Inspection on 07/05/07 for Wilhelmina House

This inspection was carried out on 7th May 2007.

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

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

Other inspections for this house

Wilhelmina House 23/11/06

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 7th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wilhelmina House DS0000025870.V336749.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.V336749.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 Mrs 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.V336749.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2006 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.V336749.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 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 2 staff and the Registered Manager. 4 service users were spoken with formally and 3 residents friends or relatives were also spoke with as a part of this inspection. 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. 2 new requirements have been made as a result of this inspection and 2 of the previous requirements remain in place, as they have not yet been fully met. 3 of the previous recommendations remain in place as they have not yet been met and 1 new recommendation has been made. Feedback on these requirements and recommendations was given verbally 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. 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.V336749.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Specific improvements are now required and recommended in the following areas: 1. The Registered Manager must arrange for detailed risk assessments (that are also reviewed) to be carried out for all those residents who self medicate. This should help ensure that risks associated with selfmedication are reduced. 2. That the Registered Manager ensures that the requirements made as a result of the Environmental Health Officer’s visit on 29.1.07. • that a hazard analysis for the kitchen be written up for food safety, • that the cooker hood canopy is deep cleaned, and • that staff ensure that the cat cannot enter the kitchen. • This should assist in helping residents to continue to live in a safe, well-maintained environment. Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 7 3. 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. 4. That all senior staff who provide supervision should receive staff supervision training. 5. 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. 6. That an administrative post be established within the home. 7. That the frequency of staff meetings be increased to once every 2 months. 8. 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. 9. That for the Manager ensures that those members of staff still have not received the POVA and NVQ training do so this year. 10. That the Manager ensures that staff contracts are placed on all of the staffing files in this home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wilhelmina House DS0000025870.V336749.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.V336749.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): Standard 3. Standard 6 is not applicable to this home as it does not provide intermediate care. 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. Residents may be assured that their needs will be thoroughly assessed and reviewed by their referring agencies, they may also be assured that their needs will continue to be fully assessed at Wilhelmina House and that fully completed documentation will always be held on their files. EVIDENCE: Standard 3 - As a part of this inspection the Inspector examined 4 service user files of the 20 residents living at Wilhelmina House. These 4 files were not the same files as reviewed at the last full key standards inspection in 2006. 2 of Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 10 the files belonged to 2 new residents who moved into Wilhelmina since the last inspection. In each of these files a comprehensive needs assessment was seen. The referring authorities had provided an assessment of the prospective residents needs prior to admission and the Inspector on each of these files saw evidence of this. There was also evidence of the home’s own thorough in house assessment of the service users needs prior to a decision being taken regarding admission. It included an 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. A review of the needs assessment is carried out every 6 months and evidence of this was also seen together with revised care planning documentation. Wilhelmina House DS0000025870.V336749.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 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.V336749.R01.S.doc Version 5.2 Page 12 EVIDENCE: Standard 7 – The Inspector examined 4 residents’ files (including 2 new resident’ s admissions) 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 regularly, 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 and 1 friend of another resident who all confirmed that the residents care plans are being reviewed and that they, or a member of the families 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. All the documents required under Schedule 3 were seen on the residents files inspected. Standard 8 – This standard concerns 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, the dentist every 6 months and the chiropodist also visits on a regular basis. This information was supported by 6 residents who the Inspector spoke to over the course of the last 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 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 are protected by safe and appropriate practices. Training records were Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 13 presented to the Inspector for the care staff and it was clear that regular training is provided on the safe handling of medicines. 2 staff interviewed confirmed that this with the Inspector. Some residents do however administer their own medication and where this is the case it is required now that the Registered Manager arrange for detailed risk assessments to be carried out for those residents and to ensure that they are reviewed as the persons needs and abilities to self medicate may change. Appropriate records (MAR sheets) were seen to have been completed properly for the administration of medicines to service users. Together with the Senior Care Staff the Inspector carried out a random stock take check of the medicines held in the home’s medicine cabinet and the numbers indicated on the MAR sheets. These tallied appropriately confirming that the administration and storage practices staff are using are accurate and appropriate. Standard 10 - The Inspector spoke with 4 of the residents at Wilhelmina House and 3 relatives of residents about the quality of the care they receive to meet their needs. As was found at the last inspection, the Inspector was impressed with the very positive remarks made about the care and support that residents receive from staff at Wilhelmina House including maintaining the dignity and privacy of the residents wherever and whenever 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 Manager told the Inspector that the staff induction programme covers the core standards of privacy, dignity, independence, civil rights, fulfilment and choice. Evidence was seen by the Inspector on the staffing files. Wilhelmina House DS0000025870.V336749.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 do feel that they are treated with respect and their rights to privacy are upheld. Residents are also likely to find that the lifestyle they experience at Wilhelmina 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 – Over the course of the last inspection the Inspector was shown the programme of entertainment and events, which are provided for the service users and residents. The Manager informed the Inspector that the Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 15 home 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. Residents had told the Inspector that they really enjoy this facility. The Inspector spoke to 4 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 Wilhelmina 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 may 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 and one friend of a resident was seen by the Inspector to be talking together in the resident’s bedroom. 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 given positively 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 – There is a 4-week rolling menu planner and the Chef draws this up after consultation with the residents at the Residents meeting forum where residents are asked for their comments on the menu provided and whether there are any special requests. Any special dietary requirements are 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 lunch and was able to speak to the residents 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. 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 Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 16 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. Where necessary and where there are special dietary requirements a daily record of the resident’s food intake is kept together with weight charts and this information is used by care staff to help support the resident appropriately. The Inspector on the service users files saw this information. The kitchen was again 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.V336749.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): Standards 16 & 18. 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 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.V336749.R01.S.doc Version 5.2 Page 18 The Manager told the Inspector that it is policy to ensure that all care staff receive training for the protection of vulnerable adults (POVA) but that some members of staff still have not received the training although they were aware of the policy via induction training. The Manager said that all the staff who have not yet received POVA training over the last 2 years are enrolled with the L.B Croydon’s POVA training programme. A Committee Member told the Inspector that if this training becomes delayed then they would consider using another source of training in order to meet their staff needs and thereby ensure the continued protection of the residents. 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. There are sufficient organisational policies to safeguard the residents’ welfare e.g. dealing with abuse and a whistle blowing policy. The Manager told the Inspector that all 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. At this inspection the Inspector reviewed 4 new staffing files and found the recruitment checks referred to by the Manager had been carried out as specified. Although the Inspector was not able to see the actual CRB certificates, given that the documentation had earlier been placed in the home’s safe, the Registered Manager confirmed that these documents were all up to date and valid at this time. Wilhelmina House DS0000025870.V336749.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 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 – the Inspector undertook a tour of the premises and the home was again seen to be clean and tidy in all areas. All areas of the home are accessible to wheelchair users and there is a lift that 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.V336749.R01.S.doc Version 5.2 Page 20 The general condition of the home and the facilities is consistently very good; communal areas and bedrooms are kept clean and odour-free. The Manager and staff 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. As with the last inspection several residents told the Inspector that they like to sit in the conservatory and to do a little bit of gardening with support from either the gardener or the handyman. The LFEPA last visited Wilhelmina on 30.3.06. This followed a visit in January 2006 at which several requirements were made. Mention of this was made at the last inspection where the Inspector viewed each requirement and reported that they had since been met. No subsequent visit has been made by the LFEPA since the last inspection. 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 – 18.1.07 • Fire bells – 8.5.07 • Emergency lighting – 27.4.07 • Environmental health – food hygiene 29.1.07. As a result of the Environmental Health Officer’s visit on 29.1.07 three new requirements were set: 1. that a hazard analysis for the kitchen be written up for food safety, 2. that the cooker hood canopy is deep cleaned, and 3. that staff ensure that the cat cannot enter the kitchen. It is required that these issues be addressed in order to ensure that residents may continue to live in a safe, well maintained environment. At the last inspection a requirement was made for the Manager to ensure that there is at least a monthly check carried out for all the hot water outlets in the home. At this inspection the Manager told the Inspector that a new system has been devised and implemented since January 2007 that does ensure these checks are carried out as required. The Inspector met the maintenance man, John Richards, who carries out these checks and he showed the Inspector the records. These demonstrated that all the hot water outlets are now being tested every month and that the hot water is within the accepted temperature Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 21 range. This will help to ensure the safety of the residents and reduce the risk of scalding or burning. The previous requirement has now therefore been met. 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, hygienic, tidy and free from offensive odours. The Inspector toured the unit and inspected all areas of the home. Three of the service users bedrooms were seen and were found to be clean and tidy and all of the residents spoken to by the Inspector said that their bedrooms are decorated and furnished, as they would wish. The Inspector saw the home’s infection control procedure that is also available in the staff room for ease of access and it seems to be effective. 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.V336749.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 good. This judgement has been made using available evidence including a visit to this service. The resident’s needs are being met by the numbers and the skills of the staff. They are being protected and kept safe by the use of appropriate recruitment policy and procedures. Records are being maintained as required. Staff are being provided with the necessary induction and training with which to competently perform their work duties. EVIDENCE: Standard 27 – the Inspector asked for a copy of the staffing rota for Wilhelmina House. The rota shows exactly who is working for the week. Staff informed the Inspector that there are usually 2 care staff on duty for the am shifts and 3 care staff for the late shifts. A manager is on duty during the day and on call at nights. There is always 2 waking night staff on duty. The rota provided supported this statement. Given that that there are 20 residents living at Wilhelmina House at present the staff: resident ratio mix seems adequate to meet the needs of the residents. The Manager told the Inspector that no agency staff is used at Wilhelmina House. Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 23 Standard 28 - At the time of this inspection there are 15 care staff in total including senior carers but excluding the Manager and Deputy Manager. Of these 15 care staff 10 now hold an NVQ at level 2 or above. Both the Manager and the Deputy Manager hold NVQ level 4 qualifications. This marks positive progress being made over the last 6 months towards meeting the target of all care staff being qualified by the end of 2007. The Manager explained to the Inspector that this year all remaining care staff will be NVQ qualified to at least level 2. 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 office at Wilhelmina House. On the files inspected the Inspector saw evidence that this process is being properly implemented. Contracts with staff were also seen on most of the staffing files and the Manager confirmed that she would ensure that copies of all staff contracts following this inspection would be placed on the files. Standard 30 – The home has a programme of induction in place. This covers staff roles and responsibilities, and key policies and procedures. Induction is ongoing for up to 4 – 6 weeks with observation, shadowing from an experienced staff member and ongoing assessment. The Manager told the Inspector that the staff induction training does include fire, manual handling, food hygiene and health and safety. With regards to staff competency it is important that all staff are familiar with the home’s policies and procedures. At the last inspection a requirement was made to ensure 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. They were then to sign to say that for each individual key policy and procedure that they have read and understood it and had the chance to discuss it with their supervisor. At this inspection the Manager told the Inspector that care staff are now carrying out this requirement and have made a start with the policy for health and safety. She said that the next policy in line is that for the protection of vulnerable adults. The Manager recognises this has been slower to implement than was hoped for but feels that now the process has been started good progress will be made towards achieving this over the next year for all the home’s key policies and procedures. Whilst the previous requirement has now partially been met the requirement will remain in place until all the key policies and procedures have been covered in the prescribed way. Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 24 Also at the last inspection of Wilhelmina House it was recommended that the Manager provide each and every one of the staff at Wilhelmina House with a staff file of their own 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 intention here was to assist staff to fully understand the homes policies and procedures and to be completely clear about their roles and functions within the unit. At this inspection the Manager told the Inspector that some progress has been made towards meeting this recommendation. A new staff handbook has been drawn up and files are to be provided for staff into which the new handbook; key procedures; job descriptions and contracts of employment as well as copies of their supervision meeting records will be placed. The Committee Member also told the Inspector that new staff lockers are to be purchased so that staff may keep these documents on site confidentially. This marks positive progress towards meeting this recommendation, which must however also remain in place until it is fully implemented. Wilhelmina House DS0000025870.V336749.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, 33, 35, 36 & 38. 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. 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. It is run in the best interests of service users who will benefit from the leadership and management approach taken in the unit. Resident’s financial interests are being safeguarded. Staff are supervised regularly however the process being used still needs some regularisation and improvement. The health and safety of staff and residents is being promoted and protected. Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 26 EVIDENCE: Standard 31 – The Manager has operated in the management role at Wilhelmina House now for over two and a half years and holds the necessary experience to undertake this role. The Manager informed the Inspector that she holds the NVQ at level 4 in management and care. The Manager receives regular supervision from a Committee Member of the Wilhelmina House Steering Group and is actively supported to carry out her duties in the job description. The Manager evidently works hard to maintain the high standards already achieved in most areas of this home but now needs some additional support with administrative work so that she may be freed up to develop those areas that still need raising in quality. It is therefore recommended that an administrative post be established. Standard 32 – At the last inspection it was recommended that the minutes of the staff meetings always need to be signed and dated if they are to form a proper record of the event. At this inspection the Manager showed the Inspector the minutes of the last staff meeting that was held on 5th April 2007 that do meet the standards of the recommendation made. However staff meetings are supposed to be held every 2 months in order to ensure that service users benefit from the ethos, leadership and management approach that may be instilled in them at team meetings. This had been the only meeting held since last November 2006. It is therefore recommended now that the frequency of these meetings is increased to once every 2 months. 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 Wilhelmina monitors the progress being made. Residents are provided with information about all aspects of this process via residents meetings and newsletters. In the last inspection report the Inspector commended Wilhelmina House on the excellent model for Quality Assurance in use. Also for the detailed system that is in place to use the information gathered, to develop and improve services being provided and feedback given to service users on the progress Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 27 made. The Manager is however reminded that this needs to be an annual process and work should start soon to cover the QA process for 2007. 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 Wilhelmina House does not look after residents monies directly and that if a resident does need something to be purchased the Manager might make the purchase but only after speaking with the resident’s relative or representative who then will repay Wilhelmina House. Standard 36 – At the last inspection a requirement was made to ensure that for supervision all care staff receive: • A single supervision-recording format 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. At this inspection visit the Manager told the Inspector that a new supervision format is now being used and that staff are routinely being provided with copies of their supervision notes. Staff interviewed by the Inspector confirmed that they do now receive copies of their supervision notes routinely. This is positive progress for which the Manager and supervising staff are to be thanked. However in order to achieve consistency with the process of supervision it remains important that staff who supervise receive training in this important area of work. This requirement therefore remains. Standard 38 - the maintenance record book for the home 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. Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 28 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 At the last inspection a need was identified for all staff to receive more regular training in the key areas above and it was recommended that for each staff member a training file be 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. Good progress has been achieved with this recommendation and it only now remains that the training needs identified in supervision for each member of staff are transposed into the new training files and regularly updated by supervisors in the supervision sessions. When a training programme is being arranged for the year ahead the Manager will be able to gain a much more accurate picture of the staff training needs using this information. 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 2. Electrical system check – 5.06 3. Lift – 18.1.07 4. Fire bells – 8.5.07 5. Emergency lighting system – 3.7.06 6. Fire fighting equipment – August 06 7. Water check for legionella organisms – valid to 30.3.07 8. Nurse call system – 2.4.07 9. Portable electrical appliances – 18.7.06 10. Hoist – 16.3.07 Records were also seen and checked by the Inspector as satisfactory for: 1. Weekly fire alarm tests – last tested 8.5.07 2. Staff fire drills every 2 months Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 29 3. Fire extinguishers visually checked monthly 4. Emergency lighting tests – 27.4.07 Wilhelmina House DS0000025870.V336749.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 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Wilhelmina House DS0000025870.V336749.R01.S.doc Version 5.2 Page 31 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 OP9 Regulation 13 Requirement The Registered Manager must arrange for detailed risk assessments (that are also reviewed) to be carried out for all those residents who self medicate. This should help ensure that risks associated with self-medication are reduced. That the Registered Manager ensures that the requirements made as a result of the Environmental Health Officer’s visit on 29.1.07. 1. that a hazard analysis for the kitchen be written up for food safety, 2. that the cooker hood canopy is deep cleaned, and 3. that staff ensure that the cat cannot enter the kitchen. This should assist in helping residents to continue to live in a safe, well-maintained environment. That all staff are asked to review the key policies and procedures DS0000025870.V336749.R01.S.doc Timescale for action 01/07/07 2. OP19 20 01/07/07 3. OP30 18 01/12/07 Page 32 Wilhelmina House Version 5.2 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. 4. OP36 18 That all senior staff who provide supervision should receive staff supervision training. 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations 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. That an administrative post be established within the home. That the frequency of staff meetings be increased to once every 2 months. 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. 2. 3. 4. OP31 OP32 OP38 Wilhelmina House DS0000025870.V336749.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.V336749.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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