Inspection on 07/12/05 for Willett House Nursing Home

This inspection was carried out on 7th December 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 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

Willett House Nursing Home 10/07/07

Willett House Nursing Home 17/10/06

Willett House Nursing Home 11/05/06

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 Cheryl Carter Unannounced Inspection 7th December 2005 10:55 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.V271196.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. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 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 Mission Care Mrs Moonwattie Janet Chuttoo Care Home 32 Category(ies) of Dementia (32) registration, with number of places Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 17 March 1997 Date of last inspection 5th July 2005 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 twenty-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. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 10.55 hours to 16.00 hours. The Inspection was carried out initially in the presence of a Registered Nurse as the manager was engaged with some relatives of a service user. The Registered Nurse showed me around the unit; however, the Inspector was concerned that as a senior member of the staff team, she should have been better informed about the plans for the home. A sample of care plans and records were inspected. The inspector spoke with two members of staff; there were no relatives available at the time of the inspection, 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. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3, 4 The pre-admission assessment undertaken with potential residents is comprehensive so that service users and their representatives can be confident that the home will meet their needs. EVIDENCE: The Statement of Purpose and a Service User’s Guide for the home must be reviewed and a copy of the revised document must be sent to the commission. The Service User Guide must be available to all the Service Users and or their representatives. This document must be more user friendly and a copies must be given to the service user or their representative. (Req.1) In a sample of care plans that were assessed there was evidence that a preadmission assessment is undertaken with potential residents. The assessments cover both the physical and psychosocial needs of the service user and these form the basis for subsequent care planning. The assessment also includes details of their previous life to enable staff to gain an insight into the resident current needs and behaviour patterns. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, All residents have individual care plans that ensure the care the service users receive meet their assessed need and that staff are aware of the appropriate action to be taken. EVIDENCE: The inspector assessed four care plans during the inspection. Each care plan contained a considerable amount of information. The daily report on each service user includes a recorded of the care that has been given. There was no evidence that the plans are regularly reviewed. There were entries in the plans that illustrated the GP makes visits and there are aids and equipment throughout the home to minimise the risk of falls. Staff were observed treating residents with sensitivity and respect throughout the visit. There are no service users that self-medicate and inspection of the medication records show good recording. The inspector was concerned that there was a room with boxes and boxes of medication that are due to be sent to a disposal centre, but the Inspector felt that keeping these medication in unlock cabinets in boxes in a room even though its locked is a dangerous practice and this must be addressed forthwith. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14, 15 The home does not offer all residents the opportunity to experience activities suited to their needs. Family and friends are able to visit the home at any reasonable time. Meals are nutritious and balanced and offer a healthy diet for residents. EVIDENCE: The home offers some activities including reminiscence and hairdressing, but the inspector did not see an activity plan. The inspector was told that the hairdresser comes to the home fortnightly. On the day of the inspection the activity coordinator was off sick and there was no activities taking place. In each unit visited there was some very soft music playing more capable of putting the service users to sleep than stimulating service users. Most of the staff spoken to on this issue claim that this is the service users wish. One member of staff commented that this is what the manager wants; the televisions in all the wings are turned off. This does not fit into the element of choice for service users. (Recommendation 1) Visitors are always welcomed to the home, but on the day of the inspection there was only one visitor in the home. The lunchtime meal looked appetising. Service users spoken to agreed that the meal was very good. Service users recently reviewed the menus following complaints. A new catering company is Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 10 now responsible for the food at Willett and service users are said to be happier with the menus. A choice is always available if residents don’t like the menu choice. It would be a good practice if the choice available were recorded. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 11 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): The home has an appropriate complaints procedure a copy of which is kept in the hall way and also given to service users as part of the Service User’s Guide. There are also regular service users meetings so that service users can be confident their complaints will be taken seriously and acted upon. EVIDENCE: There is a complaints procedure in place and residents are given a copy on Admission. The complaints book was seen. There was one complaint made to the commission regarding the moving and handling of a service user. This complaint was upheld and the staff involved disciplined. The inspector was informed that the staff concerned was sent on moving and handling training updates. Staff have received training in the Protection of Vulnerable Adults. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 12 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, 20, 26 The home is in need of refurbishment and maintenance. EVIDENCE: Despite the efforts of the staff to keep the home clean there is a strong odour of urine in the downstairs hallway. The carpets in the hallway are badly stained and this does not give a good impression of the home. The Laundry room and the main lounge is in need of attention. The manager informed the inspector that phase one of the refurbishment of the home would start soon. However no date could be given. These plans have been in place for some time. The registered provider must now issue the Commission with a date for the commencement and completion of this work as the home in its present state is not meeting the standard. (Req. 2 & 3) These are restated requirements from the previous inspection. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 13 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, 30 There is a sufficient number and skill mix of staff to meet the needs of the service users. EVIDENCE: The duty rotas were seen and indicated that the there are sufficient numbers of staff on duty to meet the needs of residents. Sixty to sixty five percent of care staff are now qualified to at least NVQ level 2. files of 3 new members of staff were seen and were in order. Criminal Records Bureau clearance was on file. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 14 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, 36, 38 Records in relation to service users needs are up to date ensuring that their assessed needs are met and information is safeguarded. Policies and procedures are comprehensive and available to staff. Staff is receiving supervision but this is not meeting the required standard. EVIDENCE: Since the last inspection the manager has had her fit person’s interview and is awaiting the registration certificate. The care plans and records relating to service users were up to date. The registered Nurses are responsible for supervising care staff. Although the staff have been given some guidance on how to carry out supervision they had not received training. Because of the issues raised by some staff, the inexperience of the staff doing supervision is apparent and therefore it is ineffective. The registered provider must ensure that staff who are carrying out supervision receive the necessary training to carry out the task effectively. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 15 A sample of records relating to Health and Safety were seen and these were in order. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 16 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 2 3 3 x N/A 2 2 x x x x x 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 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 x x x x 3 x 3 Version 5.0 Page 17 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 Willett House Nursing Home DS0000010148.V271196.R01.S.doc 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 OP 1 Regulation 6 (a) & (b) Requirement The Registered Person must review the Statement of Purpose and the Service User Guide and notify the Commission and service users of the revision. The registered provider must 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. Timescale for action 15/02/06 2 OP19 23.2.a 15/02/06 3 OP26 16.2.k 15/02/06 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 OP12 Good Practice Recommendations Activities available to residents should be more varied and meet their interests. Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Willett House Nursing Home DS0000010148.V271196.R01.S.doc Version 5.0 Page 19 - 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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