Care Home: St John`s Wood Care Centre

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What the care home does well The home had maintained good outcomes for people who use the service. The registered manager and staff have maintained good working relations with the people who use the service and their family members, and relevant professionals who had been useful for appropriate care delivery. One family member of a resident spoken to said “as a nursing home, it is very good, staff are excellent”. Staff were observed speaking respectfully to residents and taking steps to protect their privacy. One resident spoken with confirmed that staff came promptly and that he was very happy with their manner and approach. Another family member of a resident said “I come everyday, the place is good, food is good, my wife is happy, I have no complaints to make”. Another visitor said “I visit twice a day, this place is wonderful, I feel happy when I come to see my mother”. Observation of the lunchtime meal showed it to be unrushed and enjoyed by the people using the service. For example, one resident spoken to said “lunch has been always good; staff are polite and feed the people who cannot eat on their own”. Relatives and a resident spoken with were confident about raising any concerns. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 A tour of the premises was undertaken and all the communal areas were found to be clean, tidy, and free of any offensive odours. What has improved since the last inspection? Assessments and care plans are more comprehensive and are audited each month by the manager. The home had increased family involvement via family meetings. Manager’s surgery had reduced complaints in the past 12 months. This is due to openness and transparancy as well as management availability to residents and family members. The home had utilized the outside spaces of the first floor balcony and a roof top garden. They had also replaced some dining room carpets with wood effect vinyl and some furniture and bedroom carpets. What the care home could do better: When monitoring records show deterioration in a resident’s condition, prompt action must be taken. For example when fluid intake is low or where there is significant weight loss. When taking copies for recruitment checks staff should confirm with a signature and date that they have seen the original documents. When staff have missed supervision due to non availability of the deputy manager their supervision needs to be regularised. Advice regarding the recording of prescribed creams and lotions not administered by RGNs should be sought from the Pharmacist. The analysis and findings of the external satisfaction survey need to be completed and action taken as appropriate. Key inspection report CARE HOMES FOR OLDER PEOPLE St John`s Wood Care Centre 48 Boundary Road London NW8 0HJ Lead Inspector PursotamRaj Hirekar Key Unannounced Inspection 16th November 2009 10:00 DS0000010324.V376610.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St John`s Wood Care Centre Address 48 Boundary Road London NW8 0HJ 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 7644 2930 020 7644 2940 manager.stjohnswood@lifestylecare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd Earl Elliott Care Home 100 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (60), of places Physical disability (14) St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide nursing care and accommodation to service users of both sexes whose primary care needs on admission to the home are within the following categories:Old age not falling within any other category (Category OP) (no more than 60 persons). Service users with a physical disability who are aged 18 - 65 years (Category PD) (no more than 14 persons). Service users with Dementia who are over 65 years of age (Category DE[E]) (no more than 26 persons). The maximum number of service users who may be accommodated is 100. 30th July 2008 2. Date of last inspection Brief Description of the Service: St Johns Wood Care Centre is a registered care home providing 24-hour support and nursing by registered nursing staff and trained carers. . The home is owned by Southern Cross Healthcare who is established in the development and management of Nursing homes and is the Registered Provider for St Johns Wood Care Centre. The care home has block contracts with three London Boroughs, Camden, Brent and Westminster; therefore these local authorities set their level of fees. The home has a range of fees taking account of those people pay privately, are within the younger physically disabled category or who may be very frail. . St Johns Wood Care Centre is purpose built and was first registered in February 2001. The home provides nursing care for up to 100 residents. The home is situated in a prime residential area approximately ten minutes walk to local amenities and public transport. The closest underground station is Swiss Cottage. Outside space is available in the form of a roof garden and a balcony on the first floor. . The home is set out as follows: * Lower Ground Floor - up to 14 Younger Adults (18 - 65yrs) with physical disabilities - YPD Unit (Nursing). * Ground Floor - up to 23 Older People (OP) Nursing Care. *First Floor - up to 26 Older People with Dementia. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 5 *Second Floor - up to 18 Older People - Nursing Care. * Third Floor - up to 16 Older People - Nursing Care. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 16/11/09 over 7 hours 40 minutes by Sheila Lycholit, Regulatory Inspector and PursotamRaj Hirekar. The registered manager assisted throughout the site visit. The method of inspection included a study of care plans, risk assessments, staff recruitment records, the staff rota and relevant care delivery documents. There was also a discussion with the registered manager, staff on duty, visitors of people using the service and conversations with people using the service. A partial tour of the premises also took place. The annual quality assurance assessment (AQAA) – provider’s self-assessment was read and the contents used as part of the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. What the service does well: The home had maintained good outcomes for people who use the service. The registered manager and staff have maintained good working relations with the people who use the service and their family members, and relevant professionals who had been useful for appropriate care delivery. One family member of a resident spoken to said “as a nursing home, it is very good, staff are excellent”. Staff were observed speaking respectfully to residents and taking steps to protect their privacy. One resident spoken with confirmed that staff came promptly and that he was very happy with their manner and approach. Another family member of a resident said “I come everyday, the place is good, food is good, my wife is happy, I have no complaints to make”. Another visitor said “I visit twice a day, this place is wonderful, I feel happy when I come to see my mother”. Observation of the lunchtime meal showed it to be unrushed and enjoyed by the people using the service. For example, one resident spoken to said “lunch has been always good; staff are polite and feed the people who cannot eat on their own”. Relatives and a resident spoken with were confident about raising any concerns. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 7 A tour of the premises was undertaken and all the communal areas were found to be clean, tidy, and free of any offensive odours. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St John`s Wood Care Centre DS0000010324.V376610.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 St John`s Wood Care Centre DS0000010324.V376610.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People moving into the care home are confident that they have all the necessary information to ensure that the service is suitable to meet their needs. Pre-admission assessments are completed to assess the care needs of people considering using the service. EVIDENCE: The pre-inspection annual quality assurance assessment (AQAA) - providers self assessment, received prior to this inspection stated that “We ensure that all newly admitted service users and family members are informed regarding services we provide. All service users and their families have access to a service user’s guide outlining the services we provide with contact numbers of management”. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 10 The AQAA further stated that - “Assessments are more comprehensive, end of life care has improved with staff training and increased family,and GP involvement”. The Statement of Purpose and Service Users Guide contained necessary information. People moving into the care home are confident that they have all the necessary information to ensure that the service is suitable to meet all their needs. The registered manager further confirmed that potential service users and their family members were given adequate information about the service prior to their admission. The registration and employers liability insurance certificates was displayed at the reception which was accessible to all those who visit the home. We looked at care files of ten people who use the service. Those referred by the social services had copies of assessments and care plans under the care management process. All of the ten care files we saw had pre-admission assessments including risk assessments as well, completed prior to an offer of service provision being made. Information about the prospective service user was sought from their family and other health and social care professionals. The home used a structured format for assessments to maintain consistency. These assessments were carried out by registered manager except in one case and completed in sufficient detail to ensure that an informed decision could be made as to whether the staff team could meet the needs of the person. The people living in the home have diverse needs. The choice of the people who use the service is taken into consideration by the home with regard to the provision and delivery of the services. People using the service spoke positively of the care and support they receive. For example a family member of a resident said as a nursing home, it is very good, staff are excellent”. Staff training information records that were seen showed that the staff team had the necessary skills and qualifications to meet their needs. This forms the basis for a care plan for each resident. Respite care was provided in the home for one person during Friday to Monday. St John`s Wood Care Centre DS0000010324.V376610.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are comprehensive, regularly updated and show the involvement of the resident. Health care needs are met through multi professional working with GPs, Tissue Viability Nurses and other health care colleagues. The home is not always responding promptly when residents’ needs change such as a reduction in fluid intake or when weight loss is noted. The home’s handling of medication is sound. EVIDENCE: We looked at the care plans of 10 residents on the 3rd and lower ground floors. Care plans seen were up to date and regularly reviewed. Reviews include the resident and key family members. Two relatives who visit frequently were spoken with. Both were very happy with the care provided and one commented that staff helped her to feel more involved than in her relative’s previous placement. One resident whose care plan was looked at was experiencing problems with skin breakdown. Referrals to the Tissue Viability St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 12 Nurse had been made and it was clear from observation and records that her advice was being followed. Records show that regular monitoring of residents’ condition, for example food and fluid intake, normally takes place in line with their care plans. However a check of one resident’s fluid intake charts showed that these were not always fully completed. The care plan stated that fluid intake should be at least 1200ml per day but on a number of occasions her intake was well below this amount at for example 525 or 550 ml. The RGN explained that staff frequently offered her drinks, which were refused, but this was not noted on the fluid intake charts. A weekly summary sheet for fluid intake would allow senior staff to monitor intake more closely. It was noted that the weight of one resident, whose weight had previously been well maintained, had dropped by nearly 4kg in one month. A note on the resident’s care plan states that a referral should be made to the Dietician but following discussion, the RGN on duty was not able to find a record of this referral taking place. The storage and recording of medication was looked at on the 3rd floor and the Manager provided a copy of an audit of medication carried out by Boots Pharmacist in June this year. In addition, the Deputy Manager, whose post has been vacant, would normally undertake regular audits as part of their responsibility for clinical practice. Medication on the 3rd floor was safely stored, including the small supply of controlled drugs. Medication Administration Records were fully completed. It is recommended that the home seeks the advice of the Pharmacist regarding the recording of prescribed creams, which are currently recorded by a tick by the RGN who has normally not administered the creams herself. The Boots Pharmacist, who has checked medication on all floors, recommended that fridge thermometers be replaced and that dates of opening all bulk items be noted. The Manager confirmed that the recommendations had been acted upon. All RGNs have updated their medication training this year. Staff were observed to speak respectfully to residents and to take steps to protect their privacy. One resident spoken with confirmed that staff came promptly and that he was very happy with their manner and approach. The wishes of residents and their relatives regarding end of life care were recorded on each of the care plans looked at. The Manager informed us that all Registered Nurses had received training in palliative care and the home was working towards the ‘Gold’ standard. The PCT had allocated a Palliative Care Nurse to the home for the duration of the training, which the Manager stated had been of great benefit. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is committed to and promotes good relationships with people who use this service, and enable them to participate in wide range of activities that enhances their quality of life. The menu was varied with a number of choices including a healthy option. Staff are sensitive to the needs of those people who find it difficult to eat and give assistance with feeding. EVIDENCE: The pre-inspection annual quality assurance assessment (AQAA) - providers self assessment, received prior to this inspection stated that “Service users are encouraged to take active involvement in their care including outside trips, increased use garden and balconies space with service users tending flowers and vegetables. We have made available both Catholic and protestant church services, we have an open visiting policy, active family St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 14 involvement, recognition of birthdays with special celebrations for hundredth birthdays, anniversaries. A children’s choir is part of the weekly religious service and they are encouraged to visit with service users who are willing to accommodate them”. The AQAA further stated that “The activity co-ordinator keeps copies of all planned programmes and daily records of each individual’s participation”. The home had employed two activity coordinators and had a wide range of activities on offer to suit the needs and choices of residents. The activity coordinators appeared to have the appropriate skills to involve people who found it difficult to concentrate in something that stimulated them, both mentally and physically. The residents activity records and photographs seen suggest that the home had organised a wide range of activities, which were specific to individual and groups needs. The people using the services were actively engaged and appeared to have enjoyed the activities. For example, on the day of this inspection, an external person was seen making a presentation of various beauty products to a group of residents. The residents appeared to be actively participating in the event and have made enquiries about products showing interest to buy. People using the service had the opportunity to meet with their visitors in the lounge or in their own rooms. Visitors reported that they were welcomed into the home, could come and go as they pleased and felt part of the home. During the inspection 5 visitors (families) were spoken to. All the visitors spoke positively about the home and the staff. For example, one person said “I come everyday, the place is good, food is good, my wife is happy, I have no complaints to make”. Another visitor said “I visit twice a day, this place is wonderful, I feel happy when I come to see my mother”. Observation of the lunchtime meal showed it to be unrushed and enjoyed by the people using the service. Nutritional risk assessments were seen within the people’s care records. The menu plan appeared to provide people with a balanced nutritious diet and drinks were served with the meal. Staff were sensitive to the needs of those people who found it difficult to eat and gave assistance with feeding. The people expressed satisfaction with the quality, quantity, and presentation of the food. For example one person had cough and difficulty eating and the staff member and the duty nurse provided support. Another person was offered an alternative meal followed by a cup of tea, to suit her dietary needs. People using the service spoken to, have said that ‘lunch has been always good; staff are polite and feed the people who cannot eat on their own’. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s complaint’s procedure is clearly written. A system for monitoring complaints is in place and complaints are taken seriously. Safeguarding procedures are in place and senior staff have worked closely with the local Social Services staff to investigate concerns raised. EVIDENCE: Records of complaints are in good order and show that 13 complaints have been received since 1st January this year, 3 of which were handled under safeguarding procedures. Complaints varied from customer care issues, for example response to phone calls, to relatives concerns regarding the care of residents. Relatives and a resident spoken with were confident about raising any concerns. The complaints procedure is displayed, along with other key information, above the visitors’ signing-in book. The Manager made an application for a deprivation of liberty order to protect a resident who was acting in a way that risked his safety. Records show that after a full investigation by the Social Services authorised officer, the application was granted. There have been 3 safeguarding referrals since the beginning of the year. The home has fully cooperated with the investigations. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 16 Training for staff in safeguarding adults is provided in-house and by Barnet College. Training records show that the majority of staff have attended relevant training. The Manager commented that he was also hoping to arrange for staff to use Camden Council’s on-line training in safeguarding. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean, tidy, and free of any offensive odours. The environment was well maintained for the people who use the service to live in. EVIDENCE: The pre-inspection annual quality assurance assessment (AQAA) - providers self assessment, received prior to this inspection stated that “The home had a daily, weekly,monthly record of cleaning record many service users have personalized their rooms to their preferences. A full time maintenance person,and full time Housekeeper,maintains all records on a regular basis as prescribed by policy to ensure the health of safety of staff and service users”. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 18 The AQAA further stated that - “We have substantially reduced the use of side rails/cot sides, lowered incidents of falls, and falls with major injuries by lowering the beds and placing a mattress at bedside for those at high risk”. A tour of the premises was undertaken and all the communal areas were found to be clean, tidy, and free of any offensive odours. The people using the service, their rooms that were seen contained personal items, photographs, pictures, and furniture. Grab rails were also in place to assist with their mobility. The rooms were clean and tidy and no odours were detected. For example, one visitor spoken to on this inspection confirmed that the mother’s bedroom is good and well maintained. The home has a rolling programme of maintenance and decoration of the bedrooms and communal areas. The home provides a safe environment. A nurse call system is installed throughout the home and there is a fully integrated fire alarm system. Both systems are maintained by regular servicing. Some of records including catering, legionellosis water temperature, fire safety, lift, pest, electrical appliances and gas showed that there are regular maintenance checks in place. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Rotas provide sufficient staff, both Registered Nurses and care assistants to meet the needs of residents. While the Manager has established a comprehensive in-house training programme, access to NVQ training for care assistants needs to be increased. EVIDENCE: The rotas provide sufficient staff on duty including Registered Nurses and care assistants. The care of residents is provided by day staff working 8am to 8pm and a team of night staff on duty from 8pm until 8am. The home is currently fully staffed with the exception of the Deputy Manager’s post, to which an appointment has been made. The files of 3 recently recruited members of staff, including one Registered Nurse were looked at. Records showed that a sound recruitment procedure is followed, which includes taking up references, checking identity and criminal record checks. It is recommended that staff taking copies of documents, such as passports and work permits, sign and date each copy to confirm that they have seen the original. The Manager informed us that PIN numbers for Registered Nurses are checked every 3 months. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 20 The training matrix shows that core training, including refresher training, is monitored and steps taken to ensure that each member of staff completes training modules on time. Training in dementia care has been provided inhouse, using the Alzheimer Society’s Yesterday, Today and Tomorrow training package. A competency framework is in place for Registered Nurses and for care assistants. While steps have been taken to provide regular in-house training, the number of care staff completing NVQ2 remains low, with 25 out of 60 staff achieving level 2 or 3. A further 12 staff are currently enrolled on NVQ2 and 3 staff on NVQ3, which on completion will result in 66 of staff achieving NVQ2 or above. The Manager is aware of the need for greater accessibility to NVQ training and informed us that he has put a case to the company for funding for more places. A requirement has not been made regarding access to NVQ training in view of the number of staff enrolled and the steps the Manager is currently taking. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager and staff have good working relationship with the people who use the service and key stakeholders. This enabled them to promote the quality of life of people using the service. EVIDENCE: The pre-inspection annual quality assurance assessment (AQAA) - providers self assessment, received prior to this inspection stated that “The manager is an experienced clinician and administrator,he is a registered mental health nurse and is also a general trained nurse. He holds NVQ4 in St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 22 management. He has extensive knowledge and experience in long term/sub acute care,psychiatric and dementia care”. The AQAA further stated that “Health and safety is promoted through all our practice.We have regular quality audits and risk assessments. The home is ISO9001 accredited. The manager and the operations manager carry out audits on a monthly basis on all areas of the home”. It was apparent that the staff team worked well together and respected the registered manager. Staff supervision was regular, the minutes of the staff team meeting was available and showed how information is shared with staff, concerns raised by staff are addressed in the best possible way, which benefits the people who use this service. Staff said that in addition to supervision sessions they could speak to the registered manager at any time. There has been a short gap of some staff supervision as the deputy manager responsible had left the home. This was brought to the attention of the registered manager during the inspection feedback. In response, the registered manager had stated that the deputy manager’s position had been now filled and all the staff supervisions shall be regularised as appropriate. The home had an internal quality assurance system and procedure, to ensure that the quality of care provision and delivery is of always of a high standard. The service had also sought the views of people who use this service and their relatives, and other key stakeholders as well. The results of this satisfaction survey are yet to be analysed and then used to influence if any further improvement of care provision and delivery. The moving and handling techniques observed during the inspection were good, with appropriate use of slings, and the use of footrests on wheelchairs to avoid injury to staff and people who use the service. Staff and their training records confirmed that they had been trained in a variety of Health and Safety areas including moving and handling and food hygiene. The inspection of August 2007 reported that “We looked at the records of people’s personal finances that are handled by the home. The system is managed by the administrator. It is an effective system that safeguards people and it provides a clear audit trail”. The May 2009 AQAA stated that “monthly audits of budgets and monthly profit and loss is carried out”. The people, who use the service spoken to, reported that they found the staff and the registered manager to be very good listeners and all felt that they were very easy to talk to and that they trusted them. Staff said that they found the registered manager committed to the care of the people using the service and approachable. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 23 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 3 X 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X X X 3 3 X 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 3 X 3 3 X 3 St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 12 Requirement Prompt action must be taken when monitoring records show a deterioration in a resident’s condition, for example when fluid intake is low or where there is significant weight loss. Timescale for action 30/12/09 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 OP7 Good Practice Recommendations The staff should use of weekly summary sheets for fluid and nutrition intake to allow senior staff to monitor this area more closely. Staff should confirm with a signature and date that they have seen the original documents, such as passports and work permits, when taking copies for recruitment checks. The home should regularise supervision of those staff that missed due to absence of the deputy manager. The home should complete the analysis and findings of the external satisfaction survey, share with appropriate DS0000010324.V376610.R01.S.doc Version 5.2 Page 25 2. 3. 4. OP28 OP36 OP33 St John`s Wood Care Centre 5.. OP9 stakeholders and make improvements as recommended if any, in the report. Advice regarding the recording of prescribed creams and lotions not administered by RGNs should be sought from the Pharmacist. St John`s Wood Care Centre DS0000010324.V376610.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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