Inspection on 10/07/07 for Willett House Nursing Home

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Willett House Nursing Home 17/10/06

Willett House Nursing Home 11/05/06

Willett House Nursing Home 07/12/05

Willett House Nursing Home 05/07/05

Willett House Nursing Home 02/03/05

Willett House Nursing Home 19/10/04

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

CARE HOMES FOR OLDER PEOPLE Willett House Nursing Home Kemnal Road Chislehurst Kent BR7 6LT Lead Inspector Sue Meaker Unannounced Inspection 10th July 2007 10:30 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 Willett House Nursing Home DS0000010148.V340440.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. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willett House Nursing Home Address Kemnal Road Chislehurst Kent BR7 6LT 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 8402 8224 020 8325 5171 janet.chutto@missioncare.org.uk Mission Care Mrs Moonwattie Janet Chuttoo Care Home 32 Category(ies) of Dementia (32) registration, with number of places Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 17 March 1997 Date of last inspection 17th October 2006 Brief Description of the Service: Willett House is a 32-bed purpose built home providing nursing care for people with dementia. Since May 2007, the home has registered three more single rooms bringing the total number of places available to thirty-five; these rooms have been incorporated on the first floor thereby making one unit for nine residents and one of ten. The ground floor provides accommodation for sixteen residents in two units of eight. The home is a two-storey building that is now able to provide thirty-one single bedrooms and two double bedrooms. The four units are semi independent each one having its own kitchenette, dining and lounge area plus the required number of toilets and bathrooms. A lift services the two floors. In addition, the home provides a large communal lounge used for a variety of activities and events, a hairdressing salon, a clinical room and a kitchen. There are gardens at the side and rear of the building and car parking to the front. The home is situated in a quiet residential area of Chislehurst close to shops and local bus routes Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a statutory unannounced key inspection that required two days to complete; the inspection required a site visit of one day and another day to collate information from documentation received from the home at the site visit and time spent contacting relatives, healthcare professionals, Commissioners of care services for local authorities and local hospitals for their views about the care services provided by the home. Discussions were held with the Operations Manager, the Home Manager, Administrator, Maintenance person, the Chef and the trained nurses, care staff and domestic staff on duty at the time of the site visit. A tour of the home was undertaken, this included observing lunch on the Magnolia unit, inspecting the clinical room on the ground floor, observing activities in the large lounge and visiting the garden and kitchen; residents and relatives were spoken to; the GP was holding a surgery and a conversation was held with him about the care provision at the home. Relatives and friends visiting the home were also asked for their views about the home, staff and services provided; questionnaires were also received from relatives and friends. Five resident’s files, four staff files and documentation relating to medication, staff training, health and safety, activities, finance, contracts, rotas and menus were inspected; information from all these areas has been used in compiling this report. What the service does well: Whilst visiting the home and undertaking a tour of the facilities, meeting the residents and speaking to relatives visiting the home it was evident that the residents were well cared for and that the relatives were happy with the standard of care provided by the staff at the home. Staff said that they were supported and encouraged particularly concerning access to training. Comments included the following:• I feel I am leaving my wife in capable hands. • The staff are very good and have a good understanding of how to care for people with dementia. • There is always someone to talk to if I am concerned about anything to do with my husband and need reassurance. • This home provides a really good service to a vulnerable group of older people. • I am so at ease with my mum being here, I have no problems. • Care staff keep my wife clean and comfortable, the home is excellent from the point of view being a small establishment. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The Registered Person must ensure that the statement of Purpose is updated to include details of the new registered bedrooms The Registered Person must ensure that details relating to contacting the CSIC be amended; need to include the address, telephone and fax nos. email address and web address. The Registered Person must ensure that there is a copy of the organisation’s and NMC’s policy and procedure relating to the Safe Administration of Medication available on the medication files. The Registered Person must ensure that medication is recorded correctly when handwritten on to the MARS sheet, recording must include quantity, date and two signatures. The Registered Person must ensure that the bolts on bedroom doors must continue to be removed and be replaced with suitable door locks Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 7 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. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families receive information about the home, so they are able to make an informed decision as to whether their assessed personal, health and social care needs can be met. Prospective residents and their families are encouraged to visit the home to ascertain its suitability to meet their specific assessed care needs. All residents have a contract giving the terms and conditions of their residency. EVIDENCE: The home’s statement of Purpose provides comprehensive information relating to their philosophy of care, the mission statement, the contract, the complaints policy and procedure, details of the building, a brochure containing all the information about the home, the organisation and the services the prospective residents can expect. This is a very informative document but it does need to Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 10 be updated to include information about the three new bedrooms and consequently the number of residents that can now be accommodated, and the make up of the units and the staffing levels. It is recommended that the information relating to the Commission be updated just giving the name, address, telephone number, email address and web site. Similarly the Service User Guide needs to be reviewed and update so that all information given is not conflicting. Relatives surveyed and spoken to (on the day of the site visit) confirm that they had received information from their local social services or hospital and had contacted the home for further information. All residents have a copy of their contract; the original one is kept on their personal files, detailing the terms and conditions of their residency including the responsibilities of the organisation, details of the contract and services provided, general terms giving specific room number and fee payable, the residents responsibility, repairs and maintenance and consultation and communication, this contract is signed and witnessed by the resident and the organisation. This was evidenced by contracts seen on the residents’ personal files that were kept in a locked filing cabinet in the administrator’s office. From the information given in the AQAA it is evident that the home has a robust pre-admission process; a trained nurse completes a nursing history assessment form in consultation with the prospective resident and their family if appropriate. At this stage the prospective resident and their family are encouraged to visit the home and a advance care plan is discussed and formulated thereby making sure that the care provided is in keeping with the needs and preferences of residents and their carers; this document is used as a guide and is a record of what the resident wishes to happen when receiving personal, health and social care. Five residents files were inspected and found to contain a pre-admission assessment of personal, health and social care needs, there was evidence of input from family and healthcare professionals; files contained assessments of need from either local social services or local hospital. All files contained a copy of a letter sent by the home manager to say that the prospective residents’ needs could be met. Relatives surveyed and spoken to at the time of the inspection confirmed that they got enough information about the home so that they were able to make an informed decision as to whether the home could met the personal, health and social care needs of their relative. They also stated that they felt that the home successfully met their relative’s needs and that the home helped them keep in touch with their relative. Please note that Standard 6 is not applicable to this home. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans inspected reflected the personal, health and social care needs of the residents; they incorporated information from the resident, their family and healthcare professionals enabling care staff to provide care to their wishes and preferences thereby respecting their right to choice, dignity and privacy. EVIDENCE: Four care plans were looked at in detail on the day of the inspection, feedback was also obtained from the home manager and staff in respect of the completion of care plans. The care plan seen confirmed that there had been input from the resident’s family and friends and healthcare professionals. During the inspection the home’s GP was holding a surgery, he felt that the home provided a good quality service and that the staff had the necessary experience and skills to care for a complex group of vulnerable residents. He stated that he received up to date information about the residents and their Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 12 health needs by way of the care plans and he was able to make the any referrals necessary to the well being of the residents; he said that staff were aware of any changes in the residents and this was well documented. The care plans were personalised to the individual resident and identified their specific personal, health and social care needs and gave specific ways in which this needs were met respecting the independence, privacy and dignity of the individual being cared for in the home. The care plans also included risk assessments relating to moving and handling, mobility, cot sides, challenging behaviour and dementia. There were care plans relating to activities and how the residents social care needs were being met. All residents had a monthly review the outcomes were documented and signed by those present; care plans were updated as part of this review process. Services from other healthcare professionals were usually accessed via the GP, these services included referrals to the hospital consultants, psychogeriatricians, psychiatrists and physiotherapists as well as the district nurses and the tissue viability nurse. The home was able to access optical, dental and podiatry services for the residents as and when required. Relatives spoken to said that they were happy with the services provided by the home and that they felt their relative was well looked after, one relative said they were kept informed of referrals made, of hospital visits and admissions to hospital; relatives surveyed felt that the staff had the experience, skills and competency to care for their relative. The clinical room on the ground floor was inspected and the medication file for the Freesia Wing was checked. The organisation has good policies and procedures relating to the safe administration of medication, it would be useful if copies of these policies and procedures were available as part of the medication files. The home operates a nomad system for the administration of medication, and medication is only given by the trained nurse on duty, the MARS sheets all have an up to date photograph of the resident and is computerised, care needs to be taken when handwriting on the MARS sheet particularly when recording information for example, the quantity received, the date and making sure there are two signatures. When checking one MARS sheet the number of tablets was recorded but there was no signature, no date and no start date, this was rectified at the time of the inspection. The clinical room was well organised and clean and tidy; the food supplements checked were stored correctly and were within date; an accredited contractor collects unused drugs and sharps once a month. Fridge temperatures were checked and were accurate. Staff receivea training in the safe administration of medication from the local Primary Care Trust; staff spoken to confirm that they had received training and the training files inspected also evidenced that this training had been given. During a tour of the home it was obvious that the staff cared about their residents, there was an established rapport between them; the staff spoke to the residents respectfully being mindful of their right privacy, dignity and independence. Relatives spoken to confirmed that the staff were easy to talk to and would do anything for their relative; that they felt comfortable and trusted the staff with all aspects of their relative’s personal care and that they Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 13 were confident that the staff had the necessary skills, competence and experience to care for their relative. The management and staff at the home are aware of their responsibilities relating to the Data Protection Act and are trained to deal discreetly with the affairs of the residents and were aware of the need to maintain confidentiality on behalf of the residents in their care; making sure that the residents are aware of the information held about them and how it is used, how they can access it enabling them to maintain their legal, civic and political rights. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home endeavours to provide appropriate activities to the residents supporting and encouraging them to maintain their chosen lifestyle in a residential care home environment. The residents are provided with a nutritious and healthy menu EVIDENCE: The residents appear to enjoy the range of activities on offer in the home; the activities co-ordinator has devised activity care plans for each unit and these are implemented on a daily basis subject to the needs of the group of residents. The activity co-ordinator has a information file giving details of all the things the residents had done or been a part of, from arts and crafts, reminiscence, gentle exercise, hand massage and nail care to musical and film afternoons, gardening, going out for walks and church services. All activity undertaken by the residents was well documented and all records were available for inspection; the activity co-ordinator had also completed monthly activity reviews for all residents. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 15 The home has a designated space within the home for activities and on the day of the inspection some residents were enjoying an arts and craft session which included making and painting world flags for the summer fair; two residents were painting butterfly outlines, one resident was looking at a book about birds – evidently he enjoyed bird watching prior to coming into the home and the activity co-ordinator had sought to revive his interest with some measure of success. It was evident from speaking to the activity co-ordinator that she was aware of the special social needs of the residents, she said that she had received training in appropriate activities for those with dementia and challenging behaviour; this was evident from watching the residents engrossed in their particular activity and the calm and peaceful atmosphere within the activity room. She also said that she was in the process of gathering information for life history books for each resident, this was being done in conjunction with the family and friends of residents to build a picture of their life prior to coming into the home. Relatives, friends and local community groups are encouraged to visit the home; relatives surveyed and spoken to agreed that the staff in the home made them feel welcome whenever they visited, there was always someone available if they needed to discuss any concern they had and that they felt involved in the daily life of their relative; there were regular relative meetings and the minutes of the meetings seen confirmed that they are well attended and that relatives had a considerable input into arranging social events in the home and that they were very supportive of the home in this area. Some of the more able residents had enjoyed a weekend at Butlins in Bognor Regis in June this year; and were looking forward to their summer fair. Residents in the home are unable to manage their own financial affairs, this is undertaken by their relatives; the home is also able to provide information about local advocacy service for those residents who do not have anyone to help them with financial matters. The service user guide states that the home manager would be able to arrange for pensions to be collected and a savings account to be set up. All such arrangements are established and accounted properly by the homes’ administrator and overseen and audited by the home manager. Residents and their families are encouraged to personalise their bedrooms by bringing in small items of furniture, televisions, radios or music centres along with personal photographs, pictures ornaments. The organisation is happy for relatives to decorate rooms as they wish and to provide their own soft furnishing such as bed linen and cushions; a record is kept by the home of all the resident’s personal belongings. Meals in the home are provided by a contract caterer; the kitchen was visited during the inspection; the kitchen was clean, tidy and well organised, the kitchen had recently had an inspection by the local authority Environmental Health Officer and the kitchen’s Clean Food Award was renewed. It was noted that all appropriate records were kept relating to fridge and freezer temperatures, hot and cold food temperatures HACCUP documentation and the kitchen had cleaning schedules in place and documentation in place to show that cleaning was undertaken. The menus seen provide a range of appetising, nutritious, healthy and well balanced food; there is also an alternative choice Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 16 to the daily menu where residents are able to choose from jacket potatoes, fresh salads, omelettes and sandwiches; hot and cold drinks, biscuits and cakes being available at all times. The kitchen is also able to cater for special diets and on speaking to the chef it was evident that he knew about diets and was able to give examples of food suitable for diabetics, low fat, vegetarian and reducing diets. Lunch was observed on the magnolia unit; two staff were serving the meals from a hot trolley, one resident was being assisted to eat by her daughter, who said that she thought the food was good and that her mother enjoyed her meals, one resident was able o say that she thought the meals were fine and she particularly liked her rice pudding; the two staff members were encouraging and assisting residents who required help to eat their meals, this was being done in a sensitive and compassionate manner and as unobtrusively as possible. The atmosphere in the dining area was calm and peaceful with residents enjoying their meal in pleasant surroundings. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to feel safe and protected in the home due to the homes’ policies and procedures and staff training relating to complaints and the Protection of Vulnerable Adults. EVIDENCE: The organisation has robust policies and procedures in place relating to complaints, this document is to be found in the service user guide and in the homes’ statement of purpose and it is also displayed in the entrance hall of the home. From the surveys received and from chatting to relatives visiting the home at the time of the inspection; it was evident that they were aware of the complaints procedure and knew how to instigate it if necessary. Those surveyed and spoken to said that if they were not happy or if they had any concerns they would refer them to the nurses and the management of the home, they said that they felt confident that their issues would be dealt with appropriately and resolved quickly to their satisfaction. The home has a complaints log and records all the details of any complaint received, from the acknowledgement of the complaint, through the investigation to the outcome and resolution. The AQAA also confirms that a record is kept of all complaints and that the home manager informs the complainant at all stages of the investigation and of the outcome. On inspecting the complaints log it was Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 18 evident that complaints had been dealt with complying with the organisations complaints policy and procedure; since the last inspection it has not been necessary for the home manager to refer any complaints to the complaints to the CSCI or been investigated under POVA. The complaints policy needs to be updated with the name of the local CSCI office, the address and telephone number. Since the last inspection many of the staff have undertaken training in the Protection of Vulnerable Adults, this is an ongoing process and there was evidence that further training has been booked. The training has been accessed via the Local Authority Social Services through the Care Home Training Consortium. Staff received training in adult abuse during the induction process and as part of their NVQ 2 course. Staff had access to the homes’ policy and procedure relating to the Protection of Vulnerable Adults and the “Whistle-blowing”. The staff spoken to confirmed that they were aware of POVA and the different forms of abuse they also confirmed that they had attended specialist training relating to POVA and their training profiles showed evidence of specialist training courses relating to the Protection of Vulnerable Adults, training as part of the induction and NVQ process. The home has a copy of the Local Authority Multi Agency Protection of Vulnerable Adults guidelines and policy and procedure. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 19 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and hygienic, well maintained, well equipped and comfortable home, making sure that the layout and design of the home encourages and supports resident’s independence. EVIDENCE: The home is maintained to a good standard, there is a full time maintenance person and an annual maintenance programme in place. The organisation has recently completed works and registered three en-suite bedrooms in one of the upstairs units; these bedrooms are decorated and furnished to a very good standard; the home is also moving towards making the remaining double rooms it has into single rooms. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 20 The home is divided into four self contained units each with its own dining area, lounge and fitted kitchen with the benefit of a dishwasher. The four units are decorated and furnished to a good standard; the home also has a larger lounge on the ground floor used for activities, meetings and social events and the home benefits from a well-kept garden including a patio area, a greenhouse and vegetable garden. The first floor is accessed by a passenger lift or a staircase. Each of the four units have bathrooms and toilets easily accessible for the residents; toilets which are fitted with raised toilet seats and grab rails and baths fitted with hoists; toilets and bathrooms could also be accessed by wheelchair users. Resident’s bedrooms seen were all fitted with wash hand basins and some were en-suite. During a tour of the home some of the bedrooms were seen, they were personalised having items of furniture, ornaments, pictures, televisions, music centres and radios; residents families are encouraged to have input into the decoration and furnishing of their bedrooms. The bedrooms seen were decorated and furnished to a good standard; the carpets had been replaced with new flooring more suited to the residents; this change was implemented after consultation with relatives. There has been a issue in the home relating to residents going in and out of other residents rooms, the home had addressed this issue by fitting external bolts to the outside of all the bedrooms to promote security; during a visit be an inspector from the registration team and the lead inspector for the home; it was decided that these bolts were to be removed and replaced with door locks that could be accessed from the outside and inside of the bedrooms; it was noted that the bolts from the three new bedrooms had been removed and replaced with door locks and that the organisation was in the process of removing all bolts from the doors and replacing them; this was confirmed by the area manager for the home, who was present at the beginning of the inspection. The home does not have its own laundry, this is done centrally at another home within the group; however this does seem to cause a few problems with unmarked clothing and can often lead to complaints from relatives; during the inspection laundry was delivered to the home; clothing and bed linen seen were laundered to a good standard and looked to be in good repair. The home provided clean, pleasant and hygienic surroundings for residents, relatives and visitors. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 21 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, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures that all staff are trained in order to have the skills and competency necessary to meet the personal, health and social care needs of the residents in their care; this outcome is achieved by implementing thorough recruitment, selection and training policies and procedures. EVIDENCE: The rotas seen confirmed that there was sufficient staff on duty at any one time to meet the assessed personal, health and social care needs of the individual residents. Residents spoken to said that there was always a member of staff around to help them when needed and the relatives’ surveys confirmed that they felt the care staff had the right skills and experience to look after their relative properly, that they gave the support and care that had been expected and agreed in the care plan and that the staff supported the residents to live the life they chose. The organisation has policies and procedures in place to make sure that staff are recruited in line with the regulations. Personnel records showed that staff had completed an application form, were interviewed, provided two references Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 22 and completed the documentation for the CRB check, staff were also referred for a POVA check and the pin numbers of trained nurses were all check and confirmed prior to the prospective member of staff being offered employment with the organisation. Four personnel files were inspected, the files seen contained the information required by Schedule 2 of the National Minimum Standards; and therefore complying with regulation 19 of the Care Standards 2000. Personnel files also evidenced that staff had undertaken an induction programme in line with “Skills for Care”, successful completion of this programme enabling staff to be put forward for an NVQ 2 qualification in care. The personnel files also showed that staff received supervision on a regular basis; and completed an annual appraisal. Staff interviewed confirmed that they received support and encouragement from the organisation particularly relating to training opportunities and that the supervision and appraisal system, and staff meetings gave them a forum to discuss their views about the home, their residents care, any employment issues they might have and their prospects for advancement within the organisation. The home has a good programme of training on offer, and basis the annual training plan around training available from the local authority “Care Home Training Consortium”; this organisation offers all mandatory training and updates required by regulation including moving and handling, food hygiene, health and safety and first aid. The consortium also offers specialist dementia and challenging behaviour training as well as understanding older people, loss and bereavement, customer care and report writing. Training records were seen confirming that staff had attended training courses offered by the consortium along with applications made on behalf of staff for the training. Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is sufficiently qualified and experienced to run the home. The home has effective and efficient management and administration systems in place to ensure the best interests and health and safety of the residents and staff; management make sure that the administration systems ensure the home is financially viable. The home is continuing to develop their quality assurance system. EVIDENCE: The home has a competent and experienced manager who is supported by a committed staff team. The home manager is a qualified RMN, and has achieved NVQ 4 in Management and the Registered Managers Award. The Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 24 home manger understands the philosophy of the home and is able to meet its aims and objectives as set out in the Statement of Purpose. From questionnaires received and from speaking to relatives it was evident that they felt that the management and staff at the home were approachable, friendly, helpful, willing to listen, compassionate and sensitive to individual needs. They also said that any concerns they raised were dealt with in a sensitive and compassionate manner and resolved quickly with the minimum amount of fuss and that there were always members of management around and accessible. The Operations manager has the responsibility for conducting the regulation 26 visits to the home required by the CSCI and sends copies of the report to the CSCI. The Home Manager is responsible for implementing the quality assurance documentation for the home, an annual survey of the service provision is undertaken, the homes’ administrator sends out questionnaires to relatives, staff, healthcare professionals and social services to ask their opinion of the services they provide. The home holds a regular relatives meetings, that are attended by the operations manager as well as the home manager, there is also input from the contract caterers employed by the home; these meetings are well attended by relatives as shown by the minutes of the meetings seen. Currently the home does not act as appointees for any of their residents however they do support some residents by holding cash for them. Receipts are kept for all financial transactions; receipts are given for any monies received from relatives and the administrator keeps individual accounts. Documentation relating to the policies and procedures of the home, set by the organisation, were inspected and found to comply with regulations, however there needs to be written evidence to show that these documents are reviewed annually; the documents themselves should be signed and dated thereby evidencing that they are current. From information given in the AQAA it was evident that the home has an approved fire risk assessment in place; it was evident from inspecting the Fire File and from speaking to the homes’ maintenance person that the fire alarms, fire fighting equipment, fire drills and fire training are completed and recorded in accordance with the organisation’s policies and procedures. The temperature of water was checked and recorded each month. Health and Safety certificates were in date and therefore complied with relevant current legislation detailed in the National Minimum Standards – Care Homes Regulations 2000. . Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The Registered Person must ensure that the statement of Purpose is updated to include details of the new registered bedrooms The Registered Person must ensure that details relating to contacting the CSIC be amended; need to include the address, telephone and fax nos. email address and web address. The Registered Person must ensure that there is a copy of the organisation’s and NMC’s policy and procedure relating to the Safe Administration of Medication available on the medication files. The Registered Person must ensure that medication is recorded correctly when handwritten on to the MARS sheet, recording must include quantity, date and two signatures. The Registered Person must ensure that the bolts on bedroom doors must continue to be removed and be replaced with DS0000010148.V340440.R01.S.doc Timescale for action 01/12/07 2 OP1 5 01/12/07 3. OP9 13 (1)(b) 01/12/07 4 OP9 13 (2) 01/12/07 5 OP24 16 01/12/07 Willett House Nursing Home Version 5.2 Page 27 6 OP33 24 suitable door locks The Registered Person must ensure that the CSCI receives a summary of the results of the questionnaires sent out. 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Willett House Nursing Home DS0000010148.V340440.R01.S.doc Version 5.2 Page 29 - 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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