Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 26/04/05 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 26th April 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 were complimentary about the staff in the home. There seemed to be a good rapport between the service users, their relatives and staff. Staff in the home were familiar with service users and listened to them. The members of staff spoken to by the inspector, seemed to be willing to contribute to the improvement agenda of the home and seemed to require direction, support and training to help them along the way.

What has improved since the last inspection?

The bedrooms of service users were tidy and clothes were arranged tidily in drawers and wardrobes. There has been some redecoration in the home (corridors, staircases and bedrooms)

What the care home could do better:

Improve the needs assessment of service users to ensure that the needs are identified so that care plans can then be set up to meet these needs. Without this there is no guarantee that the needs of service users will be met.The provision of meals in the home must be improved as well as the provision of appropriate crockery. The home must have a plan for the redecoration and refurbishment to ensure a sustained and planned input in ensuring that the home continue to provide a high quality environment for service users. The cleanliness of the home must improve, particularly with regard to carpets and bed frames. Training of staff must improve with regard to statutory training, training in clinical areas and NVQ training.

CARE HOMES FOR OLDER PEOPLE Willesden Court Care Home 3 Garnet Road Willesden London NW10 9HX Lead Inspector Ram Sooriah Unannounced 26 April 2005 13:00hrs The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willesden Court Care Home Address 3 Garnet Road Willesden, London, NW10 9HX 020 8459 7958 020 8459 7967 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Stanford Homes Limited Najmuddin Mudhoo CRH N Care Home with nursing 59 Category(ies) of PD (E) Physical Dis (over the age of 65) 21, registration, with number OP Old Age (not falling within any other of places category) 18, DE (E) Dementia (over the age of 65) 20. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28/1/5 Brief Description of the Service: Willesden Court is owned by Standford Homes Limited. The company has now been acquired by Southern Cross Healthcare since the 1st of April 2005. Willesden Court was first registered in January 2001. It 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 59 service users in single and en-suite bedrooms. Accommodation is divided in 3 units, each of which has its own lounge, dinning 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 accommodates 20 elderly service users with mental illness. There is a unit manager in charge of each unit and the home Manager oversees the overall running of the home. The home was full at the time of the inspection. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a Tuesday. It started at about 1300 and finished at about 2000. The inspector spoke to service users, management and staff; looked at a number of records including a sample of care plans and medicines records; observed care practices; toured the building and looked at facilities in the home. After the inspection he was able to give feedback to Mr Madhoo, the registered manager, and to Ms Young, the operations manager. The inspection was the first for this financial year starting April 2005 and the fifth since April 2004. The number of inspections has been necessary to check for compliance of the service with the National Minimum Standards and past requirements, some of which have still not been met. In the past year the service has been the subject of enforcement action to ensure compliance with some of the requirements. The service now has new owners and the Commission is ensuring that the new providers have the opportunity to meet the requirements imposed on the service to improve the quality of the service that the home provides. Failure to meet the requirements within the time scale may result in further enforcement action. What the service does well: What has improved since the last inspection? What they could do better: Improve the needs assessment of service users to ensure that the needs are identified so that care plans can then be set up to meet these needs. Without this there is no guarantee that the needs of service users will be met. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 6 The provision of meals in the home must be improved as well as the provision of appropriate crockery. The home must have a plan for the redecoration and refurbishment to ensure a sustained and planned input in ensuring that the home continue to provide a high quality environment for service users. The cleanliness of the home must improve, particularly with regard to carpets and bed frames. Training of staff must improve with regard to statutory training, training in clinical areas and NVQ training. 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. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 &4 Very little progress has been made in the improvement of the needs’ assessment of service users. The relevant sections of the care records were not comprehensively completed. Without this there is no assurance that care needs will be met. EVIDENCE: The inspector looked at three care records. There was evidence that a service user who was recently admitted to the home have not had a pre-admission assessment. The admission seemed to have been an emergency admission. There was no evidence that his needs had been assessed prior to admission. All service users must have a pre-admission assessment prior to admission. The assessment of the needs of service users once admitted to the home was not always completed comprehensively. The assessment was not clear about the likes and dislikes of service users with regard to food. One of the assessments mentioned that the service user liked a normal diet, and it did not clarify what the ‘normal diet’ entailed. The assessment on eating and drinking for one service user did not elaborate if a service user had dentures or if she had her won teeth. Other issues such, as the time to go to bed, to wake up and the pattern of sleep were also not clear. The mobility for one service user Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 9 was not clarified and as a result it was not clear how independent the service user was. There was a mini mental test score and an assessment with regard to mental health needs, which was being used on the unit for service users with dementia. Two care records chosen at random on the unit for service users with dementia showed that one service user had a mental health assessment and the other service user did not have one. As a result of the above, the registered person must ensure that all service users have a comprehensive assessment of their needs. This is a repeated requirement. The home did not fully demonstrate its ability to meet the needs of the service users. This conclusion is based on a number of issues, which have been identified in this report. This includes issues such as the home not meeting past requirements which have been repeated many times; service users not having a comprehensive assessment of their needs; limited provision of training available in the home and the quality of the meals provided in the home during the inspection. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-11 Care plans did not always set out the health, personal and social care needs of service users. The health care needs of service users were not always being fully met. As a result service users could be at risk. EVIDENCE: Care plans contained plans of actions in cases where problems have been identified. These were normally reviewed monthly, but it is not clear whether this is just a routine process as some of the care plans appeared not to have been updated. The care plans did not always contain accurate information regarding service users. In one of the care plans, a plan of care said that the service user needed two members of staff with a hoist and wheelchair for transfers, while the manual handling risk assessment mentioned that the service user walked with an aid. In another case the care plan mentioned a particular mattress for the prevention of pressure sores, while a different mattress was in place. The inspector noted involvement of service users/representatives in one of the three care plans. In that care plan, they were only involved in drawing the plans of care but were not involved in risk assessment. As a result the inspector judged that there was not enough involvement of service Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 11 users/representatives in the formulation and review of the care plans and risk assessments. Service users are assessed for pressure sores using the waterlow score. Photos were available in some instances, but not on all occasions. A service user who was admitted with pressure sores did not have photographs of his sores or a mapping of the sores. The home now has a range of equipment for the pressure relief of service users. The inspector observed that a pump for the alternating air mattress overlay was set on full power and not adjusted to the weight of the service user. There was evidence that service users have been assessed for incontinence. However care plans were not always clear about the management of the incontinence and the incontinence product being used. The inspector noted a service user who was wet in the lounge area. This raises questions about the frequency at which service users are being toileted/changed and issues about privacy and dignity of service users. Two of the care records inspected showed that service users were not regularly weighed. In one case a service user lost 7.4 kg (more than 10 body weight) in the space of about 8 months. It was not clear from the records if actions have been taken to inform the GP or the dietician. Medicines were inspected on the units on the first and the second floor. A brief inspection of same was carried out on the ground floor. The inspector noted that sticky labels were used on medicines administration record (MAR) sheet. As these may come off, they must not be used since medicines records are to be kept for at least three years. Instead a pre-printed MAR sheet may be requested from the chemist when the prescription goes to the chemist, or the GP may sign the MAR sheet and enter the medicine or if the above are not possible then for two nurses to enter the medicine on the chart, sign the chart and to have copy of the prescription available for inspection. There were a few omissions with regard to not recording the medicines received in the home. In cases of multiple doses, the actual amount of medicine administered was not always recorded. The temperature of the medicine fridge was not always recorded and the thermometer was not always reset when the temperature was taken. Service users who are diabetic must have their own lancet device (or single use lancet device) and own glucometers unless these have been designed for communal use (See MDA/2004/044). Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 12 In cases where there is a pen injection device being used by nurses for a particular medicine, their use must be reviewed in line with recent guidance from the Medicines and Healthcare Products Regulatory Agency on these equipment with regard to the risk of needle stick injury (See MDA/2005/009 or visit www.mhra.gov.uk ) The inspector observed that the clothes of service users were put tidily in the drawers and wardrobes of service users. The rooms were also generally tidy. Service users were dressed in clean clothes. The inspector noted that there were two gentlemen who were not shaved and a female service user with facial hair. The inspector noted that the hair of some female users did not appear to be appropriately done. Some of them had hair, which did not looked tidy and which did not looked appropriately styled. The home has payphones, but it did not have a phone system, which would allow service users make and receive phone calls from the privacy of their bedrooms, particularly when they have taken to their beds or when they suffer from poor mobility. The care plans of service users contain a small section about the funeral arrangement of service users, which was filled in some cases. However there was no information with regard to the service users’/representatives’ wishes and instructions with regard to death taking into consideration observances, rites, cultural and religious issues. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Activities are not always provided for service users to ensure that their social and recreational needs are being met. Meals provided to service users are not always nutritious, balanced and varied. EVIDENCE: On the day of the inspection, the activities coordinator was on leave. There was no one to take the role and responsibility to provide activities for the service users. The operations manager stated that she has given staff a booklet to bring into perspectives the importance and responsibility for all staff to take part into the provision of recreational and social activities for service users. The booklet was indeed available on the units, but had not yet been acted upon. Records about the recreational and social needs of service users were not always comprehensive. There were sections in the care plan on work and play; and on personal history. These were completed appropriately in one of the three care plans inspected. Another care plan had some and the other had little information on the recreational and social needs of the service user. The new chef had reviewed the menus the week prior to the inspection and was trying the new menu. There was toad-in-a-hole as the main meal, and tuna salad as the second choice for lunch. Service users were observed Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 14 enjoying their meals. The menu however needed some more work to make it more comprehensive as some of the suppers did not look sufficiently nutritious and balanced. The chef agreed that she needed some input to ensure that the menu is appropriate for the needs of the service users. On the inspection day, service users were offered hash browns, bake beans and ham sandwiches. There was a problem with suppliers on that day as the home was switching to suppliers that supply Southern Cross. The chef stated that she tried to produce a meal from the ingredients that were available in the kitchen, but the meals did not seem to be sufficiently balanced and were not according to the choice of service users. The inspector was informed that the problem has now been resolved and that new suppliers were going to supply the home on the following day. As a result, the home must ensure that service users are always offered meals, which are nutritious, balanced and varied, according to an appropriate menu. There were records of the fridge and freezer’s temperatures. However records about the meals cooked daily in the home were not always kept. The kitchen was generally tidy and all equipment was working at the time. The inspector noted that service users were receiving their meals in small plates, which looked like side plates. These were not appropriate for service users, particularly for those who lacked a bit of dexterity. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 &18 The home takes complaints; allegations and suspicions of abuse seriously and deals with these appropriately for the protection of service users. EVIDENCE: Since the last inspection, there have been two complaints. These had been appropriately investigated. One was investigated by senior staff working for Southern Cross. The new company also has comprehensive complaint procedures, which will no doubt cascade down to Willesden Court. The current complaint procedure was in the foyer of the home and was included in the service users’ guide, which was seen in a number of bedrooms. Having spoken with the operations manager and the registered manager on the day of the inspection, the inspector believes that they do take complaints seriously. The home already has a Protection of Vulnerable Adult procedure. This was not inspected on this occasion. However, records were not available for the inspector to determine the number of staff who have had training on abuse. If this has not been provided, then training on abuse must be provided to all care staff in the home. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) A little improvement to the décor has been made. There are a number of matters outstanding which prevent the home from providing a safe, pleasant and comfortable environment for service users to live in. EVIDENCE: The outside of the home was in good order. The grounds in the front were tidy but the grounds at the back could have been made tidier by removing the weeds in the flowerbeds. There is a lot of potential to make this area attractive and pleasant for service users by growing more flowers and shrubs. There has been some redecoration of the home since the last inspection. Some bedrooms, staircases and corridors have been redecorated. The home however did not have a plan for redecoration and for the replacement of fittings and fixtures available for inspection. A record of all areas that have been redecorated was not available for inspection. The home now has CCTV camera for security purposes but its use was restricted to the entrance of the home. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 17 The inspector noted that there has been some rearrangement of the communal areas on the unit for service users with dementia. The dining room has been moved from the lounge/dining area to another communal area situated on the same floor. This has released more space in the main lounge for service users to use, but it also made it look a little bare. The inspector was informed that there were plans to buy more furniture for the lounge. The television on the unit for service users with dementia was not playing very well and the aerial needed adjusting. Bedrooms of service users now have bed tables and jug of water. There were call bells in the rooms, which were also connected. The bedrooms were tidy and clothes were arranged properly in drawers and wardrobes. Some of the bedrooms have yet to be personalised particularly on the second floor. The inspector noted stains on the carpet in two rooms, which were viewed randomly. There was also an odour in two other bedrooms. The bed frames under the mattresses were not always clean and some were covered with dust. The inspector observed that an air pressure mattress overlay was placed on a divan bed. Service users requiring nursing and a pressure relief mattress/overlay must have adjustable beds. While the doors to service users bedrooms on the ground floor were fitted with locks, the doors on the other two floors were not fitted with locks. The inspector also noted that not all service users had a lockable space. To show its commitment to ensure the privacy and dignity of service users, doors to service users bedrooms must be fitted with locks and accessible to staff in emergencies. Service users must also have access to a lockable space. Service users must be provided with keys unless their risk assessment suggests otherwise. The inspector noted during his tour of the bedrooms that a few items of furniture lacked handles and would therefore be difficult for service users to open them if they wish to. The home is experiencing an ongoing problem with regard to the supply of hot water, which fails at times. The home must have a constant supply of hot water. The inspector noted that a clinical waste bin in one of the sluices did not have a lid and that some soiled clothes were placed inappropriately in the wash hand basin. To ensure compliance with infection control procedures, there must be appropriate clinical waste bins in the sluice and management of soiled clothing. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27&30 The deployment and number of staff on the day of the inspection was appropriate for the home. The training of staff is not adequate to ensure that the needs of service users will be fully met. EVIDENCE: On the day of the inspection there was an adequate number of staff on each floor to care for the service users. A recorded duty roster was available for inspection. A training and development plan was not available for inspection. This would have confirmed whether the home was providing appropriate training for care staff. The manager showed the inspector a training grid that he was working on. There were individual training profiles sighted by the inspector in January 2005. These were not shown to the inspector during this inspection. On talking to a number of staff, it was clear that a few of them of them were studying for NVQ level 2 but at their own cost. During the course of the inspection the inspector was informed that Southern Cross would be looking at producing a training and developing plan as well as identifying training providers for NVQ level 2. In the meantime, the inspector was told that one of the training coordinator for Southern Cross would be looking at the immediate training needs of the staff. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 &38 The management has been unable to meet past requirements and to ‘turnaround’ the service. It has effected little change in the home to ensure improvement in the quality of the service that it offers to the service users. EVIDENCE: The manager is registered and has now been in post for about a year. Prior to that he has worked in other care homes. When he took over the home, there was a need to ‘Turnaround’ the service, because of its failure to meet a considerable number of national minimum standards (NMS). A number of requirements however remain not met or not fully met. The management must be able to communicate a clear sense of direction and leadership towards providing a quality service and towards meeting the NMS. It must also provide all the necessary resources to ensure that improvement and development of the service are given priority. There is therefore a need to look carefully at the NMS, the management structure of the home, the resources, the training needs and plan forward to Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 20 ensure that the NMS are met. Management of the home should be asking if the home is being really run in the best interests of the service users. The NMS have now been in place for about three years and improvement in the home could only occur when the service meets these NMS. In most of the bedrooms of the first floor, there are windows, which reach from the floor to nearly the ceiling. It is not clear if these windows are shatterproof. The inspector came to consider them after he was informed that someone had thrown a stone against one of the windows from the street. While there are metal railings in front of the windows facing the front of the home, there are none for the windows facing the back of the home. The purpose of the railings is not clear as to whether they are there to stop someone from falling out should the window break or whether they are there for decorative purposes. As a result a risk assessment must be conducted with regard to these windows on the first floor as to their ability to withstand shattering and as to their ability to prevent someone falling out should they break the window. At the time of the inspection the home did not have an appointed person for First Aid. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 1 COMPLAINTS AND PROTECTION 2 x x x x 2 x 1 STAFFING Standard No Score 27 2 28 x 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x x x 2 Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1,2) Requirement All service users admitted to the home must have a preadmission assessment. Once admitted they must have a comprehensive assessment of their needs for care planning purposes(Repeated requirement). The registered person must be able to demonstrate the ability of the home to meet the needs of service users by ensuring that all past requirements are met within the time scale. The registered person must esnure that service users’/representatives are involved in drawing and in reviewing care plans (Repeated requirement). Care plans must be updated as and when the condition of service users change to ensure that they contain up to date information about the care of the service users. The incontinence assessment of service users must be clear about the frequency of toiletting and the incontinence product to use. Service users must also be Timescale for action 30/6/5 2. OP4 14(1)(a) 30/6/5 3. OP7 15(1,2) 31/7/5 4. OP7 15(2)(b) 30/6/5 5. OP8 15(2) 30/6/5 Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 23 6. OP8 17(1)(a) 7. OP8 12(1) 8. 9. 10. 11. OP9 OP9 OP9 OP9 13(2) 13(2) 13(2) 13(2,4) 12. OP9 13(4) toiletted at regular intervals to ensure that they do not wet their clothes as far as possible. There must be clear records about pressure sores including photographs or wound mapping, pressure equipment in use and update on the progress of the sores. The pressure setting on the air compressors must be set according to the weight of the service users. Service users must be weighed at least monthly and actions must be taken in cases where there has been significant (more than 5 ) weight loss in line with the nutritional risk assessment. Sticky labels must not be used in MAR sheet as these may come off. All medicines received in the home must be recorded. In cases of multiple dosage, the actual amount of medicine administered must be recorded The temperature of the medicine fridge must be recorded daily and the thermometer must be reset once the temperature has been taken. Service users who are diabetic must have their own lancet device (or single use lancet device) and own glucometers unless these have been designed for communal use (See MDA/2004/044). 30/6/5 30/6/5 30/6/5 30/6/5 30/6/5 30/6/5 30/6/5 13. OP9 13(4) 30/6/5 The registered person must review the use of pen injection devices in the home in line with recent guidance from the Medicines and Healthcare Products Regulatory Agency (See MDA/2005/009 or visit www.mhra.gov.uk ) Version 1.30 Page 24 Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc 14. OP10 15. OP10 16. OP11 17. OP12 18. OP15 The registered person must ensure that service users have a high level of personal care at all times, to include shaving and hairstyle. 16(2)(b) The home must have a phone system, which would allow service users make and receive phone calls from the privacy of their bedrooms in cases where they may be confined to their beds (Repeated requirement). 15 The care plans of service users must contain information about the wishes and instructions of service users with regard to arrangement for death taking into consideration observances, rites and cultural and religious issues (Repeated requirement). 16(2)(m,n There must be comprehensive ) assessments of the recreational and social needs of service users. 16(2)(i) The home must ensure that service users are always offered meals which are nutritious, balanced and varied, according to an appropriate menu (Repeated requirement). 17(2) 16(2)(g) 23(2(d) There must be records of all food cooked in the home for service users. Appropriate cuttlery and crokery must be provided for service users. The home must have a plan for redecoration and for the replacement of fixtures and fittings (Repeated requirement). Service users requiring nursing and a pressure relief mattress/overlay must have an adjustable beds. Doors to service users bedrooms must be fitted with locks and accessible to staff in 12(1) 30/6/5 31/7/5 31/7/5 31/7/5 30/6/5 19. 20. 21. OP15 OP15 OP19 30/6/5 30/6/5 30/6/5 22. OP24 23(2)(n) 31/8/5 23. OP24 12(4)(a) 31/8/5 Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 25 24. OP24 23(1) 25. OP25 23(2)(j) 26. OP26 23(2)(d) 27. OP26 13(3,4) emergencies. Service users must also have a lockable space and must be provided with keys unless their risk assessment suggests otherwise. All furniture must be in a good state of repair. The registered person must ensure personalisation of the bedrooms of service users and of the home in general (Repeated requirement). The problem with the hot water supply in the home must be rectified as soon as possible (Repeated requirement). The home including the bedrooms of service users must be kept to a high standard of cleanliness and must be free from unpleasant smells. To ensure strict compliance with infection control procedures, there must be appropriate clinical waste bins and appropriate management of soiled clothing (Repeated requirement). The home must have a training and development plan with individual training profiles available for inspection.The home must ensure that 50 of the carers are trained to NVQ level 2 as soon as possible (Repeated requirement). The management of the home must be able to communicate a clear sense of direction and leadership towards providing a quality service and towards meeting the National Minimum Standards. It must also provide all the necessary resources to ensure that improvement and development of the service are given priority to ensure good 30/6/5 31/8/5 30/6/5 30/6/5 28. OP30 18(1)(c) 30/6/5 29. OP31 10(1) 31/7/5 Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 26 outcomes for service users. 30. OP19, OP38 13(4) There must be a risk assessment of the windows on the first floor with regard to the possibility of shattering and with regard to the possibility of someone falling through, should the glass break. There must be an appointed person for First Aid in the home at all times. 30/6/5 31. OP38 13(4)(c) 30/6/5 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 OP19 OP20 Good Practice Recommendations The grounds at the back of the home should be made tidier and more attractive by removing the weeds and by planting more flowers and shrubs in these areas. The aerial for the TV on the second floor should be adjusted to provide a good quality picture for service users. Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middx HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willesden Court Care Home G62-G11 S41432 Willesden Court V224033 260405 Stage 4.doc Version 1.30 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!