Inspection on 08/07/05 for Wilhelmina House

This inspection was carried out on 8th July 2005.

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 07/05/07

Wilhelmina House 23/11/06

Wilhelmina House 09/12/05

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 Peter Stanley Unannounced Inspection 8 July 2005 9:30am 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 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 G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wilhelmina House Address 21 Parkhill Rise, Croydon, Surrey, CR0 5JF Telephone number Fax number Email 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 The Durch Home for the Elderly Limited Deborah Pearson Care Home 21 Category(ies) of Old Age (21) registration, with number of places Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 7 February 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 G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted on 8 July 2005 and involved consultations with the registered manager, Mrs Pearson, care staff and service users. Service users at the home commented favourably about the care and support they receive at the home and the caring attitude of the staff team. Overall the inspector finds Wilhemina House to be a pleasant, relaxed and wellmanaged home. The registered manager, and providers, demonstrate high standards in their management of the home and the care of the residents. There has been very little turnover of staff, and the staff group is a very settled one. Staff on duty at the time of the inspection were observed to be interacting with the service users in a caring, respectful and professional manner. There is one requirement, which remains unmet from the last inspection, together with six new requirements and two recommendations from this inspection. While the home has a generally good report, the inspector was particularly concerned on two counts; that a recently admitted service user had not been fully assessed, placing the service user at potential risk; and that two recent staff appointments (of ancillary workers) did not have completed Criminal Records Bureau checks in place prior to commencing their duties in the home. Such a lapse could potentially compromise the protection of service users within the home and must not be repeated. What the service does well: Generally, service users presented as very settled and satisfied, there being a good and welcoming atmosphere in the home. Many positive comments were made to the inspector regarding the home and the support provided. The management and staff were observed to interact with the service users in a caring, respectful and professional manner. Each service user is being provided with a copy of a contract, outlining their terms and conditions, at the point of moving into the home. This provides clear information regarding the fees charged and services provided. The home is able to demonstrate that service users care needs are being properly assessed, and that the range of needs presented is being Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 6 appropriately met. Service users are having their health, personal and social care needs set out in an individual plan of care, these being reviewed on a monthly basis, the service user and his relative(s)/representative(s) being fully involved in this process. Care plans are being regularly reviewed. Prospective service users, their friends and relatives are able to visit to assess the suitability of the home, and for the service user to move in for a trial period. The home has clear policy and practice with regard to ensuring that service users’ dignity and rights are upheld in all matters associated with personal physical and medical care. Service users are being provided with a full and varied range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. Service users are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Service users have opportunities for developing and maintaining links with the local community. Service users are enabled to exercise choice and control in their day-to-day activities and routines, with appropriate support from staff being provided to help to facilitate this. Service users receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and both service users and their relatives/friends are encouraged to raise any concerns they may have. The home’s policies, procedures and practice evidence that service users are being protected from abuse and are living in a safe environment. Service users indicate that they feel secure and settled. The legal rights of service users within the home are being protected and promoted. Service users are encouraged and assisted to vote if they wish. Service users are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. The home has developed an ongoing maintenance and development programme, and there is a rolling programme of renewal and refurbishment. The home is purpose built and is pleasantly laid out, providing communal living, recreational and dining space that meets individual and collective needs. Sufficient bathing, washing and toilet facilities are provided with which to meet the needs of service users. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 7 Service users’ rooms were found to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Service users generally presented as well settled in their environment, and very satisfied with the communal and personal facilities provided. Service users are being provided with the aids and specialist equipment they require to maximise their independence and ensure safety. They are living in safe and comfortable surroundings, and the home presents as clean, pleasant and hygienic. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The manager places a great deal of emphasis on training and staff development, and all staff undertake a comprehensive induction programme. The registered manager, Mrs Deborah Pearson, is suitably qualified and experienced, and is managing the home in an open, professional and competent manner. Under her guidance and direction, she has built on the home’s good reputation and made significant improvements during the course of the last year. The home’s record keeping, policies and procedures generally evidence that the home is being run in the best interests of its service users. The home’s record keeping, policies and procedures generally evidence that the home is being run in the best interests of its service users. Generally, the inspector was satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. All safety checks and certification are in place. What has improved since the last inspection? The home has met a number of recent requirements relating to medication policy and procedures, including the need for accurate recording of medicines Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 8 dispensed, the accredited training of staff, and the completion of risk assessments for service users who self-medicate. The home has complied with a previous requirement for staff to attend adult abuse training, the majority now having done so. There is a rolling programme of training in place, with arrangements being in hand for the remaining staff to do so. The home has now drawn up a policy and procedure that precludes staff benefiting from service user’s wills. 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. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 9 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 Standards Statutory Requirements Identified During the Inspection Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 6 Prospective service users are being provided with most of the the information necessary to providing an informed choice regarding the suitability of the home. However, the Statement of Purpose requires some further revision to provide the fully comprehensive information required. Each service user is being provided with a copy of a contract, outlining their terms and conditions, at the point of moving into the home. This provides clear information regarding the fees charged and services provided. While, generally, the home is able to demonstrate that service users needs are being properly and fully assessed, the home has failed to complete an assessment for a recently admitted service user. The home is able to demonstrate its capacity to meet the individual needs of service users admitted to the home. Prospective service users, their friends and relatives are able to visit to assess the suitability of the home, and for the service user to move in for a trial period. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 11 EVIDENCE: The home has a Statement of Purpose which outlines the aims and objectives of the home, and the facilities and services it provides. Following a requirement from the last inspection, the Statement of Purpose has been revised to include all eighteen elements of Schedule 1 of the Care Homes Regulations (2001). While the Statement of Purpose has been revised to include the arrangements made for service users to attend religious services of their choice, this also needs to include information relating to Schedule 1, No. 10, arrangements for consultation with service users; No. 11, fire precautions and emergency procedures; No.13, arrangements for contact between service users and their relatives, friends and representatives; No.15, arrangements for reviews of the service user’s care plan; in addition, the home’s information leaflet needs to include reference to the home’s Statement of Purpose. The home has developed a service user’s guide which is written in a format/language suitable for the service users and contains all the elements of regulation 5(1) (2) (3). The home has a Contract in place. This clearly states all the requirements that have to be in place and the terms and conditions which are relevant to the needs of the service user. There have been two new service users admitted since the last inspection in February 2005. The inspector examined these files and found that one of the two service users, who was admitted at the end of April, has not yet been fully assessed by the home. While the inspector was informed that this service user is known to the home due to having had occasional respite stays over the last two years, a full and comprehensive assessment, by a person qualified to do so, is nonetheless required. A requirement applies. The inspector found the other file to be satisfactory, with relevant care management and internal assessments being in place. The home’s usual procedure is for the manager of the home to undertake a thorough assessment of all prospective service users prior to a decision being taken regarding admission. This includes 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. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 12 The home uses an assessment tool to ensure that the needs of each service user are met. The assessment tool includes information received from the service users care manager and other relevant professionals. The assessment format is reviewed regularly. A kardex information system, which provides detailed information regarding each service user, is updated on a daily basis by care staff at the home. The registered manager was able to demonstrate that the home has the capacity to meet the individual needs of service users admitted to the home. This is evidenced by detailed care plans for each service user which cover varying aspects of need and how these are being met. The home has a good working relationship with a local GP practice and community nurses, and with other health care practitioners. Service users spoken to by the inspector indicated that they are happy with the care and support being provided, and feel that their needs are being met. The registered person invites the prospective service user to visit the home and, if a decision to admit is taken, to then have a four-week trial stay. A review is then held with service user, family/relatives/advocate, and the care manager (when applicable), before a final decision is made by all parties confirming a permanent placement within the home. Unplanned admissions are avoided where possible. The service user and their relative or representative is met by the home’s manager prior to any admission. The home does not provide intermediate care. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Service users are having their health, personal and social care needs set out in an individual plan of care, the service user and his relative(s)/representative(s) being involved in this process. Care plans are being regularly reviewed. Service users’ health care needs are being appropriately met. While service users are generally being protected by the home’s medication policy and procedures, these needs to adequately cover service users who may self-medicate. Accredited medication training is being extended to all care staff who administer medication. Service users are being treated with respect and their right to privacy is being maintained. EVIDENCE: Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 14 Care plans are compiled on the basis of the initial assessment prior to admission, on admission and during residency. A number of care plans were examined including those for the two new admissions. The plans set out the individual needs of the residents and how the home aims to meet them. Risk assessments were in place; these include some covering issues as well as manual handling. These are carried out by senior staff and are reviewed on a regular basis. Care plans are drawn up by the home, service user and/or relatives and are reviewed monthly. These include a food intake chart so that staff can monitor any loss of appetite. Each file contains details of all visits to/from the district nurse, GP, hospital and other appointments such as eye tests and dental visits. There is an inhouse medical room available. The GP visits regularly, this providing an opportunity for staff to seek advice if there are any queries regarding service users’ care. The prevention of pressure sores is a high priority, there being no service users with pressure sores at the time of this inspection. Support in this regard is provided by the district nurse. Service users’ weight is being regularly monitored. The accidents/incidents book was inspected, all accidents and incidents being appropriately recorded. The home has met a number of recent requirements regarding the need for an appropriate medication policy and procedure, an accurate record of all medicines received, administered and leaving the home, accredited medication training for staff, and the completion of risk assessments for service users who self-medicate. All service users who self medicate have a locked cabinet. Ten staff have received accredited medication training and the home has developed medication profiles. There is a medication returns book which is audited on a regular basis. The manager advised that only one service user is now self-medicating, with homeopathic medicine, and that prescribed medicines are being administered by staff. The inspector advised that an outstanding requirement, for reviewing the home’s policy and procedure for service users who self-medicate, still applies and must be met. Advice from a pharmacist concerning the home’s policy on the safe handling and administration of medicines is obtained on a quarterly basis. All advice and guidance given at the time of the last visit has been complied with. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 15 The home has a clear policy and practice with regard to ensuring that service users’ dignity and rights are upheld in all matters associated with personal physical and medical care. Service users are able to see their GP in the privacy of their own bedroom and without the attendance of staff if they prefer. The registered manager and staff are concerned to ensure and respect service users’ privacy and dignity at all times. Some service users have telephones in their bedrooms in order to help maintain contact with friends, family and the local community. Service users are able to receive visitors in a more private area of the home, or in the privacy of their own rooms. Staff were observed to knock before entering service users’ rooms. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Service users are being provided with a full and varied range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. Service users are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Service users have opportunities for developing and maintaining links with the local community. Service users are enabled to exercise choice and control in their day-to-day activities and routines, with appropriate support from staff being provided to help to facilitate this. Service users receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. EVIDENCE: Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 17 The home provides flexibility with regard to service users’ daily living routines. Service users spoken to by the inspector presented as settled and satisfied with their daily routines. These are kept as flexible as possible so as to allow individuals to exercise choice in their daily programme. The inspector observed that service users (most of whom are currently female) are able to socialise with each other in the very pleasant main lounge and conservatory area, with conversation being encouraged and assisted by the home’s management and staff. The television was not switched on, service users being encouraged to talk to each other and participate in activities. All service users have the option of spending time in the privacy of their own rooms if they wish. Service users views indicate that visitors to the home are made to feel welcome and that their privacy for visits is respected. Feedback from relatives and friends indicates that the home has a welcoming atmosphere and that their involvement in maintaining contact with service users is encouraged. The home has a full and varied programme of activities. Service users spoken to by the inspector expressed positive views about the activities on offer; these are designed to appeal to a wide range of individual interests and preferences. An activities co-ordinator is employed at the home for four mornings and three afternoons of every week. Lists of outings and activities are displayed on the notice board in the reception area. Activities on offer at the home include bingo, painting, music/movement therapy, barbeques, quizzes, poetry sessions and outings to places of interest. There is also a computer which of the home’s service users make use of. The activity programmes of service users evidenced the full and varied choice available. Service users are able to go out into the community if they so wish, accessing shops and local facilities. Some service users attend Church or church-related activities. Restrictions only apply where there are personal safety concerns, with risk assessments being put in place. Staff will often accompany service users to activities for their own protection. Service users are provided with all necessary information and assistance to ensure that they can maximise their own personal choice and autonomy within their individual capacities. Those service users spoken to by the inspector indicated that they have flexibility in their daily routines and are able to exercise a degree of control and choice in their daily activities. All the service users at Wilhelmina House manage their own personal finances. Any valuables kept at the home are recorded and a receipt is given. Staff were observed by the inspector to be respectful and helpful to service users and to assist service users to exercise choice in participating in routines and activities of their own personal choice or preference. There are regular service user meetings every six weeks to discuss any issues in the home. A group of service user representatives meet with the home manager, the cook, and a member of the committee on a regular basis. Notes are taken of these meetings and fed back to the other service users. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 18 The service users at Wilhelmina House are offered three meals a day as well as morning and afternoon teas. The service users can choose where they wish to eat. There are facilities for making drinks on each of the floors. A copy of the day’s menu is placed on the notice board, alternatives also being available. Menus are changed on a regular basis, a wide variety of well-balanced, and nutritional food being available. The manager has stated that the food provided is discussed at service user meetings with the cook and committee representatives. Service users spoken to by the inspector expressed mostly favourable views about the food. One resident felt that there wasn’t always enough food served for supper and that she sometimes felt hungry in the evening. Any dietary needs are recorded in the service users care plan. The home keeps a detailed record of all food consumed by the service users. It has been previously noted that the cook has an intermediate food hygiene certificate, while other staff involved in food preparation hold the basic food hygiene certificate. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are encouraged to raise any concerns they may have. The legal rights of service users within the home are being protected and promoted. Service users are encouraged and assisted to vote if they wish. Generally, the home’s policies, procedures and practice evidence that service users are being protected from abuse and are living in a safe environment. The awareness of staff to adult abuse has recently been raised through relevant training, though some staff have yet to complete this. EVIDENCE: The home has an appropriate complaints policy and procedure. The complaints procedure is simple and clear; it sets down the process for managing complaints and ensures they are dealt with promptly and effectively. A complaints book at the home details the outcome of any complaint and what action (if any) was taken. There have been two complaints during the last twelve months and these have both been dealt with appropriately. The manager advised the inspector that service users and their relatives/friends are encouraged to raise any concerns which they may have. All service users are protected in this home and respect is given to each individual with regard to confidentiality. All service users are registered to vote Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 20 and are supported where necessary to attend the polling station. The home holds information on advocacy services should these be required. None of the current service users are using these as they all have relatives. A Policy and Procedures for the protection of Vulnerable Adults are in place together with a copy of the local authority’s Vulnerable Adults Policy. A whistle blowing policy is in place within the protection of the vulnerable adult’s policies and procedures. The manager has adopted an ‘open door’ culture and works in a transparent manner. Staff are made aware of the nature of various forms of abuse and are required to report any suspicions initially to senior staff in line with the procedures. The manager has complied with a previous requirement to make arrangements for staff to attend adult abuse training. The majority of staff have now attended this training, a rolling programme being in place. The inspector is concerned that arrangements for training are made as soon as possible for those staff who have not yet done so. The home has now drawn up a policy and procedure that precludes staff benefiting from service user’s wills. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Service users are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Service users have access to safe and comfortable communal facilities. Service users presented as settled and happy with their environment and with the communal facilities provided. Sufficient bathing, washing and toilet facilities are provided with which to meet the individual and collective needs of service users. Service users’ rooms were observed to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Service users are being provided with the aids and specialist equipment they require to maximise their independence and ensure safety. Service users are living in safe and comfortable surroundings, and the home presents as clean, pleasant and hygienic. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 22 EVIDENCE: The home presents as being safe and reasonably well maintained. The home has developed an ongoing maintenance and development programme for the home; this is included in the homes Strategy and Operational Policy. The home has a new kitchen and the home has a rolling programme of renewal and refurbishment. The home is purpose built and is pleasantly laid out, providing communal living, recreational and dining space that meets individual and collective needs. There is ample communal space throughout the home. The communal areas present as being comfortable, bright and appropriately furnished to a high standard with adequate facilities for service users and their visitors to meet in private. There is a large conservatory overlooking a pleasant garden at the rear of the home in which the service users spend time during the summer months. This is well equipped with garden furniture. Service users are able to smoke in their rooms or in the garden. The bathroom, shower, washing and toilet facilities were observed to meet the individual and collective needs of the service users; there are sufficient numbers of bathrooms and toilet facilities situated throughout the home. Facilities were noted to be clean, odour free and well maintained. Service users’ bedrooms all have en suite facilities consisting of a toilet and a wash hand basin. The baths and showers are within close proximity. Service users have access to a range of aids and specialist equipment within the home. The Home has been assessed by an Occupational Therapist, in November 2004, and all requirements and recommendations detailed in the report have been implemented. Stair rails, grab rails, raised toilet seats, commodes, and other aids and adaptations were observed to be present in the home during the inspection. Rails are fitted along corridors, with additional rails having recently been fitted close to an en suite room on the second floor. There is a passenger lift to all floors. A call bell system is provided to all bedrooms, bathrooms and toilets in addition to a loop system for those who are hard of hearing. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 23 The inspector viewed a number of service users’ rooms. Each service user has a bed sitting room with an en suite toilet and wash hand basin. These were observed to be safe, and pleasantly decorated and arranged, reflecting individual preferences and tastes. Service users are able to bring personal possessions with them, and items of furniture providing that these are assessed as being safe and fit for the purpose. An inventory of the service user’s belongings is kept on their personal file. The home provides beds with orthopaedic mattresses if required. Each of the bedrooms is lockable and service users have their own key to their room. The rooms also have a lockable facility for personal belongings. The home has a laundry situated on the ground floor. The laundry has a sluice; there is also a mechanical sluice located on the second floor. A new spin drier has recently been installed. The COSSH cabinet, located in the laundry area, was observed to be unlocked, constituting a potential health and safety risk for service users (requirement applies, standard 38). Service users whom the inspector met presented as settled and happy with their environment and with the personal and communal facilities provided. Those service users who spoke to the inspector indicated that they liked their rooms and that these met their needs. There is ample lighting throughout the home, this being domestic in character. Lighting includes lampshades on main lights and low level lighting accessible from the residents’ beds. Emergency lighting is provided throughout the home, with regular monthly checks being made by the providers. This has been recently serviced, on 29/4/04. Legionella testing was last carried out on 31/3/05. The Home is well-ventilated throughout. Records of fridge and freezer temperatures are being regularly maintained. Policies and procedures are in place for COSHH (Control of Substances Hazardous to Health), and Infection Control. The inspector found the home to be clean and tidy throughout. Cleaning procedures are followed to ensure the home is kept clean, hygienic and free from offensive odours. The laundry room presented as clean and well maintained, and is situated in an area away from any food preparation area. The Staff team at the home are provided with disposable aprons and gloves. There is adequate provision of hand washing facilities throughout the home. The home has clear policies and procedures in place regarding the prevention and control of infection and clinical waste management including spillages of bodily fluids and blood. The home manager has advised that the Regional Infection Control Advisor from the South West London Health Protection Unit provided infection control training for seven staff on 12th January 2004. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 24 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, these need to be more robustly applied. The protection of service users is being compromised by the failure to have obtained CRB (Criminal Records Bureau) clearance for two recent staff appointments. Staff photographs, as proof of identity, need to be attached to staff files, and comprehensive records maintained. EVIDENCE: Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 25 The manager advised that the home has three care staff on duty during the day and two waking staff at night. This was confirmed by inspection of the staff rotas. Ancillary staff employed at the home includes two cooks, one kitchen aid, two domestic staff and a part time handy man. The home also has an activities coordinator. All staff undertake an induction programme. Induction training includes input in the care and management of older persons and is in line with NTO workforce training targets. The home’s manager places a great deal of emphasis on training and staff development. The inspector was advised that five members of the current staff team have now obtained their NVQ level 2 or above in care, and that two others are studying for this. Four staff members have gained their NVQ Level 3, while the manager is qualified to NVQ level 4. The home now has ten staff qualified to NVQ level 2 or above during the course of 2005 and has, therefore, achieved the target of 50 qualified during the course of 2005. The inspector looked at a sample of staff records and noted documentary evidence of qualifications. This includes statutory training in basic food hygiene, health and safety, fire safety and manual handling. The manager advised that no new care staff have been employed since the last inspection. A handyman and a cleaner have, however, been appointed. The inspector was concerned to find that CRB (Criminal Records Bureau) certificates had not been obtained prior to the commencement of their employment at the home; these have been applied for but not yet received. The inspector made it clear to the manager, Mrs Pearson, and to Mrs Van Hoorn, of the home’s Management Committee, that the failure to have obtained an up-to-date CRB certificate is potentially placing service users at risk, and is not acceptable. CRB certificates must be obtained for these two appointments and a copy forwarded to the inspector at the CSCI in Croydon. It should be noted that all future staff appointments must have an up-todate CRB certificate in place prior to commencing their employment. A requirement applies. The inspector was concerned to note that staff photographs, as proof of identity, have not yet been attached to staff files. The manager advised that staff have recently had photographs taken and that these are awaiting development. The inspector noted in his previous report that the home must ensure that its recruitment procedures are far more robust and transparent. Staff records kept in the home must include a record of all persons employed, the name, address, date of birth, qualifications and experience; copies of the birth certificate and passport, references; the dates on which they commenced and ceased to be employed; their position and hours worked; correspondence, reports, and records of any disciplinary action. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 26 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 37 and 38 The home is being managed the home in an open, professional and competent manner by Deborah Pearson. Under her guidance and direction, the home has made significant improvements during the course of the last year. The home’s record-keeping, policies and procedures generally evidence that the home is being run in the best interests of its service users. The inspector was satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. All safety checks and certification are in place. There was, however, one safety concern relating to a COSSH (Control of substances hazardous to health) cabinet being found to be unlocked. EVIDENCE: Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 27 The registered manager, Mrs Deborah Pearson, is suitably qualified and experienced to run the home to meet its stated purpose, aims and objectives. She has a great deal of management and supervisory experience working with vulnerable people in different settings. She is qualified to level 4 NVQ in Management and has obtained the Registered Managers Award (RMA). Under her guidance and direction, the home has made significant improvements during the last year. The management approach of the registered manager was found to be an open and enabling one. The manager was observed to interact well with both staff and service users and to assist in creating a positive and inclusive atmosphere. Both staff and service users commented favourably on the running of the home. Relatives are encouraged to participate in the day-to-day operation of the home and to express their views through care plan reviews and meetings for service users and family/relatives. There are regular staff meetings. Staff members spoken to by the inspector indicated that they feel well supported. The inspector observed that staff interacted well with service users and that there was a positive commitment by the manager and staff to meeting their needs. The inspector is confident that the manager will be given every support in her desire to maintain and improve on the high standards prevailing in this home. The home has an access to files policy. Service users, relatives and carers are fully involved in the drawing up of care plans and other documents placed in their individual files. Service user’s records are kept in a locked filing cabinet in the office; this office is always staffed and is locked when not in use. The home does not have a computer or access to email and clearly this would enable the manager to access information and write policies and procedures in a more effective manner than at present. It is recommended that service user files include an extended basic information sheet to provide all the information listed in Schedule 3, No 3 (a to d, & h). The manager ensures that there are safe working practices in the home. This includes moving and handling techniques for the safety of the service users and staff. Protection with regard to Fire safety training is carried out every twelve months by an ‘approved company’ to ensure that all staff are clear of what actions to take should such an event occur. The last training session was on 11th May 2004, and the next is being scheduled for 14 July 2005. A comprehensive fire risk assessment which was updated on 18th May 2004, by the company that provides training for the home, is also due to be updated on 14 July 2005. Risk Assessments for safe working practices are in place. Food and hygiene procedures are in place, and staff have undertaken ‘approved’ infection control training. All services, equipment and facilities are maintained in a safe state to ensure the use and safety of the service user and staff. Certificates in respect of PAT testing (next due on 26/7/04), legionella Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 28 (31/3/05), gas safety (14/6/05), lift maintenance (6/4/05) and five yearly electrical check (4/2/03) were all found to be satisfactory. Fire alarms and emergency lighting are also up-to-date (20/6/05). The homes manager is well aware of the requirement to ensure that all legislation has to be complied with for the safe running of the home. All accidents and incidents are recorded in an appropriate manner. Safety procedures are in place. All staff receive an induction, and foundation training updates are facilitated. All other certificates, including Employers Public Liability insurance are found to be in order. The inspector was concerned to note that a COSSH cabinet, located in the laundry area, was found to be unlocked. This constitutes a potential health and safety risk for service users. A requirement applies. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 29 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x x x x 2 2 Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 30 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)(c), Schedule 1 14(1)a, b, c & d. Requirement The Statement of Purpose must be revised to include information relating to Schedule 1, Nos 10, 11, 13, and 15. The registered manager must ensure that new service users are admitted only on the basis of a full assessment by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. The registered person must review the homes policy and procedure for those service users’s who self medicate. (Timescales of 14/05/04 and 28/2/05 not met) The registered manager must ensure that new CRB checks are in place for all applicants prior to their being employed in the home. A CRB certificate must be obtained for two recent staff appointments, and a copy of these forwarded to the CSCI, Croydon office. The registered manager must ensure that all documentation Timescale for action 1.10.05 2. OP3 1.08.05 3. OP9 13(2) Time-scale extended to 1.09.05 4. OP29 19 (b), Schedule 2 1.09.05 5. OP29 19(b), Schedule 1.09.05 Page 31 Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 6. OP37 2, 17(2) Schedule 4 (6) 17(1)a, Schedule 3, No 2. 13(4)a & c 7. OP38 listed in Schedules 2 and 4(6), including a recent photograph of the staff member, are evidenced on staff files. The registered manager must 1.09.05 ensure that a recent photograph of the service user is attached to the service users file. The registered manager must 1.08.05 ensure that the COSSH cabinet is kept locked at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP37 OP1 Good Practice Recommendations It is recommended that service user files include an extended basic information sheet to provide all the information listed in Schedule 3, No 3 (a to d, & h). The home’s information leaflet needs to include reference to the home’s Statement of Purpose. Wilhelmina House G53 S25870 Wilhelmina V226401 080705 stage4.doc Version 1.30 Page 32 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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