seen in private if they wish. Residents confirmed this with the Inspector. Standard 14 – This standard explores issues relating to: managing financial affairs, advocacy, respecting of the right to personal possessions, and enabling access to information kept concerning a service user. A number of service users still have some control over their own affairs and this is encouraged, where appropriate and assessed on admission to the home. Permission is positively given to service users who wish to bring in items of furniture or other familiar items when entering the home; the only provisio is that these items be safe from the point-of-view of fire and soundness. Standard 15 – As a part of the inspection the Inspector spoke with the Chef at length and discussed the menu planning and the food provided to the residents. The Chef informed the Inspector that there is a 4-week rolling menu planner and the Chef draws that this up after consultation with the residents at the Residents meeting forum, who are asked what they would like to eat. Any special dietary requirements are also taken into account and provision is made in the menu plan. The Inspector saw both the 4-week menu plan and the daily menus and these menus provide a wide and healthy range of food for the residents. The Inspector was present for the lunch and evening meals and was able to speak to the residents at these times about the food. All the residents who were asked by the Inspector said that they like the food on offer to them and they confirmed that they do have a choice. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 16 Menus are displayed in the dining room and this enables the residents to see what they will have to eat and what choices they have on a daily basis. Care staff was seen to provide assistance to the residents when this was necessary and staff were seen to ask the residents before they offered any help to them. Meal times were seen to be unhurried and any resident who chose to eat in their bedrooms was enabled to do so. The Manager informed the Inspector that a nutritional assessment is undertaken as a part of the residents needs assessments and any special needs are catered for in the menu planning. The kitchen was seen to be in very good order by the Inspector and the menus offer residents a healthy, varied choice of food that they all said they enjoy. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home will deal with complaints appropriately; information about the complaints procedure is readily available to all who may wish to express an opinion about the service. Service users can be assured that the processes in the home will protect them from potential abuse by staff or others. However staff training needs to become more regularised for all staff working in the home. EVIDENCE: Standard 16 – The Registered Manager showed the Inspector the complaints policy and procedure for Wilhelmina House. This policy covers all the essential areas required for a complaints policy including a staged process with timescales and contacts for other agencies including the CSCI to contact in the event of dissatisfaction with the internal process of investigation. The Registered Manager maintains a record of complaints and the Inspector saw this. No complaints had been recorded since the last inspection. Standard 18 – Wilhelmina House has an Adult Protection policy and the Registered Manager showed the Inspector a copy of it. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 18 Of the 3 staff who were interviewed 1 confirmed that they had been on training for the protection of vulnerable adults (POVA) but 2 members of staff said that they had not, although they were aware of the policy. However from the interviews with staff the Inspector identified a need for more regular and comprehensive training for all staff and discussion through supervision to further embed the principles of the policy. There was a discussion with the Registered Manager about this and it was agreed that further discussion needs to be had with staff in the supervision process. Staff members are all thoroughly vetted and recruitment assures that nobody starts at the home until their credentials with regard to the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults Register have been checked. The Inspector reviewed 4 of the staffing files and found valid CRB enhanced checks for all these staff. The Registered Manager confirmed she was conversant with the procedures for the referral of staff to the Vulnerable Adults ‘List’ and for gaining POVA first documentation before the full CRB enhanced checks. The home’s policies and procedures cover all essential areas of guidance, including physical intervention, service user’s finances, insurance and such issues as gifts gratuities and bequests. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Residents generally presented as well settled in their environment, and as being very satisfied with the communal and personal facilities provided. EVIDENCE: Standard 19 – A tour of the premises was undertaken by the Inspector as a part of this inspection and the home was seen to be clean and tidy in all areas. All areas of the home are accessible to wheelchair users and there is a lift which provides access to all floors of the building. There are at present no residents who use a wheelchair living at Wilhelmina House. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 20 The general condition of the home and the facilities is good; communal areas and bedrooms are kept clean and odour-free. The proprietors provide a ‘homely’ touch through supplementary decoration and ornaments / flower decorations and pictures hanging on all the walls. There is a conservatory at the back of the house which has a commanding view over the garden and which all the residents said they really enjoyed sitting in at any time of the year. One or two residents said that they like to do a little bit of gardening with support from either the gardener or the handyman. The Manager showed the Inspector the fire records for the home. The LFEPA last visited Wilhelmina on 30.3.06. This followed a visit they made in January 2006 at which several requirements were made. The Inspector viewed each requirement and can now report that they have since been met and this was confirmed by the LFEPA in a letter held on the records after their visit on 30.3.06. Records were also shown to the Inspector by the Manager for other safety checks that have been carried out this year and that are part of a regular process of checks carried out to help ensure the safety of the residents. Records of the following satisfactory checks were seen: • Lift – 23.6.06 • Fire bells – 3.7.06 • Emergency lighting – 3.7.06 • Environmental health – food hygiene 8.11.06 – all satisfactory. Checks on the hot water outlets are also checked. Although the bathroom outlets are being checked weekly not all the hot water taps in residents bedrooms are being checked weekly and so it is now a requirement that a system similar to that discussed with the Registered Manager is devised so that there can be surety that all the hot water taps/ outlets have been checked at least once every month and full records made of these checks including details of what tap was checked when and what the temperature actually was recorded as being at the time of the check. The hot water check is designed to see what the absolute maximum temperature of hot water can be drawn from the tap - in order that it can be confirmed that the thermostatic mixer valves are fully operational. Staff do, apparently, check and record the temperature of bath water when bathing a service user (which is commendable) - but the risk of scalding / burns (which can occur in unusual situations) can only be properly avoided when valves are properly and regularly monitored. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 21 Bathing equipment - such as bath seats and non-slip mats at this inspection were noted to be clean and in good working order. Standard 26 – As already indicated above, the home was found at this inspection to be clean, tidy and free from offensive odours. The Inspector toured the unit together with the Registered Manager and inspected all areas of the home. Several of the service users bedrooms were seen and were found to be clean and tidy and all the residents spoken to by the Inspector said that their bedrooms are decorated and furnished, as they would wish. The Registered Manager showed the Inspector the home’s infection control procedure, which seems to be effective. Staff interviewed confirmed that they are issued with appropriate clothing and equipment for them to carry out their work appropriately The laundry area is well laid out and there is an impermeable floor laid down to prevent water ingress and easy cleaning. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, these need to be more robustly applied. Comprehensive records are being maintained, with staff photographs, as proof of identity, now being attached to staff files. Staff are being provided with the necessary induction and training with which to competently perform their work duties. EVIDENCE: Standard 27 – At the start of this inspection the Inspector was provided with a staffing rota for Wilhelmina House by the Registered Manager. The rota shows exactly who is working for the week. The Manager informed the Inspector that there are usually 3 care staff on duty for the am shifts and 3 care staff for the pm shifts. A manager is on duty during the day and on call at nights. There are always 2 waking night staff on duty. The rota provided supported this statement. Given that that there are 20 residents living at Wilhelmena House at present the staff: resident ratio mix seems adequate to meet the needs of Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 23 the residents. The home also has kitchen and domestic staff who the Inspector met over the course of this inspection. The Registered Manager told the Inspector that no agency staff are used at Wilhelmena House. Standard 28 - The staff bank numbers around 16 care staff in total including senior carers but excluding the Manager and Deputy Manager. Of these 16 care staff 7 hold an NVQ at level 2 or above. Both the Manager and the Deputy Manager hold NVQ level 4 qualifications. The Inspector explained to the Manager that by next year all care staff would need to be NVQ qualified to at least level 2. The Registered Manager told the Inspector that she is a qualified NVQ assessor. Standard 29 – Wilhelmina House does have a recruitment procedure that was inspected and seen to be appropriate for it’s purpose. As a part of this inspection the Inspector reviewed 4 of the staffing files. Applicants are interviewed, application forms completed, two written references gained, enhanced Criminal Record Bureau checks undertaken and documentation regarding all these parts of the recruitment process are held on staffing files in the main office at Wilhelmena House. On the files inspected the Inspector saw evidence that this process is being properly implemented. Contracts with staff were also seen on the staffing files and the 3 care staff interviewed all confirmed that they hold a copy of their contracts of employment with Wilhelmena House. Standard 30 – The home’s Manager places a great deal of emphasis on training and staff development. The home has a programme of induction and foundation training in place. This includes input in managing elderly persons and is in line with NTO (National Training Organisation) workforce training targets. The Manager advised that the programme includes two days of formal induction; this covers roles and responsibilities, and key policies and procedures. Induction is ongoing for up to a month with observation, shadowing from an experienced staff member and ongoing assessment. The programme includes training in Health and Safety, Food Hygiene, Fire Safety, Basic First Aid and Manual Handling, and is based on the TOPSS (National Training Organisation for Social Care) standards. Staff training files inspected evidenced training certificates and records of training undertaken. With regards to staff competency it is important that all staff are familiar with the home’s policies and procedures. The Inspector asked the Manager if staff are given the opportunity to read and discuss these policies and procedures as a part of the supervision process and whether they are then asked to sign to Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 24 say that they have read and understood the same policies. The Manager said that this practice was not carried out in all cases and not for the key policies in place for the unit. In order for this process to be fully implemented and so as to benefit residents in that the staff will know and understand what the stated policies and procedures are, it is now a requirement that all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a period of time and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. Following the discussion at supervision it is also recommended that the Manager provide each and every one of the staff at Wilhelmina House with a staff file of their own and which contains copies of the key procedures discussed with them, a copy of their job descriptions and of their contract of employment as well as a copy of their supervision meeting records. This should assist staff to fully understand the homes policies and procedures and to be completely clear about their roles and functions within the unit. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 25 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): Standards 31, 32, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Prospective residents may be assured that the home is well run and managed by a person who is fit and able to be in charge of the day-to-day operations of the unit. They will benefit from the leadership and management approach taken in the unit. The quality assurances processes being used in the home ensure that it is being run in the best interests of the residents and residents financial interests are safeguarded. Staff are supervised regularly however the process being used needs some regularisation. The health and safety of staff and residents is being promoted and protected. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 26 EVIDENCE: Standard 31 – The Manager has been in the management role at Wilhelmena House for over 2 years and holds the necessary experience to undertake this role. The Manager informed the Inspector that she supplements this experience with relevant training and evidence was seen in the training portfolio that supports this. Standard 32 – The Manager showed the Inspector the minutes of the staff team meetings that are held every 2 months. The minutes demonstrated that these meetings are well attended but it is recommended that the minutes always need to be signed and dated if they are to form a proper record of the event. Evidence of residents meetings was also provided to the Inspector and these records show that they are held every 2 months and that a wide variety of relevant issues are raised and discussed by the staff and residents together. These include food and menu planning, social activities, new residents and impending visits by any of the health professionals that visit the home regularly. Standard 33 – Monitoring of this agency, quality assurance [QA], is through formal and informal consultation with service users and from visiting relatives and professionals. Feedback forms are issued and questions asked focus on the key principles of the service e.g. privacy, dignity, independence, choice, rights and fulfilment. The information and feedback gathered from these sources is then analysed and forms the basis of the annual development plan that includes implementation targets, with dates as milestones that can be measured and monitored. Staff are allocated areas of responsibility and the Committee for Wilhelmena monitors the progress being made. Residents are provided with information about all aspects of this process via residents meetings and newsletters. The Inspector would like to commend Wilhelmina House on the excellent model for Quality Assurance and the detailed system that is in place for using the information gathered, to develop and improve services being provided and feedback given to service users on the progress made. Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 27 The general feeling within the home was warm and congenial; both staff and management were open and communicative and little sense of anxiety was apparent with service users. Standard 35 – The Manager told the Inspector that Wilhelmena House does not look after residents monies directly and that if a resident does need something to be purchased the Manager may make the purchase but only after speaking with the resident’s relative or representative who then will repay Wilhelmena House. Standard 36 – The Manager informed the Inspector that all care staff receive formal supervision at least once every 3 months and informal supervision more often, sometimes on a daily basis. Supervision records were seen by the Inspector in the staffing files inspected. These records were signed by staff in agreement with the record made by their supervisor but the records were quite varied in their recording content, some not covering sufficient detail to form a useful record. Senior staff carry out supervision as well as the Manager and a Committee Member and as a consequence several different recording approaches are taken when writing the supervision records. The Inspector spoke with a Committee member and the Manager about this and confirmed that supervision sessions held with staff should include the monitoring and review of all aspects of care practices, the philosophy of care in the home and also career and training development needs. Areas of discussion should also cover the monitoring and review of any individual work objectives that the staff member is expected to carry out. The supervision record should detail any agreements made, revised work objectives, key areas of discussion and should be signed off by both the member of staff and the supervisor. Staff who are supervised should be given a copy of the supervision record which they may keep in their staff handbook file. The 3 care staff who were interviewed confirmed that they receive supervision on a regular basis and that formally they receive supervision approximately once every 2 – 3 months and that they have informal supervision much more regularly. Staff said that they did not receive copies of their supervision records. The Manager informed the Inspector that future training on staff supervision is planned for next year and a training course programme was shown to the Inspector. This should help to ensure that supervision and staff appraisals are carried out consistently and effectively. Appropriately structured policies were seen by the Inspector for induction, training and supervision in the home’s policies and procedures manual. It is a requirement that following the inspection of this standard that: Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 28 • • • A single supervision-recording format is used that covers the areas outlined above in sufficient detail to ensure a useful record is maintained for both the staff and the management if the need arises in the future. That all senior staff who provide supervision should receive staff supervision training and that this should be completed within the next 6 months. This should help to ensure consistency in the delivery of supervision. That all staff should be given a copy of their supervision record following the supervision meeting. Standard 38 - the Manager showed the Inspector a maintenance record book for the home which details all the maintenance requirements and how and when they have been resolved. The home is generally well maintained and the process seems to work well. The Manager informed the Inspector that risk assessments have been carried out for fire risk – June 2004; COSSH – 2006; a general risk assessment – October 2006 and that individual risk assessments have been carried out for all the residents in the unit and evidence of this was shown to the Inspector. The policies and procedures manual includes policies on health and safety, risk assessment, moving and handling and fire. Some staff have been trained over the last 2 years in the following areas: • Infection control • Food hygiene • First Aid • Fire awareness • Using fire fighting equipment • Health & Safety • Safe handling of medicines • Moving and handling • POVA However there is a need for all staff to receive more regular training in these key areas and it is recommended that for each staff member a training file is compiled which includes a list of training that each staff member has received and when; certificates which evidence that the training has been given and received; and a list of training needs identified through 1:1 supervision that should be provided for by additional training in the year ahead. Certificates were checked and seen by the Inspector for the following services that are installed in the home, certificates which state that these systems have been checked by appropriate professionals since the last inspection and found to be satisfactory and fit for purpose. 1. Boiler / gas – 12.6.06 Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 29 2. 3. 4. 5. 6. 7. 8. 9. Electrical system check – 5.06 Lift – 2.4.06 Fire bells – 23.6.06 Emergency lighting system – 3.7.06 Fire fighting equipment – 18.5.06 Water check for legionella organisms – valid to 30.3.07 Nurse call system – 19.10.06 Portable electrical appliances – 18.7.06 Records were also seen and checked by the Inspector as satisfactory for: 1. Weekly fire alarm tests 2. Staff fire drills every 2 months 3. Fire extinguishers visually checked monthly Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 30 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 4 X 3 2 X 2 Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? No. 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. 2. Standard OP19 OP30 Regulation 23 18 Requirement Checks on all the hot water outlets are made. That all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a period of time and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. Timescale for action 01/01/07 01/04/07 3. OP36 18 It is a requirement that following 01/04/07 the inspection of this standard that: • A single supervisionrecording format is used • That all senior staff who provide supervision should receive staff supervision training • That all staff should be given a copy of their supervision record following the supervision meeting. DS0000025870.V321384.R01.S.doc Version 5.2 Page 32 Wilhelmina House 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. Refer to Standard OP11 OP30 Good Practice Recommendations The inspector recommends that all care staff undertake training in bereavement and loss. The Manager provide each and every one of the staff at Wilhelmina House with a staff file of their own and which contains copies of the key procedures discussed with them, a copy of their job descriptions and of their contract of employment as well as a copy of their supervision meeting records. The minutes of staff meetings always need to be signed and dated if they are to form a proper record of the event. For each staff member a training file is compiled which includes a list of training that each staff member has received and when; certificates which evidence that the training has been given and received; and a list of training needs identified through 1:1 supervision that should be provided for by additional training in the year ahead. 3. 4. OP32 OP38 Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Wilhelmina House DS0000025870.V321384.R01.S.doc Version 5.2 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. 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