Inspection on 04/09/07 for Willesden Court Care Home

This inspection was carried out on 4th September 2007.

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

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

Other inspections for this house

Willesden Court Care Home 29/05/09

Willesden Court Care Home 21/07/08

Willesden Court Care Home 23/11/06

Willesden Court Care Home 05/12/05

Willesden Court Care Home 26/04/05

Willesden Court Care Home 28/01/05

Willesden Court Care Home 13/07/04

Willesden Court Care Home 22/04/04

Willesden Court Care Home 18/02/04

Willesden Court Care Home 02/01/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Willesden Court Care Home 3 Garnet Road Willesden London NW10 9HX Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 4th September 2007 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.V344010.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.V344010.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 Manager post vacant Care Home 60 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (39) Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care, nursing care and accommodation to service users of both sexes whose primary care needs on admission to the home are within the following categories:Old age not falling within any other category (Category OP) (no more than 18 persons requiring personal care) Service users with a physical disability who are 65 years of age and over (Category PD(E)) (no more than 39 persons) Service users with dementia who are 65 years of age and over (Category DE(E)) (no more than 21 persons) Service users requiring general nursing care who are under 65 years of age (no more than 2 persons) The maximum number of service users who may be accommodated is 60 23rd November 2006 2. Date of last inspection Brief Description of the Service: Willesden Court was first registered in January 2001. It is now owned by Southern Cross Healthcare. Willesden Court is situated in one of the many multi-cultural areas of Brent. It is a purpose built 4-storey building found on the corner of Garnet Road and Mayo Road. It is about 3 minutes walk from the main road, which is served by buses. The home has a parking facility at the back and there is also parking on the roads in front and on the side of the home. The home provides care for 60 residents in single and en-suite bedrooms. Accommodation is divided in 3 units, each of which has its own lounge, dining area and kitchenette. The 4th floor is for ancillary services. The ground floor has accommodation for 18 residents. That unit was previously for the accommodation of residents requiring personal care, but the home has successfully applied that nursing residents be accommodated on that unit. The staffing on the unit has also changed to reflect that. The first floor can take 21 residents needing nursing care and the second floor can accommodate 21 elderly residents with dementia. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 5 The home has a manager and a deputy manager to oversee the overall running of the home. The home charges £400-£500 for service users requiring personal care depending on their needs; £500-£650 for service users requiring nursing and £600-£650 for service users requiring dementia care. There were 41 residents in the home at the time of the inspection, who were accommodated on the first and second floors. The residents on the ground floor have been moved to other Southern Cross Homes, after flooding affected the ground floor of the home. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 4th September 2007 from 10002100. This was a key inspection and the first for the period 2007-2008. The findings of the inspections are based on the inspection of a sample of records, a partial tour of the premises, observing care practices and interaction of staff with residents and my conversation with residents and staff. The manager also completed an Annual Quality Assurance Assessment (AQAA), which has been used for this inspection. As part of the new CSCI methodology, Suzanne Clarke an Expert by Experience assisted me to get feedback from residents and visitors to the home, to find out what it is like to live in the home. I am grateful to Suzanne Clarke for her assistance and Help the Aged for arranging this initiative. At the time of the inspection, the residents who were accommodated on the ground floor have had to move to other care homes belonging to the organisation because of flooding on the ground floor. I have met some of the residents who were moved to another care home and noted that they were satisfied with the arrangements that have been made for them and with the temporary accommodation which was all in single en-suite bedrooms. I would like to thank all residents and visitors, who spoke with us to share their experiences and views about living in the home, and the manager and all her staff for the support and assistance during the course of the inspection. What the service does well: Residents and/or their representatives receive information about the service prior to deciding if the residents want to move into the home. The needs of all prospective residents as assessed by the manager or senior members of staff before they are offered a place in the home to make sure that the home would be able to meet their needs. Members of staff are well aware of the cultural and religious needs of residents and support them in meeting these. Residents are able to exercise choices about what they want to wear and about how they spend their day. Those who are able to mobilise independently and with no risk to themselves or others do so with little interference from staff. Residents’ healthcare needs are monitored by staff and referred to the GP and other healthcare professionals as required. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 7 The home provides a variety of meals to suit the needs of the residents who come from various backgrounds and cultures. They are supported as required with their meals although in my view supervision in one of the lounges could have been better. The standard of the décor is on the whole good and the quality of furniture in the communal area is also good. The home is keen to implement the dementia care strategy of Southern Cross and staff are keen to improve the provision of this service. This includes revamping the dementia care unit on the second floor. What has improved since the last inspection? What they could do better: The manager should ensure that residents, who are publicly funded, have a copy of the agreement between the home and funding authority as soon as possible to make sure that the residents/representatives are fully aware of their rights and obligations. Care plans and risk assessments could be more comprehensive to address all the needs of residents and could have been agreed with the residents and representatives when being drawn up and reviewed. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 8 Care plans and risk assessment s for manual handling could be more comprehensive to describe the equipment to use and the manual handling manoeuvre to carry out when moving residents. Care records about tissue viability must be clear about the equipment to use to prevent pressure ulcers or to manage pressure ulcers. The home should consider recording the progress of pressure ulcers either by photos or wound mapping. Prompt action must be taken to deal with the healthcare needs of residents such as when a urinary catheter becomes blocked. More attention must be provided to the presentation of residents’ clothes and the way these are kept in residents’ wardrobes and drawers. The information about the resuscitation status of residents must be clear and there must be care plans in place addressing the end of life care needs of residents. The assessment of the social and recreational needs and life history of residents could be more comprehensive and care plans could also be put in place to ensure that all the needs of residents are being met. The home should also review the provision of activities and interactions of staff with residents in the absence of the activities coordinator. That when residents receive pureed meals, the components are not mixed together, but are served separately on a plate to enable a resident taste the different component of the meal. That the appropriate cutlery and crockery are used when serving residents their meals and drinks. That all ‘expression of dissatisfaction’ or when a resident/relative say that they want to complain be treated as complaints and recorded. The grounds of the home must be maintained to a high standard to provide some stimulation to residents. There must not be any lingering odours in the home as this causes an unpleasant environment for those who are accommodated in these areas and for the visitors to the home. Items of furniture, which are not fit for purpose, must be replaced. While there has been some progress with regards to improving the environment to care for residents with dementia, more emphasis should be given to the implementation of the dementia care strategy of Southern Cross. The manager acknowledged that the home has fallen behind with training, as the organisation did not have a training coordinator for a while. She now has plans to meet all the statutory obligations with regards to the provision of statutory training and other training to make sure that staff are able to care for the residents who are accommodated in the home. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 9 Residents who use wheelchairs must be provided with footrests for their safety, unless there is a risk assessment in place. 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.V344010.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-4 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and/or their representatives are offered enough information to enable them make a decision about whether they want to use the service. Prospective residents’ needs are assessed by trained members of staff to ensure that the home will be able to meet the needs of the residents who are offered a place. EVIDENCE: A service users’ guide was available in the home. I was informed that it is provided to all prospective residents/representatives to provide information about the service that the home provides. A copy was in the bedrooms of residents. It was noted that it does not yet contain information about the range of fees charged by the home and other information as to what the fees cover and how the home deals with other arrangements such as the free nursing care contribution. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 12 I looked at whether the contracts/statement of terms and conditions for 2 residents chosen at random were in place. The contract/statement of terms and conditions were in place and were noted to be comprehensive documents. The manager has however identified in the AQAA that the home needs to review whether all residents have a contract/statement of terms and conditions of the home. According to the figures in the AQAA provided, albeit before the flooding of the home, 19 out of all residents who are publicly funded have a copy of the agreement with the health trust or council with the home. The manager stated in the AQAA that she plan to review the contracts of residents who stay in the home. All residents who are referred to the home are assessed by the manager or senior staff. The home uses the preadmission format, which has been drawn up by Southern Cross. This has been found to be lacking particularly when assessing residents with dementia. The manager said that she takes the dementia assessment format when assessing residents who are referred to the dementia care unit. The preadmission assessments are available on file for inspection. The needs assessments and care plans from the placing authorities are also requested as part of the admission process to determine if the home is able to meet the needs of the residents. The home provides care for older people and people with dementia. It was noted that there are a number of staff that have worked in the home for some time and were familiar with the needs of the residents. The home accommodates residents from a number of ethnic, cultural and religious backgrounds. Members of staff were aware of the cultural and religious needs of residents and respected these. It was noted that the home also took into consideration the various needs of residents when providing meals to residents, supporting residents with personal hygiene and dressing, arranging activities and making arrangement for religious and other cultural celebrations. As a result of the above it is possible to conclude that the needs of residents are on the whole being met in the home. The care records of residents addressed the cultural and religious needs of residents to some extent, but a few were lacking in this respect. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are not always clear and comprehensive to address all the needs of residents. These are also not always agreed with residents/representatives to make sure that the needs of residents are being addressed comprehensively. Healthcare needs of residents are on the whole met in the home but comprehensive risk assessments are not always in place when residents use bedrails. Medicines management in the home is of a good standard to ensure the safety of residents. Care records contain little information about the end of life care of residents and therefore there is no guarantee that the end of life care needs of the residents would be met. EVIDENCE: The care records of five residents were inspected on both units. It was noted that the assessment of needs once residents were admitted to the home, were not always comprehensively completed. A number of areas in the format were left uncompleted or empty. For example areas on sexuality, sleeping, body temperature and dying were not completed. Residents did not also have care Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 14 plans addressing these areas. The assessment of breathing for a resident said that she did not have any problem even though she had a lung condition. Residents on the dementia care unit had a dementia care assessment when admitted to the home. It was noted that the standard of care plans was in general not as good as it could have been. There were some good care plans such as when the care records mentioned that a resident was not able to wear shoes. In another case the care plan of a resident addressed his swallowing difficulties. But as mentioned above the care records did not consistently describe the action to take to meet the needs of residents. The care plan for a resident with diabetes said to ‘inform GP if unexpected changes in blood glucose’ and did not clarify what was meant by ‘unexpected’. The care plan for another resident on pain said to assess location and severity and did not say whether a pain chart was to be used. There was no pain chart in the car records. A resident’s care plan on death and dying said to ‘assist with spiritual needs’ but was not clear as to what these were. The care plan for another resident did not clarify the sleeping pattern for the resident and her preferences with regards to how and where she spends her time. Some residents had care plans on the ‘alteration of sleep patterns’ without clearly identifying if this was a need of the individual resident. Another care plan said to record the likes and dislikes of residents. It was noted that four months after admission, this either still remained part of the care plan which has not yet been actioned, or the care plan has not been updated during evaluation. The home has a special format to record when residents are involved in care records. It was noted from the care records that residents and their relatives were not always involved in drawing up the care records as the format to sign was left incomplete when the care plans were drawn up. Residents/relatives were more likely to be involved in the review of the care plans six weeks after admission when social services normally conduct their review or six months when the home conducts its own review. However three out of the five residents, or their relatives have not been involved in reviewing the care plans. Staff spoken to said that they were aware of the cultural practices and religious beliefs of the residents. These were not always recorded and if recorded these were not comprehensive. For example if the religion of a resident is recorded it is not always documented whether the resident is practising his/her religion. A resident who is Jewish had records about the meals that she takes, but there was little information in her care records about the other aspects of the Jewish culture. The home uses a range of risk assessments to ensure the safety of residents. These were kept up to date and reviewed at least once a month. Southern Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 15 Cross has a comprehensive policy for the use of bed rails. This was in the process of being implemented in the home at the time of the inspection. It was noted that a resident who had bed rails did not have a risk assessment for that. Another resident, who had a risk assessment for bed rails, did not have this agreed with himself or his representative. It was also noted that one resident did not have bumpers to the bed rails. He was noted in bed with the bedrails up and following recent advice from the MHRA, precautions must be taken to prevent injury and entrapment. Manual handling risk assessments and associated care plans did not always describe the equipment to use such as the type of hoist and sling, when moving residents. The manoeuvres and equipment to use when moving residents in bed were also not always detailed. There was one resident with pressure ulcers at the time of the inspection. A care plan was in place and wound progress notes were also in place. It was noted that photos were taken at about three monthly intervals to monitor the ulcers. There was no wound mapping in place. It was noted that the care plans for this resident and other residents at risk of developing pressure ulcers were not always clear with regards to the equipment in place for pressure relief. One care plan mentioned the make of the equipment, another said to ‘ensure mattresses are soft’ and another did not mention the item of equipment in use. Residents were seen by healthcare professionals according to their needs. The GP visited the home on a weekly basis and residents were seen when referred by the members of staff. Records were kept about the input of healthcare professionals in the care of residents. Care records of one resident showed that he had a urinary catheter, which was not working well as it was bypassing urine. No action was taken for 7 days to change the catheter or to refer him to the relevant healthcare professional until the relative of the resident complained to the manager of the home. The relative had already expressed concerns one day after the catheter started bypassing but no immediate action was taken at the time. Inspection of the bedrooms of a few residents showed that a few items of bedroom furniture were broken, but it was also noted that the clothes of residents were not ironed appropriately and were not always put tidily in the wardrobes and drawers of residents. The second floor was better as making sure that the clothes of residents were put away tidily. Residents presented as appropriately dressed with clean items of clothing and generally clean and well cared for. A few residents were noted not to have been shaved on the dementia unit. They had beards, which were a few days old. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 16 Residents were offered choices about how they spend their day and about their daily life. A resident said that she chooses the clothes she wanted to wear and she wore jewellery. Another resident who had a key to her bedroom, was pleased to show Suzanne Clarke her room and family photos that she treasured. She was able to confirm that she dresses, as she wants with colourful bangles and a bright headscarf. Medicines were inspected on the first and the second floors. Medicines management was on the whole of a good standard. Medicines were mostly signed when administered and the amounts received in the home were recorded. The instructions for the administration of creams and lotions were also clearly recorded. Nurse’s knowledge about the medicines that they administering was good and the home had an up-to-date medicines reference book. The admission form contained a section to record information about arrangement of residents with regards to death and funeral. There was also a section on resuscitation. These sections were not always clarified. One resident care records said that he had a living will and subsequent probing did not clarify whether this was a living will or a normal will. A few residents did not also have care plans addressing end of life care and the fears and concerns of residents for the future. There was however evidence that staff, including care staff have been attending training in end of life care, which has been arranged by Brent PCT. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The records of residents about their social and recreational needs were not that comprehensive to make sure that these needs would be met. In the absence of the activities coordinator there is little in the home in the form of activities and interaction with residents. The home provides a variety of nutritious meals to suit the needs of the residents. EVIDENCE: The home has a format to record the social and recreational needs of residents. The first page is for the social profile and the second page is for the life history. Out of the five care records inspected, all five had the social profile completed, two had the life history completed and two had care plans addressing this aspect of care. The home has an activities coordinator. She was not on duty on the day of the inspection. A programme of activities was available in the home, but little amount of activities and interactions were observed both by Suzanne Clarke and me during the inspection. Most of the times residents sat in the lounge in a large circle with the TV on. Some residents were able to mobilise on the Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 18 floors where they were accommodated and some went to the smoking room. In the afternoon about 5-6 residents sat outside in the patio garden. Residents in the home are encouraged to maintain links with the community and their relatives and friends. I was informed that the recent flooding has caused some disruption to some of the arrangements that are normally made during summer for going out. As a result there has not been much outings. The home maintains an open door policy and a number of visitors were seen in the home. The notice board contained information about the arrangements that have been made for the representatives from the local churches to visit the home. I had the opportunity to observe lunch being served to residents. Menu sheets were completed on a daily basis about residents’ choices. While this was available on one floor, it was not on the other floor. Staff normally send the form to the kitchen for the chef to count the required number of portions of meals. In this case the form had not been returned back to the unit. Staff, however were aware of the choices made by residents, but it is recommended that the menu sheet be always made available when dishing out the meals. Portions of meals served to residents were good. It was noted that the menu also took into consideration the cultural mix of the home. Provision is made to make sure that residents from different cultural and ethnic backgrounds received culturally appropriate food. Lunch consisted of barbecue chicken, potatoes, peas and carrots. The second choice was pasta and mushroom. Residents were assisted with their meals, but more efforts could be made on the second floor with assisting residents for example with cutting the meat and supervising them. I observed a few who would have benefited from help and support. Residents who were on pureed meals had all the components of the meals mixed together instead of these being served separately to make sure that residents are able to taste the various components of the meal. We also noted that a number of residents were in the process of having breakfast in the morning when we visited. Most of them had finished breakfast but a few residents were noted to have fallen asleep with their breakfast or tea in front of them and we could not see a member of staff helping them. We were told that some of the residents refused the help and hence they were left with their breakfast to eat within their own time. It was noted that at times residents were offered drinks in cups without saucers, although saucers were available on the trolley. Residents were on the whole happy about the meals served in the home. Suzanne Clarke and I tasted the chicken and we both noted that the meat was well cooked and tasty. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. To provide confidence that the service deal with all complaints in a serious manner all complaints must be taken seriously and dealt with as per the complaints procedure of the service. Residents are safeguarded by the policies and procedures of the home EVIDENCE: The home uses the Southern Cross complaints’ procedure. This was available in the service users’ guide and on notice boards in the home. Residents and visitors spoken to said that they would approach the manager if they had any concerns. The relative of a resident mentioned to me that she had ‘complained’ to the manager about some care issues, which were then addressed. This was however not recorded in the complaints’ register and had not been dealt formally as a complaint despite the seriousness of the issues. The fact that the word ‘complaint’ was used did suggest that the relative was not satisfied about some aspects of care and that therefore she was ‘complaining’ to the home. The complainant however was confident that the manager would deal with the complaint when she complained to her and was satisfied with the action that was taken to address her complaint. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 20 There have been 9 complaints since the last inspection, including the one, which was not recorded as a complaint. The complaints covered a number of issues including the provision of care, attitude of staff, provision of bathroom facilities and the provision of meals. 8 of the complaints were upheld. The complaints were acknowledged and responded to as required except for the one, which was not recorded. The home provides training on safeguarding adults. The training records showed that the majority of staff in the home have had training on abuse. The manager and her staff are familiar of the procedure to follow in cases of allegations of abuse. There have been 2 allegations of abuse in the home since the last inspection, which have all been appropriately dealt with. Staff spoken to, were familiar with the procedure to follow in cases when there were suspicions or allegations of abuse. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment that the home provides, is generally suited to care for the residents who are accommodated in the home, except for a strong odour on the first floor and the poor maintenance of the garden areas. EVIDENCE: The front of the home was on the whole maintained. There were bushes and shrubs in the front and side of the home bordering the roads. There is a parking area in the grounds of the home at the back which is protected by gates and fencing. This area was not well maintained and tidy. The enclosed garden at the back of the home was in poor condition and looked abandoned. There were many weeds in the lawn area, between the patio slabs and the flowerbeds. The bushes and shrubs were not maintained and pruned. Residents were noted using the area and one of them decided to pull some of the weeds off. The exterior of the building was on the whole in good condition. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 22 There has been a flood in the home, which affected the carpet, items of furniture and some equipment on the ground floor. At the time of the inspection the carpet in the main corridor was being replaced and there was on going redecoration to make the ground floor fit again to re-admit the residents who have had to be sent to other homes when the ground floor flooded. The communal areas on the first and the second floors were seen. These were in an appropriate state of decoration. Residents were encouraged to use the dining areas of the home. This was noted on a greater extent on the dementia care unit than on the nursing care unit, where a significant number of residents stayed in their armchairs for their meals. There was a broken radiator in the dining area and we were informed that parts have been ordered to repair the radiator. The wardrobe and chest of drawers in a number of bedrooms were broken and needed repairing or replacing. One resident did not have a bed locker. The toilet seat in another’s resident en-suite was broken and needed repairing. Bathrooms and toilets were on the whole clean for use by residents. It was however noted that a few care staff tunics were seen hanging/drying in a bathroom, despite the home having a staff changing room. A number of bedrooms were seen by the inspector while touring the premises. Some improvement was noted with regards to helping residents identify their bedrooms. There were photos of the residents with their names on the door to help them find their bedrooms. A few bedrooms were personalised to a good standard and some remained quite bare and impersonal. Southern Cross has a strategy to develop dementia care, which involves making the environment more conducive to the care of the residents with dementia care needs. This has started to some degree in the home but there are plans to revamp the dementia care service that the home provides. There was a strong odour on the second floor. The source of which seemed to be a bedroom. This was noted by Suzanne Clarke and myself. This must be rectified as soon as possible as the resident is confined to his bed and his relatives have to visit him in he bedrooms. One of his relatives said that the odour has been there for some time and that it was getting better. It was not clear why the odour was not contained which led to it spreading to that part of the corridor. There were no odours on the first floor corridor but one bedroom on that floor was noted to be malodorous. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides staff in appropriate numbers to meet the needs of residents. The training provided to staff is not comprehensive enough to ensure that staff are fully competent and trained to care for the residents. EVIDENCE: There is 1 trained nurse and 2 carers for the ground floor and 1 trained nurse and 1 carer at night. The first floor accommodates 21 residents and is staffed by 1 trained nurse all day, 4 carers in the morning and 3 carers in the afternoon. There are 1 trained nurse on the second floor and 3 carers all day. At night there are 1 trained nurse and one carer for the first and the second floor each. As the residents on the ground floor were not in the home, the members of staff who normally look after them on the ground floor were ferried daily form Willesden Court to the home where the most of the residents were temporarily accommodated. The home also employs ancillary staff in appropriate numbers to ensure that the home is run in a smooth manner and to support the delivery of care. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 24 The personnel records for 4 members of staff were inspected. The records were well organised and kept safely in locked filing cabinets. It was noted that the 4 members of staff did not have full references.. Three of them had testimonial references, dated prior to the person applying to work for the home and one member of staff had a character reference. Two employees had gaps in the employment history, which did not seem to have been explored at the time of the interview. The organisation has an induction checklist for new members of staff. Two members of staff had one in their files. There was no evidence that new care staff were completing the common induction standards as per Skills for Care, the training organisation for the social care sector. The home has about 35-40 care staff. According to the AQAA 5 have an NVQ qualification in care and 9 are currently in the process of working towards an NVQ qualification in care. As a result the home does not yet have 50 of its care staff trained to at least NVQ level 2 in care. The training matrix for the home was kindly provided by the manager. From figures and analysis of the matrix there seem to be a number of training that has been lacking in the home. The manager also stated in the AQAA that the company has been without a trainer for a long time, which has affected the ability of the homes to ensure that all the care staff were up to date with all training, including training in statutory areas. It was noted that staff in the home last had fire training in June 2006 and were therefore out of date. 6 persons in the home have had training in food hygiene. Among the staff that have not had food hygiene training were 2 kitchen assistants who require this training. A number of care staff are also involved in dishing out meals for residents and therefore require this training. Most staff were up to date with manual handling but it was noted that 2 members of the care staff have not had training in manual handling since 2005 when the update is required yearly. Only 1 member of staff has had training in health and safety and there does not seem to have been any recent training in infection control. While it is acknowledged that the manager has been trying to compile the training matrix from records and that some of the records may be missing, it does seem that there is a need to ensure that training, particularly statutory training, is arranged as a matter of priority for all staff. The manager stated during the inspection that she has identified a trainer for food hygiene and health and safety. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 25 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): 31,13,35 and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is managed in an open and transparent manner and offers people who use the service an opportunity to contribute to the management of the home. The home has a quality control system, which is used to monitor the quality of the service that the home provides. The management of residents’ personal money is carried out to a good standard to prevent abuse. Health and safety issues were on the whole being maintained and addressed. There was some lacking with regards to training in health and safety areas. EVIDENCE: The manager has been appointed since February 2007. She has worked in NHS facilities and in other care homes in management position prior to taking this post at Willesden Court. She is not registered yet and stated that she is in the Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 26 process of being registered. She reported that she would start the registered manager’s award in the near future. A deputy manager has recently been appointed and was on his induction at the time of the inspection. His brief is to provide clinical leadership and training of staff. There is therefore some reassurance that with the management team being in a stronger position, improvement in the home will accelerate. The manager holds regular staff meeting to involve staff and to keep them informed of issues and events in the home and the organisation. Minutes of a head of department meeting, which took place on the 24th June, were seen. She has acknowledged that supervision of staff has not always been regularly carried out and she now plans to address this issue with the support of the new deputy manager. A residents and relatives’ meeting took place on the 21st August. It was noted that the Dementia Care strategy of Southern Cross was discussed in the meeting. This is commendable as it involves relatives of residents in the care of the residents as well as maintaining an open approach to the management of the home. The quality assurance procedure of Southern Cross Healthcare was in place in the home to monitor the quality of the service. As usual with this procedure there are monthly audits, which are carried out by the manager and two monthly validation audits by an external person, normally the operations manager. There were noted to be carried out and action plans were in place to address areas where the standard was lacking. The manager said that she has sent satisfaction questionnaires, which were being returned to the home at the time of the inspection. She added that she would prepare a summary of the findings and a report once the questionnaires have been returned. A copy of an action plan of the home dated August 2007 was kindly provided to the Commission which detailed areas which needed addressing to ensure that the aims and objectives of the service are being met to its full potential. This included action plan to meet previous CSCI requirements, areas where improvement is required as identified through internal and external audits and operational objectives. The personal money of some residents is managed by the home. The money is kept in a main account and individual records for each resident were also available for inspection. There were no staff in the home that were the agent for any residents. Residents who receive their personal allowances had this money accounted in their personal records in a timely manner. Records were also kept for all expenditures, which were made on behalf of residents. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 27 Health and safety meetings are held at regular intervals to look at issues, which may pose a hazard to residents, visitors and staff. The minutes of a meeting, which took place on the 15th August, were available for inspection. They mentioned that the light in the lift has been out for some time and that it has not been repaired. This was noted still out of action at the time of the inspection. A few residents were wheeled from their bedroom to the lounge/dining area in wheelchairs without footrests. This was an issue, which has also been identified by management and addressed in the health and safety meeting. However residents may be place at risk by not using footrests and action must be taken to ensure the safety of residents. Records showed that water temperature checks were carried out as required and that the necessary fire checks were being carried out. The recent London Fire Emergency and Planning Authority (LFEPA) conducted an inspection in June and noted that a few issues needed attending; such as making the risk assessment more suitable for the home, addressing issues with regards to fire exits being able to open in an emergency and the maintenance of door guards and fire doors. The manager stated that these were in the process of being addressed. A PAT certificate and an electrical wiring certificate were available for inspection. Other certificates of maintenance were available to show that equipment was being maintained and serviced as required to ensure the safety of people who use these items of equipment. Training in health and safety issues such as food hygiene, health and safety, infection control was not being thoroughly addressed as identified in the previous section. Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X x X 3 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 3 X X 2 Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 29 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. That the needs of residents once admitted to the home are comprehensively assessed and that these assessments are kept under review. 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 (Repeated requirementtimescale 31/01/07 not met). That evidence is kept about the consultation of residents/relatives in drawing up and in reviewing care plans and risk assessments. The manual handling risk assessment and associated care DS0000041432.V344010.R01.S.doc Timescale for action 30/11/07 2 OP7 14(1,2) 30/11/07 3 OP7 15(1,2) 30/11/07 4 OP7 13(5) 30/11/07 Willesden Court Care Home Version 5.2 Page 30 plan must clarify the actions to take and the equipment required for the various manual handling manoeuvres required while caring for residents with poor mobility (Repeated requirement-timescale 15/01/07 not met). 5 OP8 13(7,8) Residents who require bed rails must have comprehensive risk assessment in place, which have been agreed with the residents/representatives. Bumpers must also be used according to the risk assessment to prevent injury or entrapment. That wound progress is monitored at least monthly or more regularly either by photographs/wound mapping or by any other means to ensure that prompt action can be taken in cases of deterioration. Comprehensive records must 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. To ensure that the healthcare of residents is continuously being met, prompt action must be taken by nursing and care staff when this is required, such as in cases when urinary catheters become blocked and need to be changed. To ensure a high standard of personal hygiene the registered person must ensure that all male residents are shaved according to their individual choices and usual habit. (Repeated requirement-timescale 31/12/06 not met). To promote the dignity of DS0000041432.V344010.R01.S.doc 31/10/07 6 OP8 17(1)(a) 31/10/07 7 OP8 12(1) 31/10/07 8 OP10 12(1,4) 31/10/07 9 OP10 12(1,4) 31/10/07 Version 5.2 Page 31 Willesden Court Care Home residents, their clothes must be ironed to an acceptable standard and must then be put away tidily in the cupboard/drawers of service users (Repeated requirement-timescale 31/12/06 partly met). 10 OP11 14(1,2) To ensure that the end of life care needs of residents will be met, the care records of residents must be clear about the resuscitation status of residents and must ensure that the end of life care of residents and the arrangements in place for the management of the death of residents and the funeral arrangements are addressed. The registered person must ensure that the assessment of the social and recreational needs, including the life history of residents are carried out to a high standard (Repeated requirement-timescale 31/01/07 not met). The registered person must review the provision of activities in the home when the activities coordinator is not on duty. That the registered person review the presentation of pureed meals to make sure that the components of the meals are served separately on the plate and not all mixed together in a bowl. To deal with complaints appropriately all expressions of dissatisfaction with the service or standard of care, and situations when the word ‘complaint’ is used, must be considered as a complaint and be dealt with as such. To make sure that residents are able to enjoy the grounds of the DS0000041432.V344010.R01.S.doc 30/11/07 11 OP12 16(2) (m,n) 30/11/07 12 OP15 16(2)(i,j) 31/10/07 13 OP16 22 31/10/07 14 OP19 23(2)(o) 31/12/07 Page 32 Willesden Court Care Home Version 5.2 15 OP26 16(2)(k) home, the registered person must ensure that these are maintained to a high standard The registered person must 31/10/07 ensure that the home is free of malodours and must review the procedure for cleaning spillages to make sure that the home continues to provide a high quality environment for residents (Repeated requirementtimescale 15/01/07 not met). 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 and 30/06/07 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 (Repeated requirementtimescale 31/10/07 not met). All new care staff must complete an induction programme as per the common induction standards of Skills for Care. 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 (Repeated requirement-timescale 31/03/07 not met). The home must have a DS0000041432.V344010.R01.S.doc 16 OP28 18(1)(c) 31/08/08 17 OP29 19(1)(b) 30/11/07 18 OP30 18(1)(c) 30/11/07 19 OP30 OP38 18(1)(c) 31/03/08 20 OP31 9 31/03/08 Version 5.2 Page 33 Willesden Court Care Home registered manager as soon as possible. 21 OP38 13(4) That footrests are provided to all wheelchairs for use by residents, unless a risk assessment is in place. 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations That all residents who are publicly funded be provided with a copy of the agreement of the home with the health trust or the local authority responsible for the placement of the resident(s). That a copy of the menu choice sheet is kept on the relevant floor to make sure that staff are aware of the choices that residents made while serving the meals. That a member of staff stay at all times in the dining areas to supervise, assist and encourage residents with meals. The home must continue with progress to make the bedrooms of residents more homely and personalised. 2 OP15 3 OP24 Willesden Court Care Home DS0000041432.V344010.R01.S.doc Version 5.2 Page 34 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.V344010.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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