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Inspection on 05/07/05 for Willett House Nursing Home

Also see our care home review for Willett House Nursing Home for more information

This inspection was carried out on 5th July 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspector was told that the home does not use Agency Staff and gaps in the rota are covered by Bank staff or by the permanent staff doing over time. The manager said that the home does not have a high turn over of staff. Two members of staff have left since the last inspection to go on to study nursing. The unit has a good pool of bank staff that can be relied on, a full-time activity co-ordinator and a good range of activities.

What has improved since the last inspection?

The home now has protected meal times. This means that no appointments for residents are made around meal times. This means that other professionals such as dentists or opticians are not coming to the home during meal times to disturb residents. The manager has been reviewing policies and procedures.

CARE HOMES FOR OLDER PEOPLE Willet House Kemnal Road Chislehurst Kent BR7 6LT Lead Inspector Cheryl Carter Announced 5 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Willet House Address Kemnal Road, Chislehurst, Kent BR7 6LT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208-402-8224 Mission Care vacant Care Home 32 Category(ies) of Dementia - 32 registration, with number of places Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Staffing notice issued 17/3/97 - Imposed 1 April 2002 Date of last inspection Brief Description of the Service: Willett House is a 32-bed purpose built home providing nursing care for people with dementia. The home is situated in a quiet residential area of Chislehurst close to shops and local bus routes. The home is a two-storey building that provides twent-eight single bedrooms and two double bedrooms in four self contained units, each unit has eight service users. There are gardens at the side and rear of the building and car parking to the front. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out in the presence of the manager over six hours. The inspector had a tour of the building accompanied by the manager. Care plans and records were inspected. The inspector spoke with three service users, four members of care staff, two members of the catering team, three relatives who were visiting at the time of the inspection. Staff files were also inspected. What the service does well: What has improved since the last inspection? What they could do better: 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. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5 The Home’s Statement of Purpose provides information so that prospective service users can make a decision to visit the home. There are systems in place to ensure that residents admitted to Willett House know that their needs will be met. EVIDENCE: The home has a Statement of Purpose and a Service User’s Guide that gives prospective service users the information that allow them to make an informed decision before moving into the home. The manager and senior staff who are registered nurses are responsible for carrying out assessments to ensure that all the personal and health care needs of prospective service users can be met at the home. Service Users are issued with a contract and terms and conditions of the Home. All service users have a month’s trial, before their placement is confirmed. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11 The care planning system is consistent and provides staff with the necessary information they need to meet the service users needs. The medication policy is clear. The home has a policy on death and dying. Some of the care practices could undermine the dignity of service users. EVIDENCE: Residents Care Plans are reviewed regularly. Residents were generally well presented. Residents and relatives spoken to were very positive about the care at the home. Only the registered nurses administer medication. No service users self medicates. There was evidence to show that staff members are aware of the importance of ensuring the service users privacy and dignity. The home has a policy and guidelines on the care of the dying and what to do in the event of a death of a service user. Having set toileting times for all service users is contrary to person centred care and undermines the dignity of service users. The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner, which respects the privacy and dignity of service users at all times. Requirement 1. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Meal times are well managed. Some practices could undermine choice in terms of activities. EVIDENCE: The home has an activities co-ordinator wh has responsibility for the daily activities in the home. Service users are encouraged to attend these activities. The inspector was concerned to find notices that indicated that the television is not switched on Visits from friends and relatives are encouraged. Activities include movement and listening to music. The local vicar conducts mass once a week. There is a reminiscence room but this needs to be refurbished. Menus seen showed a balanced and varied diet for residents with some choice. The inspector was concerned that despite the manager indicating that person centred care is being advocated at the home some of the practices such as notices that states the television should not be switched on until 5.00 pm, and having set times for toileting during the day demonstrates instutionalised practices in the home. The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. Requirement 1 Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 Not all complaints are recorded. The complaints procedure should be reviewed to record all concerns and how they are acted upon. EVIDENCE: The home has a complaints procedure. There was one complaint recorded since the last inspection. The manager addressed this. On the inspectors‘ tour of the building a relative of one service user raised a number of issues and indicated that these were raised in the past. There was no record of these complaints. The complaint mainly related to food and requests made on behalf of the service user that the home was either unwilling or unable to meet. This has now been resolved, however the complaint was not recorded. Relatives spoken to at the time of the inspection where generally happy with the care however, one did say that a complaint about rough handling by some staff was dealt with by the manager and again this was not recorded. The Manager of the home must have systems in place to record all complaints made regardless of how trivial how the complaint was dealt with and the outcomes. Requirement 2 Staff interviewed demonstrated a good understanding of Adult Abuse and the protection of vulnerable adults. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 26 There have been no improvements to the décor since the last inspection. The outstanding matters do not provide an atmosphere that could enhance service users well being. The gardens should be better maintained. EVIDENCE: Parts of the home are drab and in need of refurbishment. Carpets on the ground floor are badly stained. The manager said that the home is earmarked for refurbishment sometime in October. The need to refurbish the home is urgent. The home appears run down and does not meet the standard. The gardens in some parts needs tidying up. There was an odour in the main hallway on entering the home. The registered provider must ensure that all parts of the home are kept clean and reasonably decorated. Requirement 3 The registered manager must ensure that the home is free from offensive odours at all times. Requirement 4 Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Recruitment procedures are adequate and provide the necessary safeguards to offer protection to people living in the home. There are sufficient numbers of staff available to meet the needs of the service users. Staff are aware of their roles and responsibilities. EVIDENCE: Staff interviewed were generally caring and very much in touch with the needs of the services users and aware of their roles and responsibilities. Staff files seen had the relevant documentation to offer protection for the service users living in the home. The home does not use agency staff and sickness and holidays are covered by bank staff and permanent staff doing overtime, this provides some consistency in care. There is a lot of goodwill from staff towards the management in terms of making sure that the home has adequate cover, however the inspector is of the opinion that the staff feel undervalued and disempowered. This needs to be addressed in staff meetings and supervision. At the time of the inspection there was no evidence that this was impacting on the care given to service users however this must be dealt with before it begins to effect the care at the home. The rotas seen accurately reflected the staff on duty on the day of this announced inspection. Staff are receiving supervision. The registered manager maintains supervision records however these are inconsistent. The records seen addressed only practice issues and needs to be reviewed to include staff feelings and training needs. The registered manager should make staff supervision a process that empowers and value staff. Recommendation 1 Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 38 The home has policies and procedures that take on board the safety and interests of the service user. Staff are aware if their roles and responsibilities. EVIDENCE: The manager, a registered nurse is still awaiting a CSCI Fit Person interview in order to become the Registered Manager. There are policies and procedures in place and available for all staff on matters of health and safety in the home. Fire tests are carried out weekly and fire equipment is regularly serviced. Documentation relating to servicing equipment in the home is up to date. Gas and Electrical certificates were also up to date. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 14 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 x x 3 x x x x 3 Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 15 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP10 Regulation 12.4.a Timescale for action The registered person shall make 15.09.05 suitable arrangements to ensure that the care home is conductd in a manner which respects the privacy and dignity of service users. The registered person must 15.09.05 establish a procedure to ensure that all complaints made are recorded investigated and outcomes recorded regardless of how trivial the complaint may seem. The registered provider must 15.09.05 ensure that all parts of the home are kept clean and reasonably decorated. The registered person must ensure that the home is free from offensive odours at all times 15.09.05 Requirement 2. OP16 22.1 3. OP19 23.2.a 4. OP26 16.2.k 5. OP14 12.4.a The registered person shall make 15.9.05 suitable arrangements to ensure that the care home is conductd in a manner which respects the privacy and dignity of service users. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 16 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP30 Good Practice Recommendations The gardens needs to be tidied up. The registered manager should make staff supervision a process that empowers and value staff. Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Willet House G51-G01 S10148 Willet Hse V229455 05-07-05 Stage 4.doc Version 1.40 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!