Inspection on 09/12/05 for Wilhelmina House

This inspection was carried out on 9th December 2005.

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

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

Other inspections for this house

Wilhelmina House 07/05/07

Wilhelmina House 23/11/06

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 Peter Stanley Unannounced Inspection 9th December 2005 9:30 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.V267808.R01.S.doc Version 5.0 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.V267808.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wilhelmina House Address 21 Parkhill Rise Croydon Surrey CR0 5JF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8760 0933 020 8760 0933 NO EMAIL The Dutch Home for the Elderly Limited Deborah Pearson Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th July 2005 Brief Description of the Service: Wilhelmina House was established as a registered charity by the Dutch church in London and aims to provide a sheltered environment for elderly men and women who no longer wish to live independently. It is not a nursing home and is primarily intended for people in reasonably good health. The home was opened in 1984 as a purpose built unit and is registered to provide residential care for up to twenty-one older people. Wilhelmina House is situated in a primarily residential area close to East Croydon station, Lloyd Park and other community facilities. On the day of the inspection there were twenty service users living at the home. Each service user has a bed sitting room with an en suite toilet and wash hand basin. The home has spacious communal areas on the ground floor consisting of a lounge, dining area and a large conservatory, the kitchen and laundry areas are clean and well equipped. Sufficient numbers of baths/ showers wash hand basins and lavatories are available throughout the home. There is a large well-maintained garden to the rear of the property and ample parking space. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted on 9 December 2005 and involved discussion with the registered manager, Mrs Pearson, a member of the management committee, and with service users. Service users at the home again commented favourably about the care and support they receive at the home and the caring attitude of the staff team. Wilhemina House is a pleasant, relaxed and well-managed home, with the registered manager, and providers, demonstrating high standards in their management of the home and the care of the residents. 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 has been little staff turnover since the previous inspection. From this inspection there are 6 requirements and 2 recommendations. Five of the seven outstanding requirements from the previous inspection have been met. 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. Staff are being provided with the necessary induction and training with which to competently perform their work duties. The home is being managed the home in an open, professional and competent manner by Deborah Pearson. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Prospective service users are being provided with all of the information they require with which to provide an informed choice regarding the suitability of the home. 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. EVIDENCE: Standards 1, 3, 4 and 5 assessed. Following a requirement from the previous inspection, the Statement Of Purpose has been revised and now includes all information detailed in Schedule 1 of the Regulations. The Home’s information leaflet now makes reference to the 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). Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 9 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. Since the last inspection there have been two new admissions (both selffunding), one of which followed an extended period of respite. The inspector examined the two files which evidenced that comprehensive assessments have been completed. 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. These cover varying aspects of need and how these are being met. There is, however, a need for an interim care plan to be put in place prior to a service user’s four-week review, for a recently admitted service user (see standard 7). The home has a good working relationship with a local GP practice and community nurses, and with other health care practitioners. The inspector spoke to a number of service users, who expressed their satisfaction with the care and support being provided at the home, and felt that their needs are being met. The registered person invites the prospective service user to visit the home and meet staff and residents; following a further assessment visit, during which an assessment is completed, a decision regarding admission is taken, Following an admission there is a four-week trial stay, followed by a review meeting held with the service user and relative/advocate, and the care manager (when applicable). A final decision regarding permanent placement is then made. Unplanned admissions are avoided where possible. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Whilst, generally, service users are having their health, personal and social care needs set out in an individual plan of care, the home needs to ensure that an interim care plan is put in place following admission. The health care needs of service users are being well met. With recent revision to cover self-medication, service users can be assured that they are being fully protected by the home’s medication policy and procedures. Accredited medication training is being extended to all care staff who administer medication. EVIDENCE: Standards 7, 8, 9 and 11 assessed. Service users have 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) are fully involved in this process. Care plans are being reviewed on a monthly basis. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 11 A recently admitted service user had not yet had a care plan put in place. The manager advised that service users’ care plans are developed following the initial four-week review period following admission. The inspector identified the need for an interim care plan to be put in place following admission, which details the service user’s assessed needs and actions required of staff to meet these. A requirement applies. The inspector is satisfied that the home is generally meeting the health care needs of it’s residents. The inspector met a visiting district nurse who visits on a regular weekly basis. He spoke highly of the care provided by the home and the good liaison which the home maintains with health care professional regarding any concerns which arise. Each service user’s 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 in-house 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 regularly monitored, and appropriate records are being maintained. The inspector discussed the health care needs of a service user who has developed a recent pattern of falls. The inspector evidenced that there has been ongoing contact with the Home’s GP and that her care plan is being regularly monitored and updated. While some safeguards (such as a cot side for her bed) have been put in place, there is a need for an occupational therapist to assess her needs to see what further aids/adaptations could be put in place to help minimise her falls. A requirement applies. The inspector spent some time talking in private to the service user. She indicated that she was happy with the care and support being provided to her, but clearly felt that the input of some physiotherapy might assist her to improve her mobility. This was discussed by the inspector with the manager and it was agreed that a referral for physiotherapy should be made. A requirement applies. 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. The manager advised that in addition to the previous accredited training received (from a pharmacist), six staff have recently completed their NCFE Level 2 Certificate in the Safe Handling of Medicines, a distance learning course completed over about 16 weeks with NESCOT (North-East Surrey College of Technology). A further six staff are scheduled to do this early in the New Year. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 12 A requirement that has been outstanding from previous inspections, for review of the home’s policy on self-medication, has now been met. A section has been included in the Home’s medication policy and procedure, and a self-medication consent form has been put in place. The manager advised that the Home’s policy is to administer medication according to their guidelines and not to encourage self-medication unless there is an expressed wish to do so and this has been assessed as safe. Any service user who self medicates is provided with a locked cabinet. Just one of the Home’s service users is currently choosing to do so. There has been one death (in hospital) of a service user since the last inspection. The inspector discussed the need for the wishes of the service user regarding the arrangements concerning their illness and death to be recorded on the service user’s file. A requirement applies. The inspector recommends that care staff are provided with training in loss and bereavement, so as to assist staff to develop their understanding and skills in this area, and provide positive support to service users when bereavement or loss occurs. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed. All standards met at the last inspection. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: All standards met at the last inspection. No complaints or adult protection concerns identified. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. EVIDENCE: All standards met at the last inspection. The inspector inspected the communal areas and some of the service users’ bedrooms, and talked to a number of service users. No concerns were identified. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, these need to be more robustly applied. Comprehensive records are being maintained, with staff photographs, as proof of identity, now being attached to staff files. Staff are being provided with the necessary induction and training with which to competently perform their work duties. EVIDENCE: Standards 29 and 30 assessed. There has been one new staff member employed since the last inspection. The inspector checked the staff file and found all documentation, including an upto-date CRB (Criminal Records Bureau) certificate to be in place. One CRB certificate for an ancillary worker has been applied for but has not yet been received; hence a requirement remains to be fully met. The inspector was informed that the worker’s role does not involve any one-to-one contact with service users, and that the manager is pursuing this with the CRB as a priority. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 17 The home’s manager places a great deal of emphasis on training and staff development. The home has a programme of induction and foundation training in place. This includes input in managing elderly persons and is in line with NTO (National Training Organisation) workforce training targets. The manager advised that the programme includes two days of formal induction; this covers roles and responsibilities, and key policies and procedures. Induction is ongoing for up to a month with observation, shadowing from an experienced staff member and ongoing assessment. The programme includes training in Health and Safety, Food Hygiene, Fire Safety, Basic First Aid and Manual Handling, and is based on the TOPSS (National Training Organisation for Social Care) standards. Staff training files inspected evidenced training certificates and records of training undertaken. The manager confirmed that 10 staff currently have NVQ2, 3 have NVQ 3, and 2 have NVQ 4. A further 2 staff are doing NVQ2 and 1 is doing her NVQ3. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While the home is developing its quality assurance processes, these need to be extended so as to demonstrate that the home is meeting its aims and objectives and that it is being run in the best interests of the service users. Staff are being provided with regular supervision; supervision training would, however, assist in promoting a skilled and consistent approach. Service users’ financial interests are being appropriately safeguarded. EVIDENCE: Standards 33, 35 and 36 assessed. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 19 The home has put in place questionnaires for completion with service users, relatives and friends; this needs to be extended to include a questionnaire for visiting professionals and care managers; a requirement applies. A Quality Assurance audit report was completed in January 2005; this will need to be updated to include the outcome from the questionnaires and other consultations and feedback. An annual development plan must also be put in place for the home; a requirement applies. The inspector looked at staff supervision records; these evidence that regular supervision is taking place. There is a detailed supervision format; this details issues for discussion, planned actions and decisions. Supervision should cover all aspects of practice, philosophy of care in the home and career development needs of the staff. To assist the development of supervision skills and a holistic approach to supervision, the inspector recommends that all staff involved in supervision undertake supervision training. Supervision is currently being split between the manager, a qualified nurse committee member (who provides supervision to the manager), and four senior care staff. The manager informed the inspector that receipts are given for any items held in the safe on behalf of service users for safekeeping. A personal financial record is kept for each service user that states receipts and outgoings. The Home’s treasurer checks monies held for service users, by the Home, on a regular basis. The inspector checked records and balances for three service users against the monies being stored in the safe. This indicated that records are being correctly maintained. A requirement for a photograph of the service user to be included on the service user’s file remains to be fully met; while photos had been included on service users’ files, none had been included on files for two recent admissions; hence the requirement remains outstanding. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 20 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 3 X 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X 3 3 X x STAFFING Standard No Score 27 X 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 3 2 x Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes (1) STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP11 Regulation 15(1), (2) 12(2), (3) Requirement The registered manager must ensure that a service user plan is put in place following admission. The views and wishes of the service user, regarding the arrangements concerning their illness and death, should, wherever possible, be obtained and recorded on the service user’s file. The registered manager must ensure that new CRB checks are in place for all applicants prior to their being employed in the home. A copy of the one outstanding CRB certificate must, on receipt, be forwarded to the CSCI, Croydon office. The QA process for consultation must be extended to include a questionnaire for visiting professionals and care managers The registered providers must ensure an annual development plan is implemented for the home and send a copy of the plan to the CSCI, local office. The registered manager must ensure that a recent photograph DS0000025870.V267808.R01.S.doc Timescale for action 31/12/05 31/12/05 3 OP29 19 (b), Sche 2 31/12/05 4 OP33 24(1) 31/03/06 5 OP33 24(1) 31/03/06 6 OP37 17(1)a, Sch3,No 2 31/12/05 Wilhelmina House Version 5.0 Page 22 of the service user is attached to the service users file. (Two recent admissions did not include a photo). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP11 OP36 Good Practice Recommendations The inspector recommends that all care staff undertake training in bereavement and loss. The inspector recommends that all staff involved in supervising staff undertake supervision and appraisal training. Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 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. Extracts may not be used or reproduced without the express permission of CSCI Wilhelmina House DS0000025870.V267808.R01.S.doc Version 5.0 Page 24 - 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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