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Inspection on 23/11/06 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 23rd November 2006.

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

Service users have a comprehensive pre-admission assessment of their needs prior to them being accepted into the home. The needs assessments of the funding authority are also requested as part of the decision process with regard to accepting new service users. All service users are offered a service users` guide which is left in the room of the service user, to which they can refer to if they wish to. Staff in the home are aware of the cultural diversity of service users and the home takes this into consideration when meeting the needs of service users. The provision of activities in the home continues to be of a good standard. The home was warm and airy. Staff in the home are welcoming. Service users are pleased with the level of attention that they receive from nursing and care staff.

What has improved since the last inspection?

CARE HOMES FOR OLDER PEOPLE Willesden Court Care Home 3 Garnet Road Willesden London NW10 9HX Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 23rd November 2006 10:00 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.V320986.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.V320986.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 Standford Homes Limited 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 (21) Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Dementia 21 places Old Age 39 Places Of which 21 are for elderly persons requiring nursing care and a further 18 places are for elderly persons requiring personal care. To accommodate one service user, BM, aged 62 years, for the duration of his stay. 5th December 2005 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 in front and on the side of the home. The home provides full time care for 60 service users 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 service users requiring personal care; the first floor can take 21 service users needing nursing care and the second floor can accommodate 21 elderly service users with dementia. There is a unit manager in charge of each unit and the home manager oversees 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 fifty-one service users in the home at the time of the inspection. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key unannounced inspection where all key standards as identified in this report were inspected. It started on a Thursday 23rd November from 10:00-19:00 and continued on Friday 24th November from 10:00-15:15. A random unannounced inspection took place on the 4th May 2006 to check for compliance with past requirements and to monitor progress of the home with regard to meeting a sample of the national minimum standards for older people. The findings in this report are based on the inspector looking at a sample of records, touring some of the premises and talking to some service users, the manager and some of his staff. The inspector is grateful to all service users who spoke to him and to the manager and his staff for their cooperation and assistance during the course of the inspection. What the service does well: What has improved since the last inspection? The standard of the care records has improved. These are now more comprehensive than they have been previously but there is still some progress to be made with regard to the assessment of the needs of service users once Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 6 admitted into the home. There is evidence of the increased involvement of service users and of their representatives in care plans. The management of pressure ulcers has improved in the home. Photographs and wound mapping are used for the monitoring of pressure sores and wound progress records are completed when dressings are renewed. The standard of décor of the environment and the quality of the furnishings continue to improve. The manager has been in post for about 8-9 months and is now familiar with issues in the home. He is also now more familiar with the national minimum standards and the care homes legislations with which the home must comply. The home has started to apply its quality assurance procedure to monitor the quality of the service that it provides. What they could do better: The service users’ guide must include more information about the range of fees charged by the home. All service users must also be offered the terms and conditions of the placement. The assessment of the needs of service users must be more thorough to ensure that all the needs of service are appropriately addressed. Similarly records with regard to the life and background of service users must be more comprehensive. Although the management of pressure ulcers in the home is generally good, there should be records of the pressure relief equipment in use in the home. The personal care of service users must be of a higher standard. A number of male service users were noted to be without socks and female service users without tights or stockings. A few male service users were also noted to be unshaven and a few female service users were noted to have facial hair. The registered person must ensure that all new members of staff have at least two references and all the other records as required by schedule 2 of the Care Homes Regulations 2001 before they are offered work in the home. The home should have a training and development plan based on the individual profiles of members of staff. The registered person must ensure that all staff have the appropriate induction and statutory training. The manager is not registered yet. He must be registered as soon as possible to manage a registered care home. The management of the personal allowance of existing service users was generally good, but there was a lack of records to ensure tracking/auditing of Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 7 some aspects of the management of the allowances. For example it was not clear how many residents had money in the service users’ account and what happened to the money of service users who were no longer in the home. Valuables and possessions of service users must be comprehensively recorded when received or removed from the home to enable tracking of these. All records must be dated and signed as required. It is recommended that the way that the satisfaction surveys are carried out be reviewed to ensure that feedback is more comprehensive and useful and that a report is produced with the key points from the survey. 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.V320986.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are admitted after a preadmission assessment of their needs to ensure that the home is able to care for them. Service users’ guides are offered to all users of the service. These could be made more comprehensive by including information about the range of fess charged by the home. Not all service users receive a contract/terms and conditions. As a result they may not be fully aware of their rights and entitlements. EVIDENCE: The inspector noted that all service users had a copy of the service users’ guide (SUG) in their bedrooms. The manager confirmed that he ensures that each bedroom has an updated copy of the SUG ready when a new service user is admitted to the home. On asking service users if they knew that they had a SUG containing relevant information about the service, few were in a position Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 10 to respond to the inspector and the two who responded were not clear what the SUG were. They however had the SUG in their bedrooms to which they could refer if they wanted more information about the service. It was noted that the SUG did not contain information about the range of fees charged by the home. Service users who were self-funding received a contract which clearly gave information about the range of fees charged by the home and the arrangement in place for the management of the Free Nursing Care Contribution. There was also some information about fee increases. Service users who paid a personal contribution did not have a contract in place although the organisation did have a format for that and service users who were publicly funded had a copy of the contract with the home and the local authority in place, but there was no evidence that statements of the terms and conditions of the placement were provided to these service users or their representatives at the point of moving into the home. The inspector looked at six care records and three of these were for service users admitted into the home in 2006. He noted that all new service users had a comprehensive pre-admission assessment which was carried out by the manager. The needs’ assessments of the funding authorities were also available on file. A service user spoken to by the inspector confirmed that he/she had the opportunity to visit the home, prior to accepting to come into the home. It was noted that service users generally looked well cared for and seemed contented. Staff were aware of the needs of service users and could explain how they were meeting the needs of the service users. The home had service users from a range of ethnic minorities and cultural backgrounds and members of staff were representative of the ethnic minorities. Members of staff have received training in clinical areas to understand the needs of service users. It was noted that a few members of the care and nursing staff have had some training in dementia care (normally a one day training). It was also noted that the unit was not yet staffed by a registered mental health nurse or by a trained nurse with in-depth training in dementia care, and none of the trained nurses working on the dementia care unit were registered mental health nurse. The manager is however a registered mental nurse and he stated that the deputy manager who has been recruited is also a registered mental nurse. He added that he was going to cascade more dementia care training to staff. He has completed a trainer’s course to train staff on the ‘Yesterday, Today and Tomorrow’ course in dementia, but unfortunately there were no days identified yet for this training on his training schedule for 2006-2007. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care records particularly the needs assessment of service users were not always carried out comprehensively to ensure that all the needs of service users were identified. Service users healthcare needs were met in the home. Medicines management was not as thorough as it should have been to ensure safe practice. Staff in the home take the ‘end of life care’ of service users seriously and address these in the care records. EVIDENCE: The inspector noted that care records were in good order and were kept safely in filing cabinets. The content of the needs assessment of service users at the point of admission has improved but some needs’ assessment could have been more comprehensive to accurately describe the needs of the service users. Some sections of the assessments were not completed at all and some others Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 12 that were completed contained little information about the needs of service users. Care plans were on the whole appropriate and addressed the needs of service users. These were sufficiently detailed to describe the actions that staff needed to take to meet the needs of the service users. It was noted that the care plans were agreed with service users or their representatives where that was possible and that service users/representatives were also kept updated about the care of the service users in review meetings. This was good practice. Care plans generally contained interventions with regard to meeting the healthcare needs of service users. Records showed that service users were seen by the relevant healthcare professionals and that staff in the home referred the service users through the GP to the relevant healthcare professionals as needed. There were two service users with pressure sores in the home. The manager and members of staff stated that both service users had pressure sores after a short stay in hospital and that they (the service users) did not have pressure sores when they were admitted to hospital. The home kept good records about the management of the pressure ulcers. There were care plans in place, photographs and wound mapping as well as regular wound progress notes. From evidence seen the inspector concluded that the pressure ulcers of both service users were healing and that the home has improved its standard of care with regard to the management of pressure ulcers. The home used a range of risk assessments for service users. The waterlow risk assessment is used for the risk assessment of pressure ulcers and equipment was provided by the home in cases where service users were identified at risk. The care plans of service users however did not always make clear the pressure relief equipment in use while the service users were in bed or while they were seated. It was noted that the manual handling risk assessments did not always describe the action to take for the various manual handling manoeuvres such as turning in bed and moving up and down the bed. The equipment to use for these manoeuvres was not always described in the care plan or in the risk assessment. The inspector observed that at least two men were unshaved with beard which looked at least a couple of days old, when their care records said that they should be shaved daily for one and every other day for the other. Some female service users were noted with facial hair. Most male service users were not wearing any socks and most female service users were not wearing any tights Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 13 or stockings. These above observations led to the conclusion that there was ample room to improve the personal care of service users. Medicines were inspected on the first and second floor units. It was noted that some service users had not received their medication on one unit because there was a problem with ordering the medicines. A few areas were noted where there were omissions of signatures or when codes were not always used to describe the reasons for the medicines not having been administered. In a few cases a code was used but the code did not accurately described the reason why the medicines had not been given. The knowledge of nurses about medicines could have been better to ensure that they were able to recognise the adverse effects of the medicines that they were administering. The needs’ assessments have a section dealing with arrangements that may have been made by the service user/relatives about funeral arrangements. These were completed in a few cases and the manager stated that efforts have been made to receive this information and information about the resuscitation status of the service users where possible. All care plans contained a plan addressing the end of life care and arrangements in place to deal with the death and funeral arrangements of the service user Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides appropriate activities for service users but the section of the care plans addressing the assessment of the social and recreational needs and the life history of service users were not always appropriately completed. Meals are provided to service users taking their choices and tastes into consideration and according to their ethnic and cultural background. EVIDENCE: The home had a full time activities coordinator. She normally prepares a weekly programme of activities which she then places on all the units. This is well presented with different colours and laminated to draw the attention and interest of service users to it. On the first day of the inspection there was a ‘ball throwing session’ and a video/film session in the afternoon. Service users gave positive feedback about the activities which were arranged in the home and about the input of the activities coordinator. The inspector noted that most service users had a plan of care addressing their social and recreational needs. While a few care records had a comprehensive assessment of the social and recreational needs and information about the life Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 15 history of the service users, others did not have this information even if some of the information could have been collated from the needs assessment of the funding authority. A number of outings have been arranged for service users and the inspector was informed that another one was planned for the month of December. A few service users who were mostly from the unit for personal care are able to go out, mostly when accompanied by a member of staff. The manager stated that representatives from the local church visit the home to offer spiritual support to service users. The minister from the Methodist church indeed visited the home in the afternoon of the second day of the inspection. The inspector was informed that the representative from the Roman Catholic Church also visit the home regularly. Service users continue to make full use of the dining areas and were being encouraged to engaged with each other during the meal times. The dining areas were appropriately prepared to provide a congenial environment for service users to enjoy their meals. On the first day of the inspection there was jumbo sausages as the first choice and vegetable burger as the second choice. There were also potatoes, cauliflower, broccoli and pineapple sponge and custard as well as yogurt and ice cream for those who wanted that. On the second day of the inspection there was also a choice of fish prepared to suit Afro-Caribbean service users. From conversation with service users and from an inspection of the daily menus it was noted that appropriate meals are provided to service users according to their cultural dietary needs. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately in the home, but more records could have been kept to demonstrate that this was happening. The manager and his staff take allegations and suspicions of abuse seriously and are aware of the procedures to follow in these circumstances. EVIDENCE: The manager explained that the home has had a number of verbal complaints from one source. He stated that he has acknowledged the complaints verbally, has looked at the issues and has provided a verbal response to the complainant. The issues raised were also addressed in care records to prevent these from recurring. While the care plans were available for inspection, there was not much else in writing in the complaint register (such as a tracking form) about the complaints, for example about the dates when the complaints were received, acknowledged and responded to. The inspector asked two service users if they had seen the complaints’ procedure. They were not sure that they had seen it, even though the complaints’ procedure was noted on the door of every bedroom that was seen by the inspector. The complaint procedure is also available in the service users’ guide and the foyer of the home. The manager should consider ways of raising awareness of service users and of their representatives about the complaints’ procedure. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 17 Since the last inspection there has been three allegations of abuse. These were investigated and referred to the appropriate authorities as required and the necessary action was taken to ensure the protection of service users at all times. There was also evidence that training has been provided to members of staff on abuse issues. The manager stated that all unexplained bruises are monitored closely and are fully investigated to prevent recurrence. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 18 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, 22,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is generally suited for the accommodation of service users that the service provides care to. A few bedrooms were still not personalised to provide a homely environment for the service user. The home was on the whole clean and mostly free from odours. EVIDENCE: The bushes and shrubs in front and on the side of the home were mostly maintained. There were some items of furniture and other items at the back of the home which were awaiting disposal. The exterior of the building looked in a maintained state. The home has CCTV camera to monitor the area around the building to improve the management of security. The inside of the home was warm and airy. The reception area, corridors and communal areas were in good decorative order. Communal areas consisted of dining and lounge areas. These areas Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 19 were appropriately furnished and there were TV’s and music systems in the lounges for service users to enjoy. It was noted that service users were encouraged to use these areas. Bedrooms of service users were mostly in good decorative order and painted in warm colours. It was also noted that the home had a list of bedrooms and other areas which were next due for redecoration. There has been some progress with the personalisation of some bedrooms, but a few were still quite bare and would benefit from more personalised items such as duvet covers, curtains, pictures/photos and other items of decoration. The manager who accompanied the inspector for part of the tour of the premises on the second floor agreed and stated that he would explore these issues further. Some service users spoken to by the inspector stated that they liked their rooms and that they could choose to stay in their bedrooms or go out in the lounges. The standard of cleanliness was good, but it was noted that there was an odour in a few bedrooms. The inspector also observed that the procedure for cleaning spillages was not always followed and that on one occasion a spillage of body fluid was not cleaned immediately to ensure that there would not be an odour in the home. On one occasion, the inspector noted that a service user could not find the toilet. As is common in dementia care units, the environment is normally assessed with regard to facilitating the orientation of service users by the use of colours and other accessories, while taking into consideration the individual background of service users. It is therefore recommended that the dementia care unit is assessed by a competent person, such as a dementia care specialist, with regard to evaluating the contribution that could be made to the physical environment, to improve the orientation of service users to their environment and thus increasing their independence, within a risk assessment context. Clinical waste was disposed of in yellow bags which were in the toilets or in the sluice rooms. The sluice rooms were locked and were mainly tidy. The sterilisers were in good working order and were maintained. The manager said that old mattresses which were noted during the last inspection and which had cracks in them, had been replaced. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has adequate numbers of staff to ensure that the needs of service users would be met in the home. The recruitment procedure was not always observed thoroughly to ensure the safety of service users. Training in the home was not provided comprehensively. Without appropriate training there is a danger that service users’ needs may not be met appropriately. EVIDENCE: There was one trained nurse and three carers on the first and second floors each and three carers for the ground floor, which provides personal care. At night there is one trained nurse and one carer for the first and second floors each and two carers for the ground floor. These staffing levels were judged satisfactory to meet the needs of the service users accommodated in the care home at the time of the inspection. Some of the trained nurses were new in the home and some members of the care staff were noted to be also new. The manager stated that there was a vacancy for one trained nurse in the home. The personnel files of four members of staff were inspected. They had most of the required records in place, except that one new member of staff only had one reference in place. Another member of staff did not have a record of his Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 21 employment history completed to the nearest month to enable an exploration of all the gaps in employment. Records were however in place to show that new members of staff have had a CRB check prior to starting work. An induction programme was in place, but the home had not been using the Common Induction Standards from the Skills For Care Council. However a new induction format was shown to the inspector which was going to be used for all new staff and which contained the Common Induction Standards. The inspector noted that the records of a new ancillary member of staff did not have an induction in place. All new members of staff must have an induction in relation to their area of work and this must be recorded. The manager provided a training grid and a training programme for the inspector. Training that has been provided included care planning, communication skills, customer care, restraint, abuse, medicines training, fire, manual handling, food hygiene and first aid. It was noted that most members of staff have had manual handling training and training on abuse. There were however no records of staff attending health and safety training. 38 out 47 care, nursing and catering staff have not had food hygiene training. 34 out of 57 members of staff were not up to date with the annual fire training. 49 out of all members of staff have not had infection control, but according to the training schedule a session has been arranged for December 2006. The training schedule also did not have dates, venues, times, providers of the training and staff that the training was geared to. The home did not yet have a registered mental health nurse to work on the dementia care unit at the time of the inspection. The manager is a registered mental health nurse and the inspector was informed that a deputy manager has been recruited for the home, who is also a registered mental health nurse. There were 11 members of staff who have had training in dementia care, of which 7 were carers. It was noted that 1 member of staff have had training in customer care and another member of staff in communication skills. These are important areas which have in the past been identified as areas where staff in the home needed training. A date has been arranged for Customer care training in April 2007. The manager produced a format to record a comprehensive training and development plan for the home based on an analysis of the individual training needs and profiles of staff. This has not yet been drawn up for the home. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. 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, he has however not yet been registered. The home has a quality assurance procedure but it was not being consistently applied to ensure the full benefits of the quality management system. The records with regard to service users’ personal allowances and personal possessions and valuables were slightly lacking. Health and safety aspects of the service were managed appropriately. Staff however were not always up to date with regard to training in health and safety related subjects. EVIDENCE: Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 23 The manager has been in post for about 9-10 months. He is now familiar with issues in the home and with his responsibilities as the manager of the home. He continues to keep an active presence on the floors and is familiar with the needs of the service users, who in turn are also familiar with the manager. The manager does not yet have a deputy manager and he stated that a deputy manager is due to start work in the home. There was evidence that the manager runs the home in an inclusive manner. He has an open door policy and he has held a number of staff, service users and relatives meetings. A number of service users and members of staff were observed speaking to the manager. Service users stated that they knew the manager and that they would approach him if they had issues that they wanted to raise with him. The manager has however not yet been registered by the Commission. Section 11(1) of the Care Standards Act requires that any person who manages a registered care home be also registered. The home has a quality assurance procedure and a quality management system. Monthly audits are carried out by the manager which are then validated by the regional manager every two months. The audit addresses key areas of the service. An action plan is drawn up after the monthly audit to address the issues identified in the audit. A copy of a monthly audit and the action plan following the audit was seen by the inspector. A copy of a validated audit was not available for inspection. The inspector was informed that satisfaction surveys are carried out monthly by the sampling of 10 of service users. A few satisfaction questionnaires completed by service users were seen by the inspector. The outcomes of the surveys were not always analysed in a report to identify strengths and weaknesses and an action plan was not produced to address the issues which might have been identified. It was not also clear whether all stakeholders of the service including placement authorities, relatives of service users and visitors to the home were being sampled for their views. The management of the personal allowances of service users in the home is normally the responsibility of the administrator. It was noted that some service users receive personal allowances of service users directly from the local authority and others receive some personal money from their relatives/next of kin for expenses incurred on behalf of the service users such as for hairdressing, toiletries, clothing and outings. The home has a main account where all the money of service users is banked. Access to this account is by head office staff. The home then keeps a small amount of cash from which money for the personal expenditures of service users are drawn. Records were kept for each service user about expenditures, receipts and withdrawals of money. However there was no balance of the cash float in the home for audit Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 24 purposes, although it is acknowledged that access to this float is restricted to the administrator and the deputy. Although there were individual balances of the personal money for each service user who kept money with the home, a list of service users who had money in the common bank account was not available. It was also not possible to track the money of service users who were no longer in the home and to find out whether interests rates were being paid to service users who had money in the bank account. The home kept records of the personal belongings and possessions of service users in the care files. It was noted that the records were not dated and signed by staff, service users/representatives. It was also not clear whether these were being kept up to date when new personal belongings were brought into the home for the service users or taken away from the home. This could later cause problem later when an inventory of service users possessions is carried out. The health and safety records showed that there were weekly in-house fire detector tests, emergency fire tests, monthly wheelchair checks and monthly water temperature checks. Records were available to show that equipment in the home was being appropriately maintained and serviced. Certificates with regard to the electrical wiring system, portable appliances test, gas safety and treatment of water for Legionella were available for inspection. A Fire Risk Assessment and a Fire Emergency Plan were not available during the inspection but the manager confirmed shortly after the inspection that these were forwarded to the home. A Health and Safety Risk Assessment was available for inspection. The manager said that he keeps the risk assessment under review. It was noted in the previous section, that staff were not always up to date with regard to statutory training such as training with regard to fire training, food hygiene and health and safety. Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 25 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 2 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 26 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 The service users’ guide must contain information about the range of fees charged by the home. All service users, including those who are wholly or partly publicly funded, must be provided with a copy of the contract/statement of terms of conditions of the home. The registered person must 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. 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. The registered person must ensure that the following issues DS0000041432.V320986.R01.S.doc Timescale for action 31/01/07 2 OP2 5(1)(ba) 31/01/07 3 OP7 14,15 31/01/07 4 OP7 13(5) 15/01/07 5 OP9 13(2) 15/01/07 Willesden Court Care Home Version 5.2 Page 27 6 OP10 12(1,4) 7 OP10 12(1,4) 8 OP12 16(2) (m,n) 9 OP26 16(2)(k) are addressed: -All service users must have an adequate stock of medicines to ensure that they receive their daily medicines as required. -All medicines must be signed for or a code must be used when the medicines has not been administered. -That any code used to describe the reason for a medicine not to be administered is described (Repeated requirementtimescale 15/07/06 not met). -Nurses and other staff who administer medicines must have a good knowledge about the medicines that they administer to ensure that they are able to recognise and monitor for adverse effects of the medicines. The registered person must ensure that all male service users are shaved according to their individual choices and usual habit. The incidence of female service users having facial hair must also be reviewed according to the individual wishes of service users. The clothes of service users must be ironed to an acceptable standard. The clothes must then be put away tidily in the cupboard/drawers of service users. Male service users must be provided with socks and female service users must have tights or stockings if they are used to wearing these. The registered person must ensure that the assessment of the social and recreational needs of service users, including the life history of service users are carried out to a high standard. The registered person must ensure that the home is free of DS0000041432.V320986.R01.S.doc 31/12/06 31/12/06 31/01/07 15/01/07 Willesden Court Care Home Version 5.2 Page 28 10 OP28 18(1)(c) 11 OP29 19(1)(b) 12 OP30 OP38 18(1)(c) 13 14 OP31 OP35 9 17(2,3) malodours and must review the procedure for cleaning spillages. The registered person must have a plan to ensure that care assistants are trained to NVQ level 2 as soon as possible. (Repeated requirement, timescale of 30/6/5, 30/06/06 not met). The registered person must ensure that all members of staff 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. The registered person must ensure that members of staff are trained in all statutory areas, including fire training, health and safety and food hygiene training as soon as possible. The manager must be registered as soon as possible. The registered person must review the way that the personal allowances of service users is managed in the home to ensure that appropriate records are kept to facilitate audit of the management of the personal allowances. The records of the personal possessions and valuables of service users must be always signed and dated by the member of staff and by the service user/representative whenever possible. 30/06/07 31/01/07 31/03/07 28/02/07 31/01/07 Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 29 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 OP8 OP16 Good Practice Recommendations Comprehensive records should be kept about the type of pressure relief equipment in use for the residents at risk of pressure sores or for those who have pressure sores. The manager should ensure that comprehensive records are kept with regard to complaints. He should also consider ways of raising awareness of service users and of their representatives about the complaints’ procedure. The manager should produce a comprehensive training and development plan for the home based on the individual training profiles for the home. The training programme should be more comprehensive to include the time of the training, location and staff who need to attend the training. The registered person should review the way the satisfaction surveys are conducted and analysed to reap the full benefits that may result from a satisfaction survey. The validation audits should be carried at the intervals as indicated in the quality management system. 3 OP30 4 OP33 Willesden Court Care Home DS0000041432.V320986.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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.V320986.R01.S.doc Version 5.2 Page 31 - 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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