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Inspection on 21/07/08 for Willesden Court Care Home

Also see our care home review for Willesden Court Care Home for more information

This inspection was carried out on 21st July 2008.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents who are referred to the service receive information to help them decide if they want to move into the home. They are also offered a contract/statement of terms and conditions for them to be fully aware of their rights and obligations. All residents who are referred to the home can expect to have a preadmission assessment of their needs, for the home to confirm, if it will be able to meet the needs of the prospective residents. There has been an improvement of the standard of care plans. The needs` assessments of residents who are admitted to the home are completed more comprehensively than previously and care plans are written to address the identified needs of residents. The care plans are reviewed monthly and there was evidence that residents/representatives were involved in drawing up and in reviewing care plans. The home is close to the GP surgery and enjoys good GP support. As a result residents who are registered with local surgery do not have to wait long to be seen, when they are not well. The management of medicines in the home is on the whole of a good standard. There are good systems in place to ensure the safety of residents. The home is commended. The home benefits from the services of the activities coordinator who arranges a programme of activities to suit residents in the home. The level of interaction between residents and members of staff seemed to have increased as compared to past inspections. This is good and the home should continue to make progress in this area. The home has a comprehensive quality assurance procedure which is applied. There are regular audits that are completed and the findings are used in drawing out the action/development plan for the home.

What has improved since the last inspection?

Residents and or their representatives are offered a contract to inform them of their rights and obligations while living in the home. It was noted during the last inspection that the needs of residents have not always been appropriately assessed and recorded. On this occasion we found that residents` needs were on the whole assessed properly. There is therefore an assurance that appropriate care plans will be formulated to address the needs of residents. There was evidence during this inspection that residents and/or their relatives are involved in the care planning process and that their views are taken into consideration. The standard of personal hygiene that residents receive seemed to have improved. Residents presented as appropriately dressed, groomed and clean. Male residents were shaved as appropriate. In the past there have not always been appropriate records about wound care. On this occasion there were photographs and wound progress notes to provide information about the progress of wounds. People can be confident that their concerns and their complaints will be listened to. We found that all complaints, including all expressions of dissatisfaction about the service, were appropriately recorded and dealt with. The home was on the whole clean and free from malodours. Adequate numbers of support staff were employed to make sure that this area of the service is addressed appropriately. The enclosed garden has been attended to, to improve its appearance. The flowerbeds have been weeded and the lawn has been cut short. There are also benches for people to sit out. The home is taking part in the " Breath of fresh air campaign" to encourage residents to go outside instead of always staying inside the home. According to the AQAA the home now has in excess of 50% of its care staff trained to NVQ level 2 or above. This is commended. There was evidence that the home was addressing the issue of communication among staff and between staff and residents/relatives by providing training in this area. Staff said that the training was very good. The home has improved the management of the personal money of residents. Each resident who keeps money with the home has a sub account of the main residents` account, which bears interest. As a result residents do not loose out and records are easily available for auditing.

What the care home could do better:

The service users` guide has still not been fully updated to make sure that residents have all the up to date information about the service. The standard of pressure area care must be improved. Repositioning regime when residents sit out was not always identified in the care records and the knowledge of staff about pressure relief equipment was not so good. As a result residents may be put as risk. At the time of the inspection the home accommodated at least three residents who were terminally ill. Whilst staff were involved in the management of pain under the guidance of the palliative care nurse, there was no evidence that staff have had training in the management of end of life care and understanding of pain management. Staff also found it difficult to address the end of life care needs in the care plans. The provision of meals in the home was found to be lacking. Whilst there was some evidence of choice being offered, we found that this was mostly related to the more vocal residents. Other residents who were less vocal seem to receive the main meal on the menu. The home did not always prepare meals according to the content of the menu and at times the second choice that should be on offer, was not written on the menu choice sheet. As a result staff did not ask residents about their second choice. More could also be done by preparing soup from fresh ingredients and providing cakes/scones/biscuits for residents when they have tea. The serving of meals could be better bypresenting food to residents in an appropriate manner such as by making sure that residents are always offered a cup with a saucer. A number of issues were noted, which needed to be addressed to improve the quality of the environment that the home provides. For example it seems that the bathrooms, toilets, showers and clinical rooms have not been redecorated since the inception of the home. The quality of the kitchenettes and the kitchen units in the kitchenettes also need attention to improve that environment. The home must improve its recruitment and induction process. We found one member of staff with only one reference and we did not find induction records for new members of staff and evidence that new care workers had started the common induction standards. We also found that staff need more training in relevant clinical areas such as end of life care, dementia care and pressure area care to make sure that they are competent to meet the needs of residents who are accommodated in the home. Staff were not fully aware of the whistleblowing procedure despite the whistleblowing procedure being given to them during their induction. Staff could have been made more aware of this for example during supervision. The manager has been in post for more that a year, but she has not been registered yet. Any person who manages a care service must be registered to assess his/her fitness to manage the home. For the quality control system to be fully effective, there must be a summary of the customer satisfaction survey to provide an analysis of the survey and to identify areas where improvement may be required. The home must ensure that all maintenance issues are addressed in a timely manner, to ensure that the items of equipment that are used by staff and other people who use the service, are safe to use.

CARE HOMES FOR OLDER PEOPLE Willesden Court Care Home 3 Garnet Road Willesden London NW10 9HX Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 21st July 2008 10:15 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 Willesden Court Care Home DS0000041432.V365974.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. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willesden Court Care Home Address 3 Garnet Road Willesden London NW10 9HX 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 8459 7958 020 8459 7967 willesdencourt@schealthcare.co.uk Standford Homes Limited Manager post vacant Care Home 60 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (39) Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (Maximum number of places 18) Dementia -Code DE (E) (maximum number of places 21) 2. Physical disability -Code PD (E) (maximum number of places 39) The maximum number of service users who can be accommodated is: 60 4th September 2007 Date of last inspection Brief Description of the Service: Willesden Court was first registered in January 2001. It is now owned by Southern Cross Healthcare. Willesden Court is situated in one of the many multi-cultural areas of Brent. It is a purpose built 4-storey building found on the corner of Garnet Road and Mayo Road. It is about 3 minutes walk from the main road, which is served by buses. The home has a parking facility at the back and there is also parking on the roads in front and on the side of the home. The home provides care for 60 residents in single and en-suite bedrooms. Accommodation is divided in 3 units, each of which has its own lounge, dining area and kitchenette. The 4th floor is for ancillary services. The ground floor has accommodation for 18 residents. That unit was previously for the accommodation of residents requiring personal care, but the home has successfully applied that nursing residents be accommodated on that unit. The staffing on the unit has also changed to reflect that. The first floor can take 21 residents needing nursing care and the second floor can accommodate 21 Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 5 elderly residents with dementia. The home has a manager and a deputy manager to oversee the overall running of the home. The home charges £400-£500 for service users requiring personal care depending on their needs; £500-£650 for service users requiring nursing and £600-£650 for service users requiring dementia care. There were 59 residents in the home at the time of the inspection and 1 resident was in hospital. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. This report contains the findings of a key unannounced inspection that started on Monday 21st June from 10:15- 19:45 and finished on Tuesday 22nd July from 10:00-15:30. This is the first inspection for the period 2008-2009. Out of twenty-five comment cards sent for residents, we received ten comment cards back. One of them was not fully completed. During the course of the inspection we also spoke to two visitors, four residents who use the service and seven members of staff. We also received an Annual Quality Assurance Assessment (AQAA) that had been completed appropriately by the manager and which was used where possible in this report. We made a partial tour of the premises to get information about the quality of the environment that the home provides, and inspected a sample of records that the home keeps to evidence the quality of the service. We spent one and a half hours in the lounge of the dementia care unit observing the care that residents on that unit receive. The findings were useful in confirming the standard of care that residents with dementia care needs receive on that unit. We would like to thank all people who spoke to us to share their views about the service, and the manager and all her staff for their kind support and assistance during the inspection. What the service does well: Residents who are referred to the service receive information to help them decide if they want to move into the home. They are also offered a contract/statement of terms and conditions for them to be fully aware of their rights and obligations. All residents who are referred to the home can expect to have a preadmission assessment of their needs, for the home to confirm, if it will be able to meet the needs of the prospective residents. There has been an improvement of the standard of care plans. The needs’ assessments of residents who are admitted to the home are completed more Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 7 comprehensively than previously and care plans are written to address the identified needs of residents. The care plans are reviewed monthly and there was evidence that residents/representatives were involved in drawing up and in reviewing care plans. The home is close to the GP surgery and enjoys good GP support. As a result residents who are registered with local surgery do not have to wait long to be seen, when they are not well. The management of medicines in the home is on the whole of a good standard. There are good systems in place to ensure the safety of residents. The home is commended. The home benefits from the services of the activities coordinator who arranges a programme of activities to suit residents in the home. The level of interaction between residents and members of staff seemed to have increased as compared to past inspections. This is good and the home should continue to make progress in this area. The home has a comprehensive quality assurance procedure which is applied. There are regular audits that are completed and the findings are used in drawing out the action/development plan for the home. What has improved since the last inspection? Residents and or their representatives are offered a contract to inform them of their rights and obligations while living in the home. It was noted during the last inspection that the needs of residents have not always been appropriately assessed and recorded. On this occasion we found that residents’ needs were on the whole assessed properly. There is therefore an assurance that appropriate care plans will be formulated to address the needs of residents. There was evidence during this inspection that residents and/or their relatives are involved in the care planning process and that their views are taken into consideration. The standard of personal hygiene that residents receive seemed to have improved. Residents presented as appropriately dressed, groomed and clean. Male residents were shaved as appropriate. In the past there have not always been appropriate records about wound care. On this occasion there were photographs and wound progress notes to provide information about the progress of wounds. People can be confident that their concerns and their complaints will be listened to. We found that all complaints, including all expressions of dissatisfaction about the service, were appropriately recorded and dealt with. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 8 The home was on the whole clean and free from malodours. Adequate numbers of support staff were employed to make sure that this area of the service is addressed appropriately. The enclosed garden has been attended to, to improve its appearance. The flowerbeds have been weeded and the lawn has been cut short. There are also benches for people to sit out. The home is taking part in the “ Breath of fresh air campaign” to encourage residents to go outside instead of always staying inside the home. According to the AQAA the home now has in excess of 50 of its care staff trained to NVQ level 2 or above. This is commended. There was evidence that the home was addressing the issue of communication among staff and between staff and residents/relatives by providing training in this area. Staff said that the training was very good. The home has improved the management of the personal money of residents. Each resident who keeps money with the home has a sub account of the main residents’ account, which bears interest. As a result residents do not loose out and records are easily available for auditing. What they could do better: The service users’ guide has still not been fully updated to make sure that residents have all the up to date information about the service. The standard of pressure area care must be improved. Repositioning regime when residents sit out was not always identified in the care records and the knowledge of staff about pressure relief equipment was not so good. As a result residents may be put as risk. At the time of the inspection the home accommodated at least three residents who were terminally ill. Whilst staff were involved in the management of pain under the guidance of the palliative care nurse, there was no evidence that staff have had training in the management of end of life care and understanding of pain management. Staff also found it difficult to address the end of life care needs in the care plans. The provision of meals in the home was found to be lacking. Whilst there was some evidence of choice being offered, we found that this was mostly related to the more vocal residents. Other residents who were less vocal seem to receive the main meal on the menu. The home did not always prepare meals according to the content of the menu and at times the second choice that should be on offer, was not written on the menu choice sheet. As a result staff did not ask residents about their second choice. More could also be done by preparing soup from fresh ingredients and providing cakes/scones/biscuits for residents when they have tea. The serving of meals could be better by Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 9 presenting food to residents in an appropriate manner such as by making sure that residents are always offered a cup with a saucer. A number of issues were noted, which needed to be addressed to improve the quality of the environment that the home provides. For example it seems that the bathrooms, toilets, showers and clinical rooms have not been redecorated since the inception of the home. The quality of the kitchenettes and the kitchen units in the kitchenettes also need attention to improve that environment. The home must improve its recruitment and induction process. We found one member of staff with only one reference and we did not find induction records for new members of staff and evidence that new care workers had started the common induction standards. We also found that staff need more training in relevant clinical areas such as end of life care, dementia care and pressure area care to make sure that they are competent to meet the needs of residents who are accommodated in the home. Staff were not fully aware of the whistleblowing procedure despite the whistleblowing procedure being given to them during their induction. Staff could have been made more aware of this for example during supervision. The manager has been in post for more that a year, but she has not been registered yet. Any person who manages a care service must be registered to assess his/her fitness to manage the home. For the quality control system to be fully effective, there must be a summary of the customer satisfaction survey to provide an analysis of the survey and to identify areas where improvement may be required. The home must ensure that all maintenance issues are addressed in a timely manner, to ensure that the items of equipment that are used by staff and other people who use the service, are safe to use. 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. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 10 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 Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 11 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): 1-4 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive information about the service for them to decide if they would like to move into the home, although the information was not as up to date as it could have been. Residents or their representatives receive a contract to inform them of their rights and obligations. Prospective residents’ needs are assessed comprehensively for the home to decide if the residents’ needs would be met in the home. EVIDENCE: We noted that a copy of the service user’s guide (SUG) was in the bedroom of each resident and that residents were able to point to the document when we asked them about it. The manager stated in the action plan following the last inspection that the SUG would be updated as the information about the fees that are charged by the home, was lacking. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 12 During the inspection we found that the SUG that was given to a newly admitted resident, did not contain information about the fees that the home charges and that it contained a complaints procedure that has not been updated and which included the names of people who no longer work for the organisation. The manager checked a copy of the SUG that was kept in the foyer of the home and found the same issues. One resident said that his relatives visited the home to find out more about the service before he/she was admitted. Another resident said that the manager visited her and she had the opportunity to ask questions. However, she said that not having had the experience of a care home for the elderly, she did know which questions to ask and she said that she felt that she was not provided with enough information about the type of service that the home offers, for her to make an informed decision about moving into the home. Seven out of ten residents who responded to comment cards said that they were provided with enough information before they moved into the home and three said that they were not. This is obviously an area where the home could improve. We checked whether residents receive a contract/statement of terms and conditions by asking two residents who were newly admitted, and by looking at their records. They both had copies of the contract/statement of terms and conditions. However, out of nine people who responded to comment cards, five said that they have received a contract/statement of terms and conditions and four said that they have not received one. The manager did say in the AQAA that the home was in the process of checking whether residents who have been in the home for some time, had the home’s contract. There was evidence that the needs of all residents that were referred to the home were assessed by the manager or by her deputy before the home accepted the residents. They used the Southern Cross Healthcare format for preadmission assessment, which if completed properly should provide comprehensive information about the needs of residents. We looked at the needs assessment of two residents who were recently admitted to the home, and found that these were comprehensively completed. There were also copies of the needs assessment of the funding authorities of the residents in the care records to provide more information about the background and the needs of the residents. We found that on the whole the home is able to meet the needs of residents who are admitted. We also found that residents are on whole appropriately allocated to the different units according to their needs. There was however one instance when we noted that the needs of one resident had changed and that it was not clear whether the unit where she was admitted, continued to be suitable for her. There had been a review meeting and the care manager had reviewed the needs of the residents and staff have stated that they were able Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 13 to continue to meet the needs of the resident. However it was not clear if the impact of the behaviour of the resident on other residents who live in the unit had been taken into consideration. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 14 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): 7-11 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst an improvement in the standard of care planning was noted, a few areas were identified, which must be addressed to make sure that care plans address all the needs of residents. There are some areas within healthcare where residents experienced good outcomes but there are other areas where the outcomes are not so good. The management of medicines was on the whole carried out to a good standard to ensure the safety of residents. The home did not demonstrate conclusively how the end of life care needs of residents would be met. EVIDENCE: We looked at the care plans of four residents. The care plans were appropriately completed and on the whole were in good condition. These were kept in filing cabinets at the nursing station. Once admitted to the home the needs’ assessments of residents were carried out. Out of the four care plans, one assessment of needs was not very well completed and contained a few gaps, but the other three were satisfactory. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 15 Care plans were then drawn up to meet the needs of residents. Care plans were reviewed monthly and were kept up to date. The care plans were discussed in internal reviews with residents and /or their representatives and agreed with them. We talk to one resident who said that the nurse has discussed the care plan with her. Another resident said that the care plan had been discussed with his relatives. We noted that one of the residents’ care plans had not been fully completed but the nurse said that the care plan of the resident was in the process of being re-written. Care plans contained a range of risk assessments that were kept up to date and reviewed. There were other risk assessments such as when there were instances where the liberty of residents might be infringed such as when bed rails were used or when residents were not offered a call bell because that could be risky for them. We found that in these cases the risk assessments were not always agreed with the residents or their representatives. The residents who are accommodated in the home come mostly from the Willesden/Harlesden area and therefore reflect the diversity of the local community. Staff in the home tend to come mostly from ethic minority groups and are therefore not always representative of the residents in the home, but they were aware of the cultural and social needs of residents. The manager explained how staff in the home try to address the various cultural, ethnic and religious needs of residents by celebrating the various festivities, supporting residents to attend the religious meetings in the home and being sensitive to the diet of the residents. Care records on the whole contained some information about the background and the religion of residents, but care plans did not always reflect the individuality and the cultural background of residents and did not always clarify the spiritual activities that the residents engaged in. For example the care plans on hygiene for West Indian residents do not always reflect the way that their hair should be attended to, their likes and dislikes with regards to food, and the care to the skin, although this seems to be managed quite well in the home. We found that the care plans on manual handling did not fully reflect the manoeuvres required to move residents. Whilst transfers from bed to chair/commode was generally clear with regards to the hoist and the sling to use, moving residents in bed was not always addressed. This is necessary to make sure that residents are not placed at risk by staff not being clear how to move the residents in bed, the equipment to use if any, and the number of persons required for the manoeuvre. We observed residents being transferred by through arms lifts on two occasions. Through arms lifts are not recommended techniques for moving residents as they can cause pain and injury to residents. Comments have in the past been raised by social care professionals about inappropriate manual Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 16 handling techniques being used in the home. Although staff are trained in manual handling, there must be a monitoring process to make sure that they are applying what they learn. Residents on the whole presented as being appropriately cared for. They were dressed appropriate to the weather and those residents who were able to speak to us said that they were consulted about the clothes that they wanted to wear. We noted that male residents were appropriately shaved. Residents on the whole wore ironed clothes, but we found that the clothes of residents are not always put away tidily in the wardrobes or drawers of residents. Two members of staff who spoke to us mentioned that staff rush in the morning to get residents up, washed and dressed before breakfast. They said that instead staff should plan their work and not rush to get all residents up before breakfast and only help the residents who choose to get up early. They could then continue to get residents washed and dressed after breakfast and by so doing, give more individual care to residents. The manager agreed that residents should not be rushed in the morning and said that she would look into this issue. Two residents had pressure ulcers in the home. One resident has two pressure ulcers, one on either side of the junction of the buttock/thigh. We noted that he sat out of his chair from about 09:30 to 14:00 without pressure on these areas being relieved by him standing up or him going to bed. There was a foam/sponge pressure cushion but there could have been an air pressure cushion considering the length of time that he sat out. There was a care plan in place addressing the management of the ulcers and the dressings to use. There were also photographs and wound progress notes. The care plan however did not address the repositioning regime of the resident while he was seated in the chair. We were informed that the resident enjoys sitting outside and does not like going to bed. However, even if the resident enjoys sitting outside instead of going to bed, pressure could have been relieved from the buttock by moving the resident such as by the use of the hoist. We also found that two air mattresses were on maximum pressure when these should be adjusted according to the weight of the residents. We also found that staff were not very clear whether items of equipment used for pressure relief were mattress replacement system (goes directly on the frame on the bed and used without a normal mattress) or mattress overlays (goes on top of a normal mattress). It transpired that the said items of equipment were mattress overlays equipment. We did find that there was one overlay, which was placed directly on the frame of the bed. In another instance a mattress was mal-functioning. It was flatter than usual and the light to show that it was working normally, was not on. This had not been noted and when we mentioned it on the first day of the inspection, nothing was done about it as we still found it in the same condition on the second of the inspection. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 17 The training records also showed that training in the management of pressure ulcers and pressure area care has not been provided recently in the home. From the findings during this inspection we concluded that this was a training that staff would benefit from. There were two residents in the home who were on strong analgesia for the management of pain. They both had care plans in place. Each of the care plans said that the pain of the residents should be assessed for ‘nature, location, intensity, duration and frequency of pain’, but we did not find a pain assessment chart in place for either of the residents to enable the assessment of the pain. As a result we were not sure how staff were assessing and recording the pain of residents to ensure that the management of pain was appropriate. We spent one and half hour on the dementia care unit using an observational tool called the Short Observation Framework for Inspection (SOFI). This tool is used to get an insight of the quality of the experiences of people who are unable to provide feedback due to their cognitive and communication impairments. We observed four residents within a timeframe of 5 minutes and made conclusion as to whether they we were having good experiences and whether the interaction of staff with residents was appropriate. The records are then analysed to get a view on the overall experiences of residents. We found that on the whole the experiences of people who are accommodated on the Dementia Care unit were good. Residents were either in a positive or passive state of mind most of the times. We did not see any resident who was in a negative state of mind which would have been characterised by a disturbed behaviour, tense facial expression, restlessness or shouting. The four residents at times interacted with other residents and at times staff interacted with them. We found that most of the interactions were positive but at times we observed staff talking to residents while perched on the sides of chairs instead of lowering themselves to the same level as the residents and that at other times they would do things to residents without telling them what they were going to do. For example we observed staff putting a bib around a resident without telling her what they intended to do and staff moving residents without telling the residents what they were doing. We concluded that staff could improve their approach to residents by making sure that staff receive more in depth training in dementia. The training records showed that not all staff have had the awareness training in dementia and that none of them have had the Yesterday, Today and Tomorrow programme, a training programme that have been drawn up by the Alzheimer’s Society. Residents were also engaged in some form of activities. There were some games, led by staff and the activities coordinator that residents were engaged in. Other residents were sufficiently alert to observe what was happening around them and to communicate and make comments to each other. One of Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 18 the residents, who seemed to be severely cognitively impaired, was given a doll that she engaged with. She held the doll close to her, at times rocked the doll and was careful not to drop it. There was evidence that residents’ resuscitation status was addressed in the care records, but end of life care was not always clarified particularly when the home had residents who have been admitted for palliative care. Care plans had instructions such as ‘assist to meet spiritual needs’’ ‘educate family with end of life care’ and ‘discuss about death/burial’. We think that this information should be available considering that the residents had been in the home some for more that three months. There was no evidence that end of life care had been discussed with the residents/relatives to find out their wishes and instructions with regards to this aspect of care. It was therefore not clear how the end of care of residents would be met. Records showed that the residents were regularly seen by the palliative care nurse. However on talking to at least one nurse who worked in the home and who was responsible to care for residents who required palliative care, we noted that she had not yet had training in this area. Two new carers also did not fully understand this aspect of care. As the home is accommodating residents who require palliative care, training must be provided to nurses and care staff who look after residents with palliative care needs to understand the management of pain and also to understand the care of the dying. Medicines management was inspected on all three floors. We found that the clinical rooms were on the whole tidy but would benefit from redecoration and more shelves to make sure that things are not stored on the grounds. All medicines were recorded when received in the home, signed when administered and recorded when sent for destruction. The management of controlled medicines was also of a good standard and records were kept as required. We noted that the second floor did not have any first aid equipment or equipment to assist people who require first aid. There were suction machines, but these were not put into use as these were still in their boxes on top of a cupboard. There were no airways or ambi-bags on that floor. There were therefore no items of equipment that could easily be picked and carried to a person who require first aid. The first floor had an ambi-bag, airways and a suction machine, but these were not prepared in a tray/trolley ready to be used in an emergency if required. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 19 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): 12-15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides suitable leisure and social activities for residents to take part in according to their individual choices. The meals that are prepared in the home do not always reflect the menu and there was little evidence of residents being offered choices for their meals. EVIDENCE: The home employs a full time activities coordinator. There was a programme of activities in the home and on the whole we found that the home adhered to this programme. During the inspection, there were many activities that we observed such as games of dominos, colouring, bingo and ball throwing. We also noted that residents were visited individually for one to one sessions and others were taken outside to sit in the garden. We however also saw that the TV played at the same time as the radio and we were not sure whether any body was watching the TV. Music played by the home were appropriate to the needs of the residents and many sang, moved, danced or tapped their feet to the music. Two residents that we spoke to were pleased with the activities that were arranged in the home. Three people who responded to comment cards said Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 20 that there are always activities that they can take part in, one said usually, four said sometimes and one said never. We did note positive interactions between residents and members of staff. The manager stated in the AQAA ‘we are proud of the effort we have made in ensuring that all our care staff participate in the activities for the residents in the home’. The format of the care plan contains a section where information about the social profile and the life history of residents are recorded. We found that the social profile of residents was on the whole completed, but the life history section was not always completed. The life history of residents is important particularly if the home purports to provide person centred care. It is also important in the provision of dementia care, as it may help to understand the behaviour of some residents. Residents had care plans addressing their social and recreational needs. We asked about outings and found that there have not been many outings to places of interests. The last one that took place was to see the Christmas lights. Some residents who were more mobile normally went out to the local shops. One resident said that she has been out with a friend. Another said that he goes out on his own. We were informed that the home was planning a trip to the seaside for the residents on the ground floor. There did not seem to be many outings for residents on the other floors. The home benefits from the visit of a Christian minister every week and a representative from the Roman Catholic Church comes every two weeks. We were informed that residents could go to church if they wanted to with the support of their relatives. We were able to observe lunch being served on the first day of the inspection on the first and second floors. On the first floor there were four tables for residents to sit at. However due to the position of the tables and the lack of space there were only five residents who sit at the tables while the rest of the residents sat in their arm chairs or stayed in their rooms for lunch. The manager agreed that residents should have the opportunity to sit at a dinning table to have their meals and said that the home plans to make the smoking room a dining room and that there will be another smoking room on the ground floor. On the second floor there was a dining area, separate from the lounge area which was prepared appropriately for residents to have their meals. Lunch on the first day of the inspection consisted of chicken pie, potatoes and corn. We were told that residents were asked about their meals in the morning and that their choices were recorded on a menu choice sheet. The menu choice sheets were then sent to the kitchen with a copy kept on the floors. We found that the menu choice sheets were not available on two units when staff were dishing out the meals. The meals of the day were also written on the menu choice sheet for staff to ask residents what they wanted for their meals. We Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 21 noted that the menu choice sheet for the first day of the inspection only included one choice. There was no second choice, but some residents who did not want to eat the chicken pie were offered an alternative. We asked at least two care staff about the week for the menu, as the home had four-weekly menus. They were unable to tell us which week menu it was. We also found that the meals being served did not always match the menu. For example on the day of the inspection chicken pie was served but that was not on the weekly menu. For supper there should have been chicken nuggets, instead there was scampi. There were also sandwiches for supper and a number of people commented that the sandwiches normally contained the same fillings. It would have been better perhaps if the choice of filling for each resident was noted and provided. Staff also tended to give residents a mixture of the main meal and of the second meal for supper. It was not clear what residents had chosen as the menu choices sheet was not available for inspection on the floors. On Sunday 20th July there should have been spaghetti, potato wedges and lentil soup for supper. Instead residents received leek soup and ravioli. On Saturday 19th July there are no records of a second choice for residents. On Thursday 17th July there should have been Cornish pasty, instead there was tuna, tomato mixed vegetables. For lunch Lancashire hotpot was served instead of beef Bourguignon. The menu mentioned that biscuits or scones are served with tea. On the first day of the inspection we did not see biscuits or cakes being served in the morning to residents. We were informed that residents would not eat lunch if they ate biscuits with their tea. In the afternoon, biscuits were on the trolley but were not always offered to residents. These were also put on the sides of the saucers of the cups and a few residents could not as a result put their cups properly in the saucers, as the biscuits were there. It would have been better to put the biscuits in a side plate. One resident said that she has not seen a scone ever since she has been admitted in the home since February. The chef for the day said that the home does make scones but has not done so recently. One resident mentioned that the home did not make soup from fresh ingredients and that residents are given instant soup (made by adding boiling water to powder). This was confirmed by the catering staff when we asked them about this. We were unable to find an appropriate reason for fresh soup not to given to residents for them to enjoy. Three residents who sent comment cards said that they always like the meals that are served, three said that they usually like the meals, one said sometimes, one said never and one did not respond to that section. The provision of meals seems to be an area where the home scored less as compared to other areas. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 22 We were informed that residents are given the opportunity to eat culturally appropriate meals. At least once a week a West Indian option is offered to West Indian residents. One West Indian resident said that he/she does receive West Indian food and that at times his/her relatives bring the food for him/her. We also observed tea being served in cups without the saucers and that biscuits could be served in side plates instead of this being placed on the side of the saucers. At least one resident commented that just because he/she was old does not mean that she should not be served tea properly. Two residents mentioned in comment cards that they would prefer smaller portions of food and one resident commented that the way that the meals were served do not make the food appear appetising. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 23 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): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaints will be listened to and that any allegations of abuse are taken seriously and appropriately dealt with by the service. Staff were however not too familiar with the whistleblowing policy of the home. EVIDENCE: Nine residents who responded to that section of the comment cards stated that they knew how to make a complaint. A copy of the complaint procedure is attached in the service users’ guide, which although not having been updated with the names of new staff, essentially contained the steps to take to make a complaint. A complaint poster was also available in the foyer of the home. We looked at the records of complaints and noted that there have been ten complaints made to the service since the last inspection that took place in September 2008. There were records to show that the complaints were appropriately acknowledged and addressed. Three were substantiated and two were partly substantiated. In cases where the complaints were substantiated we noted that appropriate action was taken to address the complaint to prevent recurrence. The manager also wrote in the AQAA that she has an open door policy, which has led to people talking to her about their concerns before these escalated into complaints. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 24 There have been three referrals to the safeguarding adult team of the Borough. None of the allegations were substantiated and we noted that the home dealt appropriately with all the allegations by following the right procedures. We asked two new members of staff about the home’s whistleblowing procedure. They were unable to tell about this procedure and we concluded that they were not familiar with these. However the manager did show us evidence that new members of staff were given a copy of the whistleblowing procedure. The home must therefore make sure that ‘whistleblowing’ is covered as part of the induction and supervision of new staff. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 25 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): 19,24 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home on the whole provides suitable and comfortable accommodation for residents, although a few areas are noted where improvement can be made. EVIDENCE: We found that the grounds in front of the home were not well maintained. The bushes were not always kept trimmed and there were weeds in the grounds. There were also bags of rubbish that have been left by people (not from the home) on one side of the home. The car park area was equally not that well maintained and looked untidy. The enclosed garden has been attended to and flowerbeds have been weeded. The lawn, although kept short, was in a poor state and needed to be treated to remove the weeds as appropriate. The home has purchased some benches for residents to sit out, which we observed were put to good use. It would have been good to have more colours in the garden by having more flowers such as by the use of flowerpots and hanging baskets to make these areas much more inviting for residents. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 26 The home was on the whole clean and there was evidence of maintenance, although this could have been more sustained. We noted that eight electric bulbs needed replacing in the lounge of the second floor and that two of the lamp shades were missing. We found that whilst there has been redecoration of the communal areas and of the bedrooms of residents, there has not been redecoration of the communal bathrooms, toilets, showers and of the clinical rooms. These areas would benefit from redecoration, as it seemed that these have not been redecorated since the inception of the home. Furniture in the communal areas was appropriate for the needs of residents, but we noted a lack of space for residents to sit at dining tables for their meals on the first floor, as detailed in the section ‘Daily life and Activities’. The manager stated that she had plans to convert the smoking room into a dining area for residents and transformed an unused shower on the ground floor into a smoking room. This would then provide a dining area for residents on the first floor. The bedrooms of residents were on the whole appropriately personalised and we were informed that staff always encouraged residents/relatives to bring items of decoration, photos and pictures for the residents’ bedrooms. There are kitchenettes on the first and on the second floors with a number of kitchen furniture. We found that the kitchenettes were not very well maintained, particularly the kitchen units, which were not very clean and looked stained from old spillages. There has been an attempt to upgrade the standard of the kitchen units on the first floor by changing the doors of the base unit and the work surface. However the frame and body of the base unit and the whole wall unit remained the same and looked past their useful life. We noted an area where the tiles had come off and which needed to be replaced. Seven people from nine who responded to a question about whether the home was fresh and clean said that this was always the case and two said that this was usually the case. We found that the home was on the whole clean and free from odours except for some walls that needed to be cleaned after they had become dirty. We noted that there were a number of cleaners in the home who were responsible to keep the home clean. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 27 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): 27-30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides staff in adequate numbers to meet the needs of residents. Whilst staff receive statutory training as required, they do not always receive training in some clinical areas for them to be fully competent in meeting the needs of residents that are accommodated in the home. The induction procedure is also not always followed as required. The recruitment procedure is not always robustly adhered to for the protection of people who use the service. EVIDENCE: The duty roster was kindly provided to us to assess the staffing in the home. We found that there were one trained nurse and four carers for each of the first and second floors from 08:00 to 14:00 and one trained nurse and three carers for each of these two floors from 14:00 to 20:00. There were one trained and two carers for the ground floor during the day. The ground floor has now started to accommodate residents requiring nursing. At night there were one trained nurse and a carer for each of the floors. We judged that these were appropriate staffing levels and also noted some flexibility with staffing levels. For example more staff were booked to escort residents for out patient appointments. At least two members of staff stated that at times when there were shortages in cases of sickness/absence there were not always staff to cover the Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 28 shortages. The manager stated that she endeavoured to cover all shortages and that at times due to the lateness of being informed about sickness/absences, they were not always able to provide cover either from the bank staff or from agencies. The personnel files of four members of staff were inspected. All of them had appropriate application forms and some of them also had CV’s. There was evidence that CRB checks had been conducted and that checks had been made with regards to the eligibility of the person to work in the UK. We however found that one of them only had one reference in place and had already started work in the home. We did not find any induction records for new staff. There were no records of an in-house induction and we did not find evidence that new staff were started on the common induction standards from Skills for Care. The manager said that the organisation was still in the process of finalising the final induction format to use. New members of staff confirmed that they have been shown around the home and had worked supernumerary during the first few days of their employment. We looked at the training matrix that was kindly provided by the manager to assess the standard of training that is provided by the home. We had already noted in the section under ‘Personal and Health Care’ that more training could be provided in end of life care, dementia care and pressure area care. The training matrix also confirmed this. There was no evidence that staff have recently received training on pressure area care. Some members of staff have received dementia awareness training but according to the matrix none have received the more in-depth training in dementia that is covered by the ‘Yesterday, Today and Tomorrow’ programme. The home however does have two registered mental nurses, but as they do not always give direct care, carers who work with residents with dementia must have more in depth training and understanding of dementia. With regards to statutory training we found that most members of staff were up to date with fire safety training, food hygiene, manual handling and infection control. Most staff have also received training on safeguarding adults except for new members of staff when this training has yet to be provided. According to the AQAA the home has thirty care staff and out of that number sixteen have an NVQ qualification or above. There are also two carers working towards NVQ level 2 or above. As a result the home does have more than 50 of its care staff trained to NVQ level 2 or above. The training grid provided by the home showed that 93 of the care staff have had training in food hygiene. There was also positive feedback from staff about the recent training that was held regarding communication. The manager was addressing the issue of communication at all levels including between staff and Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 29 between residents/relatives as she identified that this area was lacking. This was evident, as she had discussed this issue in staff meetings, as confirmed by the minutes. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 30 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): 31,33,35 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager runs the home in an open and inclusive manner but she has not been fully tested about her ability to run the service, as she has not been registered yet. There home has a quality assurance procedure but it is not fully applied, as the result of an annual stakeholders’ survey is not available, to provide a summary of the feedback about the quality of the service. The management of the personal money of residents is carried out safely but the possessions and property of residents are not recorded appropriately to provide an audit trail. Health and safety issues are in the main managed appropriately to make sure that people who use the service are safe. EVIDENCE: Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 31 The manager has now worked in the home for more than one year. She is however still not registered. According to the Care Standards Act 2000, she has to be registered to run a care service. She stated that she has completed the registered managers’ award. She is also a trained nurse. Feedback from staff about the management of the home was on the whole positive. Most members of staff that we spoke to said that management listen to all staff and do not rush to make decisions. One said that there is a strong management team which will be able to implement any change that is required to improve the service. There were a few members of staff who however said to the contrary. Residents and relatives that we spoke to stated that they knew who was the manager of the home and they reported that they would approach her if they had any concerns or issues that they needed to discuss. This is confirmed by the response from comment cards where seven said that they always or usually knew who to speak to if they were not happy. There was evidence of regular staff meeting, including trained nurses and care assistants meetings. There were also relatives/residents’ meetings that were held at three monthly intervals. The manager said that this ensured that staff and residents were given the opportunity to contribute to the management of the home. The home uses the quality assurance procedure for Southern Cross. The manager said that satisfaction questionnaires are sent yearly to residents/relatives. There was however no report that has been formulated to summarise the findings of the last survey. There is a system of audit in the home where the manager carries out a monthly audit and when the regional manager caries out a two monthly validation audit. The manager then produces the home’s action plan to address the development and improvement of the home. The manager reported that this is reviewed every month. The management of the personal money of residents was inspected. The home has now fully implemented a new account system, where each resident has a sub-account into the main account dedicated to the management of the personal money of residents. We carried out checks on the accounts of three residents chosen at random. We found that these accounts were up to date particularly when their social benefits were paid by the local authorities (some local authorities act as the agent for the resident) to the home monthly. They are thus able to earn interest on their money without delay. The home was taken over by Southern Cross Healthcare 2-3 years ago. Prior to that time there was a residents’ account where the personal contribution of residents were kept. Apparently no one has been able to access that account Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 32 and residents still have money in this account but cannot access their money. This situation must be rectified as soon as possible. We checked the expenses that were made on the behalf of residents and found that receipts were kept for the expenses and that two signatures were in place when residents withdrew money. This was found to be good practice. An area, which was not so good, was the management of the property/valuables that residents brought into the home. We found that the residents or their relatives did not always sign the ‘records of client’s belongings’ form and that this was not always kept updated when new things were brought for residents. The home kept good records about weekly fire detector tests, monthly emergency lights tests and about water temperature checks. There were also monthly visual wheelchair checks. Records showed that on the whole fire drills were completed every three months. There was evidence that items of equipment were appropriately maintained and serviced. An electrical wiring certificate, a portable appliances test and a gas certificate were available for inspection. The home also had a health and safety risk assessment as well as a fire risk assessment. A fire emergency plan was also in place. The home has had an Environmental Health Inspection and was awarded three stars out of five stars. The kitchen was on the whole tidy but a number of recommendations were made following that inspection that must be addressed to ensure compliance with legislation and good practice. There was an up to date LOLER (Lifting Operations and Lifting Equipment Regulations 1998) certificate for the lift, but the LOLER certificates for the hoists and the bath hoists were no up to date. The hoists were serviced and tested shortly after the inspection and copies of the certificates were forwarded to the Commission, but the home should have its own system to make sure that all maintenance and testing of equipment were carried out within the appropriate timescale and in a timely manner. There was evidence that accidents were monitored and audited. There are three monthly audits of accidents. The report for the period of March to May 2008 was seen. It showed that there has been about 25 accidents/incidents in the home and that about half of that were related to falls. Accidents/incidents were on the whole appropriately investigated to ensure the safety of people who use the service. Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 33 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 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 2 X 2 X 2 X X 3 Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 34 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(1)(b) Requirement Timescale for action 30/09/08 2 OP7 13(7,8) 3 OP7 15(1,2) To make sure that people receive up to date information about the service, the service users’ guide must have information about the range of fees that are charged by the home and must be updated to contain the latest information about the service. 30/09/08 There must be comprehensive risk assessment in cases where residents are being subjected to what could amount as a deprivation of some of their liberty such as when bed rails are used. The risk assessments must be agreed with the residents or their representatives and the relevant healthcare professionals must be involved as far as possible. The registered person must 30/09/08 ensure that the care records are sufficiently detailed, accurate and individualised to reflect the needs of residents, while focusing on the ethnic and cultural diversity of the resident and must include the actions to take to meet these needs DS0000041432.V365974.R01.S.doc Version 5.2 Willesden Court Care Home Page 35 (Repeated requirementtimescale 31/01/07 and 31/11/07 partly met). 4 OP7 13(5) The manual handling risk assessment and associated care plan must clarify the actions to take and the equipment required for the various manual handling manoeuvres required while caring for residents with poor mobility (Repeated requirement-timescale 15/01/07 and 30/11/07 not met). That staff are trained to use safe and appropriate manual handling techniques when moving residents. The practice of getting residents up, washed and dressed before breakfast must be reviewed to make sure that residents are not rushed in the morning and that they receive individual care according to their needs and wishes. That the care plans of residents who are at high risk of developing pressure ulcers and of those with pressure ulcers address the repositioning regime of the residents when they are seating out to make sure that they do not go for long periods (to be determined by their individual circumstances but not longer than 2 hours) without any pressure relief as this can lead to the formation of pressure ulcers, a deterioration or non healing of pressure ulcers. For pressure relief equipment to be useful, this must be used as indicated and in line with the residents’ needs. Air pressure relief equipment must be adjusted to the correct pressure DS0000041432.V365974.R01.S.doc 30/09/08 5 OP8 12(1) 31/08/08 6 OP8 17 31/08/08 7 OP8 23(2)(c) 31/08/08 Willesden Court Care Home Version 5.2 Page 36 8 OP8 12(1) 9 OP10 12(1,4) 10. OP11 14(1,2) 11 OP12 16(2) (m,n) 12 OP15 16(2)(i,j) and there must be a system in place to make sure that all items of pressure relief equipment are checked regularly to make sure that they are working appropriately. Without this residents will still be placed at risk. For residents’ pain to be managed appropriately and to evaluate the effectiveness of the medication regime in managing pain, a pain assessment tool must be used to assess resident’s pain. To promote the dignity of residents, their clothes must be ironed to an acceptable standard and must then be put away tidily in the cupboard/drawers of service users (Repeated requirement-timescale 31/12/06 and 31/10/07 partly met). To ensure that the end of life care needs of residents will be met, the care records of residents must be clear about the resuscitation status of residents and must ensure that the end of life care of residents and the arrangements in place for the management of the death of residents and the funeral arrangements are addressed (Repeated requirementtimescale 31/11/07 not met). The registered person must ensure that the assessment of the social and recreational needs, including the life history of residents are carried out to a high standard (Repeated requirement-timescale 31/01/07 and 30/11/07 partly met). That meals be provided to DS0000041432.V365974.R01.S.doc 31/08/08 30/09/08 30/09/08 30/09/08 31/08/08 Page 37 Willesden Court Care Home Version 5.2 13 OP18 13(6) 14. OP19 23(2)(o) residents according to the planned menu and that they are offered choices about their meals. The meals that are provided must be suitably varied, wholesome, nutritious and properly prepared to meet the needs of the residents. To ensure the dignity of residents, food must be presented and served appropriately to them. Staff must be familiar with the whistleblowing procedure of the home to make sure that they are aware of how to raise any concerns if they have any. To make sure that residents are able to enjoy the grounds of the home, the registered person must ensure that these are maintained to a high standard (Repeated requirementtimescale 31/12/07 partly met. Consideration must be given to redecorate the bathrooms, toilets, showers and clinical rooms as these are starting to look shabby. The home must review the provision of grab handles in toilets and bathrooms to make sure that people with impaired mobility are not disadvantaged by the lack of grab handles such as when grab handles are provided on only one side of the toilet. The kitchenettes on each unit must be made good. The kitchen furniture must be replaced where required and must be kept clean. Tiles that have come off must be replaced. This is required to ensure a high standard of hygiene. The registered person must ensure that all members of staff DS0000041432.V365974.R01.S.doc 31/08/08 30/09/08 15 OP19 23(2)(a) 31/10/08 16 OP19 23(2)(n) 30/09/08 17 OP19 23(2)(a) 31/10/08 18 OP29 19(1)(b) 30/09/08 Page 38 Willesden Court Care Home Version 5.2 have 2 references, one of which must be from the last employer. The work history of applicants must also be completed to the nearest month and gaps in employment must be explored during interview with records kept (Repeated requirementtimescale 31/10/07 and 30/11/07 not met). 19 OP30 18(1)(c) All new care staff must complete an induction programme as per the common induction standards of Skills for Care (Repeated requirement-timescale 31/11/07 not met). This must include an induction about the home that is recorded. The home must have a registered manager as soon as possible (Repeated requirement-timescale 31/03/08 not met). The home must have a report to summarise the findings of the annual satisfaction survey as part of the process to monitor the quality of the service that it provides. The belongings of residents must be recorded appropriately when these are brought into the home and the list must be kept updated as far as possible when resident receive new things into the home. Residents and/or their representatives must agree to the records kept. This is necessary to ensure the safety of residents’ property. That the situation be resolved where by residents cannot access their money, which was kept in the old resident’s account that was managed by the home. 30/09/08 20 OP31 9 31/01/09 21 OP33 24 31/10/08 22 OP35 17 30/09/08 23 OP35 16(2)(l) 31/10/08 Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 39 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 OP1 Good Practice Recommendations The home should review the information that it provides to residents/representatives before the resident move into the home for them to have all the necessary information to make an informed decision about moving into the home. When reviewing whether the needs of a resident continue to be met on a particular unit, the needs of other residents should also be taken into consideration. Consideration should be given to making sure that there are items of equipment on each floor, that are prepared and ready to be used in an emergency for the delivery of first aid That more shelving be provided in the clinical rooms to ensure that things are not stored on the floors The television should ideally not be on at the same time as the radio, in the same area. That more flowers be provided for the enclosed garden where residents sit to make these areas more inviting and pleasant. Cleaning of bedrooms should also include cleaning stains and marks on the walls and skirting boards. All equipment in the home must be serviced, maintained and tested according to the manufacturers’ instructions, legislation and good practice. 2 3 OP4 OP8 4 5 6 7 8 OP9 OP12 OP19 OP26 OP38 Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 40 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Willesden Court Care Home DS0000041432.V365974.R01.S.doc Version 5.2 Page 41 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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