Care Home: Wellesley Road

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What the care home does well When people were asked what the service does well, we received the following comments: Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 “Everything is well” “They make you feel at home if you had a problem” “They do very well for me and I am content with the service” People with whom I spoke at the site visit praised the food and two individuals asked for compliments to be passed to the chef for the meal served the previous day. Comments about the food from people using the service were as follows: “Good food, good housing, good all round” “Good meals, attention and support” This care home is community based and older people can actively choose to move to live there. Their needs would be generally met according to their individual wishes and respect and privacy would be ensured. These intrinsic values are embedded in the home’s philosophy and included in their statement of purpose. People using the home continue to be encouraged to maintain the lifestyle and relationships they had prior to moving into the home. Friendships with other residents are also encouraged inside and outside the home. For example, other homes managed by the provider are visited on occasions for activities and other events like garden parties from time to time. People living here are also given the choice of when to get up and where and when to eat or whether they wished to be disturbed during the night for example. The homes environment is outdated and plans are in place to rebuild the home with much upgraded facilities; in the meantime however, the manager and her staff have made some improvements and a pleasant, relaxed and welcoming environment is prevalent. People using the service are consulted and also family members as appropriate about any pertinent issue that may arise. The Annual Service Review undertaken in October 2008 reflected that people using the service were happy living at the home and that the menu and range of activities had improved. This was scrutinized at the visit and the home continues to make improvements in these areas. People with whom I spoke said they were happy and or content with the delivery of services and staff were described as “caring”. A staff member commented positively about the service in her survey response. There was evidence also of good interaction and respectful relationships between people using the service and staff. Staff at this home definitely take the wishes and feelings of individual people using the service upper most in their minds and make attempts to accommodate their needs and desires. There is good relationship with the local GP’s surgery and other local health services. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 Page 7I evidenced examples of good team working in two of the units that I visited. The home was proactive in dealing with issues following feedback of the inspection findings. What has improved since the last inspection? There were no requirements or recommendations from the previous inspections. As outlined in the (AQAA) Annual Quality Assurance Assessment document, the appearance of parts of the home had been improved They had invested in new flooring, furniture, pictures and ornaments to make the transformation. New kitchenettes were now installed in each unit. The walls in the hall areas on the ground and first floors were repainted and a pleasant appearance was observed. Toilets within the home and bathrooms have also been attended to. Outdoor activities had increased with input from voluntary services. Improvements were also made to the garden and paths, making the area more accessible for people to use. What the care home could do better: At the time of this inspection the home was attending to some areas of deficiencies such as reviewing and updating the care plans of individual people using the service; they are aware of the areas to be improved and are working towards these. Three requirements were made in respect to and to ensure that the manager knows the contents of Certificate issued by the Criminal Records Bureau for staff employed at the home; that the monthly monitoring visits occur regularly and the risk assessment are written more robustly. Four recommendations were also made relating to a review and update of a number of policies and procedures in the home; that supervision occurs at least six times per year for individual staff; that the names of care staff are removed from the statement of purpose and the name of the Care Quality Commission is featured in the complaints procedure.Wellesley RoadDS0000037326.V378196.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Wellesley Road Wellesley Road 1 Wellesley Road London NW5 4PN Lead Inspector Pearlet Storrod Key Unannounced Inspection 16th October 2009 09:00 DS0000037326.V378196.R01.S.do c Version 5.3 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. Wellesley Road DS0000037326.V378196.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 Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellesley Road Address Wellesley Road 1 Wellesley Road London NW5 4PN 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 7267 0856 020 7424 0999 London Borough of Camden Margaret June Charles-Dover Care Home 48 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (48), Mental disorder, excluding learning of places disability or dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (48), Old age, not falling within any other category (48), Physical disability (2), Physical disability over 65 years of age (48) Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 beds in short stay unit registered for adults under the age of 65. Date of last inspection 17th October 2007 Brief Description of the Service: Wellesley Road is a care home providing personal care for up to 48 older people. The home caters for both male and female service users who are aged 65 years and older. The certificate of registration reflects that the staff are caring for people within the categories of dementia, mental disorder, old age and physical disability. The home not only provides long-term residential care but also three separate units for emergency admissions, respite and interim care. The current level of fee is £893.03 per week for long stay residents and £73.36 flat rate fee per week for up to 8 weeks in the interim or respite unit. The permanent service users are accommodated on the ground floor and the three other services are on the first floor. The units are self contained and staffed separately. They are organised so as not to impact on the lives of the long stay service users. The owned is operated by Camden Council and has been registered under The Care Standards Act 2000. It is situated with good access to public transport, shops and community facilities. The home was purpose built about thirty years ago therefore not all the rooms’ sizes and corridor widths meet with the national minimum space standards. All the bedrooms are single occupancy however forty of them are slightly below the national minimum space standard and eight of them measure over twelve square meters. The home is three storeys high although accommodation for service users is on the first two floors only. A shaft lift gives access to the second floor; the third floor is not registered. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection where we assessed the home’s performance in meeting the anticipated outcomes of the National minimum Standards (NMS) for Care Homes for Older People, as published by the Department of Health. The inspection took nine hours to complete. Prior to the site visit information held at our office had been reviewed. This included reports that had been sent to us on a monthly basis, and about any incidents/changes that had occurred since our last visit. The manager had completed an Annual Quality Assurance Assessment (AQAA), also referred to as a self-assessment document, which gave us information about the people living and working in the home. It also gives information about the home’s compliance with respect to the key standards. An inspection plan was developed and used to conduct the inspection based on the key standards where a full judgement could not be made without a visit. Questionnaires had been sent to the home for people using the service and for staff. Nine surveys were returned from people using the service and one was returned from a staff member. During the visit I spoke to people living in the home and examined five case files in depth. I was able to speak to individual people throughout the visit and I also had an opportunity to eat lunch with some of the people using the service. This was an enlightening experience as it indicated some areas that required attention, which staff proactively dealt with once the matters were discussed with them. As part of the inspection process records were examined; a tour of the building occurred and a sample of the files for people using the service and of the staff was examined. The information collected from the various sources was used to form the judgement made in this report. What the service does well: When people were asked what the service does well, we received the following comments: Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 Page 6 “Everything is well” “They make you feel at home if you had a problem” “They do very well for me and I am content with the service” People with whom I spoke at the site visit praised the food and two individuals asked for compliments to be passed to the chef for the meal served the previous day. Comments about the food from people using the service were as follows: “Good food, good housing, good all round” “Good meals, attention and support” This care home is community based and older people can actively choose to move to live there. Their needs would be generally met according to their individual wishes and respect and privacy would be ensured. These intrinsic values are embedded in the home’s philosophy and included in their statement of purpose. People using the home continue to be encouraged to maintain the lifestyle and relationships they had prior to moving into the home. Friendships with other residents are also encouraged inside and outside the home. For example, other homes managed by the provider are visited on occasions for activities and other events like garden parties from time to time. People living here are also given the choice of when to get up and where and when to eat or whether they wished to be disturbed during the night for example. The homes environment is outdated and plans are in place to rebuild the home with much upgraded facilities; in the meantime however, the manager and her staff have made some improvements and a pleasant, relaxed and welcoming environment is prevalent. People using the service are consulted and also family members as appropriate about any pertinent issue that may arise. The Annual Service Review undertaken in October 2008 reflected that people using the service were happy living at the home and that the menu and range of activities had improved. This was scrutinized at the visit and the home continues to make improvements in these areas. People with whom I spoke said they were happy and or content with the delivery of services and staff were described as “caring”. A staff member commented positively about the service in her survey response. There was evidence also of good interaction and respectful relationships between people using the service and staff. Staff at this home definitely take the wishes and feelings of individual people using the service upper most in their minds and make attempts to accommodate their needs and desires. There is good relationship with the local GP’s surgery and other local health services. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 Page 7 I evidenced examples of good team working in two of the units that I visited. The home was proactive in dealing with issues following feedback of the inspection findings. What has improved since the last inspection? What they could do better: At the time of this inspection the home was attending to some areas of deficiencies such as reviewing and updating the care plans of individual people using the service; they are aware of the areas to be improved and are working towards these. Three requirements were made in respect to and to ensure that the manager knows the contents of Certificate issued by the Criminal Records Bureau for staff employed at the home; that the monthly monitoring visits occur regularly and the risk assessment are written more robustly. Four recommendations were also made relating to a review and update of a number of policies and procedures in the home; that supervision occurs at least six times per year for individual staff; that the names of care staff are removed from the statement of purpose and the name of the Care Quality Commission is featured in the complaints procedure. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.2 Page 8 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. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 9 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 Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 10 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 and 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 using this service have sufficient information about the home to make and informed decision about whether the service is right for them. The personalised needs assessment enables people’s diverse needs to be identified and planned for before they move into the home. EVIDENCE: The home’s statement of purpose had been reviewed by the newly appointed manager. The document includes the names of all the care staff and their qualifications. The names of staff were not required to be included with the exception of the names of the manager and responsible individual. The statement of purpose needs to be reviewed with a general statement about the staff and their qualifications. This would prevent needless reviews each time a Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 11 member of staff leaves the provider’s employment. The issue relating to consent from individual staff members should have been sought prior to the inclusion of their names in the document. Basic information was available to staff to ensure they could meet the social, emotional and care needs of new service users. The home is responsive to referrals whether they are planned or unplanned, this ensures emergency and other short stay placements at the home are appropriately accommodated and the needs provided for. It should be noted that three people had asserted that they did not have enough information to make an informed decision about living at the home. The three people concerned commented positively about other aspects of the home. There were however, evidence of written contracts and Camden’s terms and conditions of residence for the home were on each person’s file. People who use the service were given the information they need about the service and the costs for residing there. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 12 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 and 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. There is continuous assessment, care planning and review which make sure that the personal and healthcare needs of the people living in the home are met. EVIDENCE: Five care plans were examined. Scrutiny of the care plans demonstrated that staff continued to work towards developing the care plans to be person centred. There was evidence of multidisciplinary input according to individuals’ needs and reviews were observed to occur regularly. Inspection of the risk management plans for individual people’s care needs and activities showed that a more robust approach was needed. For example an individual noted from the records was said to be unable to weight bear when they experienced (UTI) Urinary Tract Infection; the risk assessment included a scoring chart in Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 13 respect of falls and mobility. This individual was also referred to as being hard of hearing and refuses to wear a hearing aid. There was no recorded information evident in regard to potential risks of harm for the individual concerned and no guidance as to the actions to be taken by staff in the event of an emergency such as fire. Another example of the need for robust risk assessment is reflected in the next outcome area. A small audit of the medication system and medication administration charts was carried out. The procedures, and training, were discussed with the manager and the process seemed satisfactory. The General Practitioner attends the home weekly to conduct a surgery. The medication policies, procedures and practices appear sound and people are supported to control their own medication where it is appropriate to do so. I observed care workers treating individual people using the service with dignity and respect, which is inherent within the home’s philosophy of care as noted in the Statement of Purpose. People with whom I spoke also confirmed that they were treated with dignity and that their privacy was respected. Nine surveys were returned from people using the service. Some information fed back to us is given below. One survey had negative comments in that they said, “the home does nothing well, should be changed to a hospital”. All other comments received were positive such as, “”everything is well;” “they make you feel at home if you had a problem”; “they do very well for me and I am content with the service”. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 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. People using the service followed their preferred lifestyle where possible and can engage in opportunities for stimulation and occupation. EVIDENCE: The care plans we looked at made reference to and included the wishes and preferences of the residents. A programme of activities was available and it was clear that people using the service had the opportunity to choose whether to participate in an activity or not. Community involvement is encouraged. It was noted that religious beliefs of individual people using the service were recorded. For example, a Jewish person though none practising, did not wish to eat pork; the relatives of this individual were consulted as and when necessary. This individual was self-funding and their financial affairs were managed via solicitors. In discussion with the manager she confirmed that staff had not consulted the individual about here wishes in the event of her Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 15 death. The manager was advised that staff consult with people using the service and relatives if appropriate, about the wishes of residents’ in the event of death and to include the care planning process. With regard to another individual with whom I spoke, this person voiced a concern that he would like to live in the same home as his wife who is placed in another home approximately a mile and a half way from this home. The manager gave an undertaking to call for a review regarding this matter; the manager was proactive and a review date was set in respect to this. Family members were seen in the home at the site visit and I spoke to two people who said they were satisfied with the care and support of their relatives. I had the benefit of being invited for lunch with some of the people using the service. The meals served were presented well and the people, with whom I sat, appreciated the food served to them. One person at the table was unwell and there was insufficient staff around to assist, which was an unusual situation. The carer on duty explained that the other carer was busy doing something else; nonetheless this carer coped well under the circumstances in supporting the individual concerned and the other residents. In the previous outcome area I explained that risk assessment would be raised again under this outcome area; whilst sitting at the dining table I observed an individual at another table in the room putting large portions of food in his mouth and he clearly required assistance with cutting up his food in manageable portions. This was drawn to the attention of the care staff who immediately addressed the issue. Another individual with whom I sat took the cranberry juice in my glass for wine, we had a brief discussion and realized that he would preferably like wine with his meals as that was his custom. Again, this was discussed with staff in the home and it was agreed that this would be followed up. The individual discussed this with his relatives who visited the home on the day; we spoke briefly and they were pleased that wine would be offered to their relative with his meals. The two examples above are areas that staff should include as part of the individuals assessments of needs together with risk management plans, with input from specialists as necessary. Staff agreed to take the issues on board. People with whom I spoke at the site visit praised the food and two individuals asked for compliments to be passed to the chef for the meal served the previous day. Comments about the food from people using the service were as follows: “good food, good housing, good all round”; “good meals, attention and support”. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 16 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 and 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. People using the service feel safe and listened to and are supported by the policies and procedures of the care home. EVIDENCE: There were complaints recorded as noted in the (AQAA) Annual Quality Assurance Assessment. This was discussed with the manager and an assistant manager who both confirmed that they have had minor complaints that was dealt with promptly. They had not recorded the issues because of this. They immediately set up a book for complaints; this would enable the home to analyse the complaints received and improve the quality of the services offered to people using the service. A complaint register was immediately put in place by the manager and her assistant. Three surveys returned from people using the service commented that they did not know how to make a formal complaint. All nine confirmed that they knew who to speak to if they were unhappy about the service; six said they knew how to make formal complaints. The manager should ensure that key-workers and assistant managers discuss this with their clients and to raise the issue of making formal complaints on the house meeting agenda as a standing item. A Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 17 copy of the complaints process was on notice boards on each floor and a brief reference is made in the statement of purpose. A summary of the procedure is available in an easy read format, a copy of which was shown to me at the inspection. The manager explained that the easy read format is given to every client. The procedure is available to people living in the home and their relatives. The document should make reference to the Care Quality Commission. The service has a robust policy and procedure on adult protection, which reflects the policies and procedures of the local authority. All members of staff receive (POVA) Protection of Vulnerable Adults training as part of the induction process with refresher training thereafter. Staff had awareness and knowledge of the Mental Capacity Act; there were evidence of referrals and staff training in respect to (DoLs) Deprivation of Liberty safeguards. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 18 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 and 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. Staff strives to ensure that people using the service live in a safe, clean and comfortable environment. EVIDENCE: The home is in a good location for easy access to public transport and local amenities. A relaxed and friendly atmosphere throughout the home was apparent. The previous key inspection report made reference to the building being outdated; consultation with people using the service and their families have occurred with regard to building and running a new home with nursing and extra care sheltered housing services. Younger and older people within the community and residents are working together to design this new project. In Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 19 the meantime, staff had worked with individual people to personalise their bedrooms. Improvements to two bathrooms on the ground and first floors had taken place and there are proposals to upgrade two other bathrooms on both floors. Also, improvement to the shower room on the ground floor and toilets throughout the home were evident. The appearance of the hall areas on both floors was also improved. An infection control policy in place and the home was clean with no malodour. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 20 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 and 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. Staff were trained and competent to do their jobs, meet the needs of people using the service. EVIDENCE: People using the service were asked for their views, and positive comments were made about the staff, describing them as having “caring attitudes”; staff are always willing to help”. Staff were observed interacting with people using the serviceand in one unit for example, two carers were blowing up balloons in preparation for the impending birthday party for a resident. The residents present were hitting the balloons as they were blown and tied and they seemed to be enjoying themselves. The following comments were outlined in a survey return from a member of staff, “staff appears to support the service users very well”. “The staff do all that is possible to maintain the daily living skills and independence of the service users”. “The meals provided are of good standard and the diversity of the service users are always (from my observation) accounted for”. They added, “More staff could be provided so that service users can experience Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 21 support with activities such as going out more”. The manager had commented in discussions that they were looking at recruiting more volunteers who would assist in this regard. There was evidence of a stable staff team and some staff working at the home had worked there long term. The manager herself was an assistant manager at the home prior to her appointment as service manager. Those with whom I spoke demonstrated clear commitment to their work. There was a rolling rota, so that staff did know the shifts they would be doing, this allows people using the service to know who would be on shift on any date. There was also a senior member of the staff team on shift at all times. A duty manager system was in place. Domestic staff and the cooks were also recorded on shift to ensure the smooth running of the home as noted at the inspection and confirmed in the self-assessment document. The issue of staff vacancies were raised in discussion with the manager who confirmed that they were four vacant posts. An assistant manager’s post had been appointed to fairly recently though it was proving difficult to fill the vacant posts. The home is currently reliant upon agency staff though this happens with continuity and consistency in mind to ensure the appropriate meeting of needs. The manager further explained that they had been discussing the possibility of using Camden’s internal bulletin to advertise the vacant posts as opposed to using resources to advertise outside in view of impending transitions within the next two years. A sample of recruitment files were checked as part of the inspection process. It was apparent that the information included on a Criminal Record Bureau form had not been shared with the registered manager. Nonetheless, a protocol is required to be drawn up to prevent the situation from recurrence as the manager has responsibility to ensure compliance under the Care Homes Regulations and National Minimum Standards. Wellesley Road is registered to accept a range of categories because of the role that it has as a community-based service. A training plan is in place and individual training needs were generally identified through supervision and annual appraisals. It was however noted from examination of a sample of staff files that supervision had slipped, which was confirmed by the manager and an assistant manager. Staff training and appraisals were found to be in satisfactory order and learning development opportunities were recorded in the files observed. Mentoring for example was mentioned as an area for an individual’s learning development. Most staff had completed NVQ 2 or higher and some have completed training in relation to dementia care. Agency staff were also included in in-house training such as the Mental Capacity Act and mandatory and other training were occurring. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 22 Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 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 home is being managed I the best interests of the people who live there. EVIDENCE: Discussions with the manager during the site visit demonstrated a good level of awareness of the strengths of the service and the areas where improvements are necessary. The manager’s registration had been approved and she is qualified to manage the home. She holds the NVQ Registered Manager/Assessor Awards and NVQ level 4. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 24 The judgements in preceding sections of his report contributed to the judgement in this outcome area. The care home has a welcoming environment and promotes an open and transparent style of management. The manager also had a pro-active approach and dealt with issues as they arose. The self-assessment reflected that feedback from residents is achieved by reviews, residents’ meetings, survey and informal every day contact. Residents’ satisfaction surveys were noted to have been issued and completed in August of this year. The results of the surveys were displayed on the notice board and this showed that no person using the service described dissatisfaction with the delivery of services. The provider had invested in the continuing development of the staff team and this is borne out in the training and appraisal records. People using the service were encouraged to manage their own money and where this is not possible; service users’ monies are maintained by the local authority. Slippage in respect to the monthly monitoring visits for a period of time prior to this inspection had occurred. Supervision as mentioned earlier had slipped, and the manager and assistant manager gave an undertaking and commitment to address this problem. The self assessment document reflected a number of outdated policies and procedures. This was discussed with the manager who acknowledged an awareness; she indicated and showed me evidence that they were currently reviewing all the policies and procedures held at the home. The process needs to continue to ensure that staff have updated information for guidance as and when the need arises. Samples of health and safety records were looked at and these confirmed that the home is being managed responsibly with essential checks being made. The provider monitors health and safety in the home. There are robust procedures in place to monitor compliance. Equipment is serviced regularly and where required, repaired or replaced. As mentioned previously, an infection policy was in place. Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 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 x 3 x x 3 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 2 3 Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 26 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 OP15 Regulation 13(4) Requirement The registered person must ensure that risk assessments are more robust and that individual people using the service have risk management plans associated with managing to eat their meals appropriately without the risk of choking The registered person must ensure that information on CRB Certificates is shared/discussed with the manager of the home The registered person must ensure that regular monthly monitoring continues to occur. Timescale for action 20/02/10 2 OP29 19, Schedule 2 26 20/02/10 3 OP33 20/01/10 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 OP1 Good Practice Recommendations The registered manager should ensure that the names of care staff are removed from the statement of purpose and then review the statement of purpose accordingly. DS0000037326.V378196.R01.S.doc Version 5.3 Page 27 Wellesley Road 2 3 4 OP16 The easy read complaint procedure should make reference to the Care Quality Commission The registered person must ensure that care staff receive formal supervision at least six times a year The registered person should ensure that the outdated policies and procedures are updated. OP36 OP37 Wellesley Road DS0000037326.V378196.R01.S.doc Version 5.3 Page 28 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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