Inspection on 05/12/05 for Willesden Court Care Home

This inspection was carried out on 5th December 2005.

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

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

Other inspections for this house

Willesden Court Care Home 29/05/09

Willesden Court Care Home 21/07/08

Willesden Court Care Home 04/09/07

Willesden Court Care Home 23/11/06

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 Unannounced Inspection 5th December 2005 12:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 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 Stanford Homes Limited Najmuddin Mudhoo Care Home 59 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (21) Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Dementia 20 places Old Age 39 Places Of which 21 are for elderly persons requiring nursing care and a further 18 places are for elderly persons requiring personal care. Temporary variation agreed for one named individual (Mr FO`S) aged 64 years for the duration of his stay. 26th April 2005 Date of last inspection Brief Description of the Service: Willesden Court is owned by Standford Homes Limited. The company has 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. The management structure in the home consists of unit managers, in charge of each unit, a deputy manager and the home Manager, who oversees the overall running of the home. There were fifty-one service users in the home at the time of the inspection. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the period 2005-2006. It started on Monday 5th December from 1230-1920. The inspector then arranged to return to the home on Tuesday 20th December from 0945-1330 to complete the inspection. During the course of the inspection, the inspector spoke to service users; visitors to the home; Liz Young, the operational manager; Barbara Warner; the home manager; and her staff. He also looked at a sample of records, toured some of the premises and observed care practices. He would like to thank the service users, the manager and all her staff for a kind welcome to the home and for their support and cooperation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The assessment of the needs of service users must be improved. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 6 Infection control procedures must be adhered to at all times. The provision of NVQ training must be reviewed to ensure that more staff are enrolled on this course. The procedure with regard to the record and storage of service users’ valuables must be observed and followed at all times. 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 DS0000041432.V271419.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The home has new formats for the assessment of the needs of service users, but these were not always completed comprehensively. Without this there is no guarantee that the needs of service users will be identified. While the needs of service users were in the main being met, the input of a nurse trained in mental health/dementia to oversee the care of service users accommodated on the dementia unit would be beneficial. EVIDENCE: The inspector looked at the care records of five service users. There was evidence that new service users who were admitted to the home have had preadmission assessments, which were normally carried out by the manager. These were comprehensive and copies were available for inspection. Copies of the needs’ assessment of the placement authorities were also available on file. The inspector judged that the needs of service users are appropriately assessed prior to admission. Once service users are admitted to the home, they have a needs assessment for care plans purposes. The assessment is based on the activities of daily living. The inspector noted some progress with regard to the content of the Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 9 needs assessment of service users but there was still room for improvement. Although there is an attached sheet, which provides guidance about filling the assessment of needs, the inspector found that the guidance was not always followed when the assessment of needs are being completed. In the case on one service user, the section on maintaining a safe environment consisted of circling two boxes, one about whether he was aware of his surrounding and the other about whether he was able to self-medicate. There was no information about his level of comprehension, his independence with maintaining his own safety and his level of compliance with interventions to care for him. The needs assessment for another service user had five sections, which were not completed. The inspector also noted that the likes and dislikes of service users with regard to food were not always recorded. The assessments of the needs of service users were also not always updated when the needs of service users changed. For example, the assessment of a service user said that there was no problem with the sleep pattern, yet there was a care plan with regard to a ‘disturbed sleep pattern’. The inspector also noted that service users with mental health needs, such as those who are accommodated on the unit for service users with dementia did not always have a comprehensive assessment of these needs. As a result of the above, he concluded that the assessment of the needs of service users were not as comprehensive as they could have been. On talking to staff and through the records, it was noted that members of staff were familiar with service users and their needs. While probing the training and qualifications of staff who work on the unit for service users with dementia, the inspector noted that there were no trained nurses on that unit, who have had accredited training in dementia care or who were Registered Mental Nurses. There was evidence that there has been some training for carers in understanding dementia and aggressive behaviour. The manager also stated that she has done some training in dementia and that she has a special interest in this area. However this being a unit for service users with dementia and who have complex needs, there is a need to have nurses with specialist training in this area. Such a person would be able to implement evidencebased practice in dementia care, introduce new concepts in the care of service users with dementia such as Dementia Care Mapping and person centred care. The manager added that there are plans for a registered mental nurse to join the unit in January. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Care plans were in the main appropriate, but they could have been more comprehensive to include all the actions that need to be taken to ensure that the needs of service users were met. The healthcare needs of service users are being met in the home. The system with regard to the management of medicines in the home could have more robust to ensure the safety of service users at all times. EVIDENCE: Care plans were comprehensive on most occasions. Although the needs’ assessments at times were not comprehensive, to ensure that all the needs of service users will be met, there were care plans to address some of the needs of the service users. For example, although there were no mental health needs’ assessments, care plans were in place to address issues such as aggressive behaviour, wandering and absconding. There were also behaviour record sheets in place. The home uses a range of risk assessments including manual handling, pressure sore, nutritional and falls risk assessments. The inspector noted that the manual handling risk assessment is normally followed by a plan detailing the various actions to take to manage the manual handling of the service Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 11 users. These did not however cover all manual handling manoeuvres to be carried out with service users. They mostly described the transfer of service users from bed to chair, but did not always describe the manual handling of service users such as for turning in bed or for moving up and down the bed. The care plan which followed the continence assessment of service users were not always clear with regard to the promotion of continence or/and the management of incontinence, particularly with regard to the type of incontinence pads to use to manage the incontinence and the frequency and time to change the pads. As a result of the above the registered person must ensure that care plans contain clear actions to meet the needs of the service users. The inspector noted that some of the care records have been signed by service users or by their representatives. This demonstrated the involvement of relatives/representatives in the care plans. There was also evidence of review meetings being held where relatives/representatives were invited to take part. This is good practice. Service users were registered with a GP. There was evidence a number of healthcare professionals have visited service users when that was needed. Records were kept about the outcome of these visits. The manager however did say that it was proving very difficult to arrange for a yearly check up of service users in the home by the dentist. In cases where service users were at risk of pressure sores or had pressure sores, there were care plans in place. These were generally comprehensive. There were wound assessment charts in place, which were completed to give information about progress with regard to the sores/wounds. The inspector noted that the pressure relief equipment in use was not always documented and that there were not always photographs/wound mappings of the sores/wounds. In one case a service user, who had sores/ulcers in the lower legs, did not have a bed cradle. This could have helped with reducing pressure caused by the bed linen and promote wound healing. However during the second day of the inspection the inspector was informed that a bed cradle could not be provided for the service user because of a certain risk to the service user and there was a risk assessment in place as a result. The inspector checked the medicines on the 2nd and 1st floors. Medicines record charts were signed in most cases and there were records of medicines, which have been received into the home and of medicines, which have been sent for disposal. The home has an arrangement with the chemist for the disposal of medicines. The date of opening of some medicines was recorded appropriately on medicines. Records of the temperature of the medicines fridges were made daily. The inspector also noted that the temperature of the medicines’ fridge on the second floor was reading above 9 degrees centigrade for at least a week. He found that the instructions for the eye medicine for a service user was not clear with regard to which eye should the medicine be administered. It said ‘one drop in the eye at night’. The instructions for another medicine (calogen) was also not clear with regard to the frequency and the amount to be Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 12 administered. A service user’s medicine, which was on a previous chart, was not transferred to the current chart. Although written for as required it was not clear if this service user was receiving that medicine or if that medicine has been discontinued. The inspector noted that the knowledge of nurses with regard to medicines could have been more comprehensive with regard to knowing the indications for the use of the medicines and the side effects to observe for. While in general service users appeared appropriately dressed and groomed, the inspector noted that there were a number of male service users on each unit who had not had a shave. One service user, who did not have a call bell, did not have a risk assessment, agreed with her or with her representative, in the care records to address this issue. The clothes of service users were appropriately ironed and were generally placed tidily in the cupboards of the service users. The manager has a qualification in Palliative Care. She has also sent a number of trained nurses on three days courses and carers on a one-day course on palliative care. She stated that service users could stay in the home if they are dying unless their needs cannot be met in the home. Care plans contained a section on ‘dying’ and on resuscitation. Four out of the five care plans did not have both of these sections completed. One of the care plan said that the service user was unable to express her views. There were no attempts at asking the next of kin about the instructions of the service user with regard to end of life care and with dying. While staff may very well cope with looking after service users who are dying, it is not very clear to what extent the wishes and instructions of service users with regard to this aspect of care are being followed. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 The home provides a range of activities, which service users enjoyed. However the recreational and social needs of service users were not always assessed comprehensively and a plan was not always in place. Service users receive appropriate meals in pleasing surroundings. EVIDENCE: The care plans contain a separate sheet for the assessment of the social and recreational needs of service users. This consisted of two parts: client social profile and a life history. The first part was filled most of the times and the second part was not always completed. The manager however explained how the home together with the dementia specialist for Southern Cross Healthcare were developing a comprehensive format for a life history which would include various sections for different stages of life. It was also noted that there was not always a plan to address the social and recreational needs of service users. The manager again clarified that plans will be developed once staff in the home start to use the new format for the life history of service users. While the above would certainly improve the information about the recreational and social needs of service users, at the time of the inspection this part of standard 12 was not fully met. While on the unit for service users with dementia, the inspector observed service users taking part in drawing, which they were clearly enjoying. The Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 14 home has apparently won a drawing competition by the residents within all of the Southern Cross Homes. There were comprehensive programs of activities for each unit which were made in an attractive manner and which were posted on notice boards on each unit. The inspector concluded that although there were not always life histories and individual care plans to address the recreational and social needs of service users, the home does provide a range of activities which generally meets the needs of the service users. The activities coordinator informed the inspector that she has been arranging outings in the local community for service users. She added that it is difficult to arrange transport to take service users on outings, and she will try and do that when the weather improves in summer. There were a number of activities that were being arranged for the holiday period including a party in the home and a party for Caribbean service users outside the home. The home has an open door policy and a number of visitors were observed in he home. The visitors were able to see the service users in the bedrooms of the service users or in one of the quiet communal areas. The manager stated that it is possible to access advocates for service users with no representatives. The home has arrangement with a number of religious representatives to visit the service users in the home on a regular basis. There are dining rooms which are appropriately furnished on each floor. These were clean and pleasing for service users to have their meals in. Lunch on the first day consisted of chicken casserole, boiled potatoes and mixed vegetables. The supper consisted of soup, chicken nuggets, coleslaw, sandwiches and yogurts. Service users on the ground floor said that they are able to choose the meals that they want when the trolley comes on the floor. There was evidence that the home also ordered Halal meat for service users who require this. The manager stated that service users are able to choose and have West Indian meals at least once monthly. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 The organisation and the home take all complaints, allegations and suspicions of abuse seriously and take actions to deal with these as appropriate. EVIDENCE: The home has received three anonymous and two named complaints via the Commission for Social Care Inspection since the last inspection. It has also received one complaint in house. The complaints were all appropriately investigated within the timescales. They were found to be unsubstantiated. The complaints procedure was available in the service users’ guide and was found in the foyer of the home. The manager also stated that she has an open door policy and that she also visits the units regularly. She is therefore easily approachable and can discuss issues about care and the service provided by the home to those willing to talk to her. Service users said that they knew who the manager was and that they could speak to her if they wanted to. The home has an abuse procedure. There was evidence that there has been training on abuse. The home provides some in house training, which consists of watching a video and answering questions. The manager stated that the certificated training that she has arranged for staff in November on the Protection of Vulnerable Abuse has not taken place and that the training has been deferred to the beginning of the new year. The manager has in the past appropriately referred allegations and suspicions of abuse to the necessary authorities. She has also received appropriate support from her line managers who have taken these cases very seriously and who have worked in an open and cooperative manner with the authorities. After a conversation with the Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 16 manager on this subject, the inspector is reassured that all cases of suspicions or allegations of abuse are dealt appropriately by the home. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26 The management takes the decoration of the home seriously and has started dealing with this issue in an order of priority. More input is however required to ensure the personalisation of some of the bedrooms. Some practices with regard to infection control were not appropriate and must improve. EVIDENCE: The front of the home needed some attention with regard to weeding, but the back was generally tidy. The exterior of the building was also in an appropriate condition. Since the last inspection the organisation has prepared a plan for the redecoration of the home. The corridors and the communal areas of the home have been repainted. Carpets in the lounges and in the first and second floor corridors have been replaced. Flooring in all the dining areas have also been replaced. There was evidence that the home has been provided with additional items of furniture for the communal areas and for some bedrooms and that furniture which was in a poor condition of repair has been replaced. The Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 18 curtains in some areas have also been replaced to give the home a brighter and more homely feel. Locks have also been placed on doors on the second and ground floors. There was therefore evidence that the home was complying with its redecoration programme. Some bedrooms have been redecorated but most of them will need to be redecorated in the near future and some items of furniture in the bedrooms may also need to be replaced. The bedrooms continue to lack personalisation and continue to be bare. The manager stated that she has plans to address these in an order of priority within the redecoration programme. The inspector noted that reality/sensory boards were placed in the corridor for service users on the Dementia unit. This is good practice. The inspector noted that there were carpets in the bedrooms of service users which needed to be cleaned as they were stained. He was informed that the two carpet shampooers in the home were broken. He indeed noted that these were being repaired on the day of the inspection. He observed that there were dirty clothes left on the floor in one en-suite and that incontinence pads were disposed of in the bins for domestic rubbish in that same en-suite and in one of the showers. He also noted that rubbish which looked like clinical waste was left on a bin in the sluice instead of being put in a yellow bag placed in the bin. This poor practice could be putting service users at an increased risk of cross infection. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The home has appropriate numbers of staff on duty. Recruitment procedures are appropriate to ensure the safety of service users. Most members of staff are up to date with regard to statutory training. The home does not yet have half of the number of carers trained to NVQ level 2 EVIDENCE: Duty rosters were available for inspection. There were one trained nurse and three carers for the first and second floor each; and two carers for the ground floor, where there were fourteen service users. There are normally three carers on the ground floor when the unit is fully occupied with eighteen service users. The inspector looked at four personnel files chosen at random. The files contained appropriately completed application forms. Each employee had references, photographs and proof of eligibility to work in the UK as well as evidence of CRB checks. There was also a medical questionnaire in place, but there was no evidence in the questionnaire that the immunisation status of staff was being addressed in the health questionnaire. There were eight carers trained to NVQ level 2 and two more carers were on the programme studying to achieve the NVQ level 2. There are in excess of twenty carers in the home and therefore the home will not meet this standard by the end of 2005. The inspector was informed that the company was looking at ways to secure NVQ training for its care staff. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 20 A training programme was kindly provided to the inspector. There was evidence that a range of training has been provided to staff. Most of the home staff have had training in fire training, manual handling and food hygiene. The manager stated that she was looking for training in infection control and that she has identified a trainer for this training. This is indeed an area where staff would benefit from training (see standard 26). Staff have also had training in areas such as palliative care, challenging behaviour and managing incontinence. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 The management of the home is able to demonstrate that it discharges its responsibilities fully and that it operates within an open and inclusive culture to ensure improvement of the service. Some health and safety aspects were identified which could put service users at risks. EVIDENCE: The current manager has been in post since April. She is an experienced manager and has worked abroad and in the UK for many years. She was also a registered manager of another service prior to starting at Willesden Court. She is fully aware of her responsibilities and has a job description. She is familiar with issues in the home and has started dealing with the issues in an order of priority. The inspector noted that the manager made regular visit to the floors and that she was familiar with her staff and service users, who were also quite familiar with her. The evidence seen during the inspection indicates that the Turning Around process of the home has started. This process takes time and Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 22 the manager stated that she has started dealing with the most urgent issues in an order of priority. She confirmed that she has been supported closely by the management team from Southern Cross. The regional manager visited the home on the first day of the inspection to offer support to the manager of the home. Issues that have been raised in the past with the home have been taken seriously and have been dealt with promptly. There are no reasons to doubt that this would not happen in the future. The manager stated that she holds a number of meetings with her staff. Minutes of some of these meetings were available for inspection including monthly meetings with trained nurses and carers; bimonthly meetings with head of departments. The manager stated that she had arranged for a relatives/service users meeting in November 2005. She had not done the minutes yet. There was a schedule for the supervision of members of staff. The manager’s own figures with regard to supervision of staff were around 25 , there was therefore still room for improvement in that area. The home follows the quality assurance procedure for Southern Cross Healthcare. There are monthly medicines audit, monthly home manager’s audit, facilities audit every three months and regulations 26 visits, reports of which, are sent monthly to the Commission. The inspector enquired about the personal monies of service users. The manager and her staff are not agents or representatives for any of the service users. Service users receive personal monies, which are kept in a main resident bank account. Appropriate statements were kept for each service user, albeit not always up to date, because of a difficulty with reconciling the accounts with up to date bank statements, which have not always been coming promptly to the home. The senior administrator who was visiting the home on the day clarified that the home was in the process of changing the bank account and that there will be a facility for each service user to have a subaccount. This is indeed desirable as the interest for each service user would be much easier to calculate and passed on to the service user. All records of service users were generally appropriate and correct with individual receipts being kept for all expenditures. The inspector looked at the recording of the possessions and valuables of service users. He noted that the forms were not always signed by the nurse or service users/representatives and dated. There was also a lack of information with regard to tracking the location of some of the valuables. This could pose a problem in the future when a request is made for these valuables. A yellow metal ring for a service user, who has not been in the home for a few months, was found in the drug cabinet on one of the floors. The home had an up to date electric wiring certificate, chlorination and gas safety certificates. The Portable Appliances Test has been carried out, but the certificate had not yet been forwarded to the home. A copy must be forwarded to the Commission when this is available. There was evidence that equipment Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 23 in the home was being maintained. There was however no up to date LOLER certificate for the lift and for the hoists, according to the Lifting Operations and Lifting Equipment Regulations 1998. Smoking in the home is now permitted only in the smoking room on the first floor. There was a Health and Safety risk assessment in the home, but a fire risk assessment and an emergency fire plan were not available for inspection. There were comprehensive checks, which were being carried out with regard to fire equipment, exits and detectors. There were also records of regular fire drills. Apart from the above the handy man carries out checks on wheelchairs and walking aids; water temperatures; window restrictors and bed rails. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 24 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 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 2 x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 2 Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? No 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 Timescale for action 28/02/06 2 OP4 18(1)(c) 3 OP7OP12 15(1) 4 OP8 17(1)(a), 3,(3)(n) The registered person must ensure that the needs (including the mental health needs) of service users are comprehensively assessed, and reviewed as and when the needs changed. (Repeated requirement, timescale of 30/6/5 not fully met) The registered person must 31/03/06 ensure that there is at least one nurse trained in mental health or one who has certificated training in dementia to work on the unit for service users with dementia. The care plans must set out in 28/02/06 details the actions which need to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The registered person must 28/02/06 ensure that the condition/size /depth of pressure sores is recorded either by using wound mapping or by photographs. Comprehensive records must also be kept about the type of pressure relief equipment in use DS0000041432.V271419.R01.S.doc Version 5.0 Willesden Court Care Home Page 26 5 OP9 13(2,4) 6 7 OP10 OP10 17(1)(a), 3(3)(q) 12(1)(a) 8 OP11 15(1) for the service users at risk of pressure sores or for those who have pressure sores. (Repeated requirement, timescale of 30/6/5 not met) The registered person must address the following with regard to the management of medicines in the home: • Ensure by replacing/repairing the medicine fridge on the second floor that the temperature reading of the fridge is between 2-8 degrees centigrade at all times • that the instructions on the labels of all medicines are clear with regard to the frequency and the amount to be administered • that all medicines are correctly transferred to new medicines chart when the old medicines chart is full • that all nurses who administer medicines have a comprehensive knowledge of the medicines, indications as well as side-effects. Service users who are not offered a call bell must have a risk assessment in place. The registered person must ensure that all service users are shaved according to their personal preferences. (Repeated requirement, timescale of 30/6/5 not met) Care plans of service users must contain information about the wishes and instructions of service users with regard to end of life care and death. A note must be made in the care DS0000041432.V271419.R01.S.doc 28/02/06 31/01/06 31/01/06 28/02/06 Willesden Court Care Home Version 5.0 Page 27 9 OP24 10 OP26 11 OP28 12 OP35 13 14 OP38 OP38 records if this information is not available. (Repeated requirement, timescale of 31/7/5 not met) 23(2)(a,b) The registered person must ensure that the bedrooms of service users are decorated, furnished and personalised to a high standard. (Repeated requirement, timescale of 30/6/5 not met) 13(3) The registered person must ensure compliance with procedures with regard to infection control such as the appropriate disposal of clinical waste and the management of soiled clothes. (Part of the requirement is repeated, timescale of 30/6/5 not fully met) 18(1)(c) 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 not met) 17(2), sch The registered person must 4(9) ensure that the personal possessions/valuables of service users are managed appropriately in the home. 23(4) The home must have a Fire Risk Assessment and an Emergency Fire Plan 23(2)(c) There must be up to date LOLER certificates for the hoists and the lift as per the Lifting Operations and Lifting Equipment Regulations 1998. 30/06/06 31/01/06 31/03/06 28/02/06 28/02/06 28/02/06 Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 28 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 OP8 Good Practice Recommendations The manager should continue with her efforts to identify a dentist who would carry out a yearly dental check up of service users in the home. Willesden Court Care Home DS0000041432.V271419.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow 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 DS0000041432.V271419.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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