Care Home: Wilhelmina House

Similar services:

• Henry Nihill House
• Birchwood
• The Infirmary
• Orchard House Nursing Home
• St Josephs Rest Home
• Red Court Nursing Home
• Spinney (The)
• Queen Elizabeth House

What the care home does well The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their relatives and friends are able to visit and to assess the quality, facilities and suitability of the home. The health care needs of service users are being well met.Service users are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Service users generally presented as well settled in their environment, and very satisfied with the communal and personal facilities provided. What has improved since the last inspection? Since the last inspection a number of improvements and service developments have been achieved and the Registered Manager and her staff team are to be commended on making this positive progress. 1. Risk assessments have been implemented for all those residents who self medicate. This should help ensure that risks associated with selfmedication are reduced. 2. The requirements made as a result of the Environmental Health Officer`s visit on 29.1.07 have been addressed. 3. A start has been made on raising staff awareness on the key policies and procedures for the home. 4. All senior staff who provide supervision have received supervision training. 5. Staff files have been improved and now contain most of the documents required. 6. An administrative post has now been established within the home. 7. Each staff member now has a training file which includes a list of training that each staff member has received and when; certificates which evidence that the training has been given and received; and a list of training needs identified through 1:1 supervision that should be provided for by additional training in the year ahead. 8. All staff have now received POVA and NVQ training as required. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Wilhelmina House 21 Parkhill Rise Croydon Surrey CR0 5JF Lead Inspector David Halliwell Unannounced Inspection 6th November 2008 10:00 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 Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilhelmina House Address 21 Parkhill Rise Croydon Surrey CR0 5JF 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 8760 0933 020 8760 0933 deborahpearson@btconnect.com The Dutch Home for the Elderly Limited Mrs Deborah Pearson Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 21 7th May 2007 Date of last inspection Brief Description of the Service: Wilhelmina House was established as a registered charity by the Dutch church in London and aims to provide a sheltered environment for elderly men and women who no longer wish to live independently. It is not a nursing home and is primarily intended for people in reasonably good health. The home was opened in 1984 as a purpose built unit and is registered to provide residential care for up to twenty-one older people. Wilhelmina House is situated in a primarily residential area close to East Croydon station, Lloyd Park and other community facilities. On the day of the inspection there were twenty service users living at the home. Each service user has a bed sitting room with an en suite toilet and wash hand basin. The home has spacious communal areas on the ground floor consisting of a lounge, dining area and a large conservatory, the kitchen and laundry areas are clean and well equipped. Sufficient numbers of baths/ showers wash hand basins and lavatories are available throughout the home. There is a large well-maintained garden to the rear of the property and ample parking space. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The stars quality rating for this service is good. This means that people who use these services experience good quality outcomes. Service users said that they like to be called residents. This was an unannounced inspection visit of the service at Wilhelmina House. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 3 staff and the Manager and 6 of the residents. A completed AQAA was received prior to the inspection. No enforcement activity has occurred since the last inspection. There have not been any changes in the ownership or management of Wilhelmina House and the Whitgift Foundation remain the provider agency. The Manager is registered with the Commission for Social Care Inspection as the Manager. 5 requirements have been made as a result of this inspection and 5 recommendations. Some of these are repeated requirements and should be addressed within the new timescale if enforcement action is to be avoided. Feedback on the requirements and recommendations was fully explained to the Manager at the end of the inspection visit. We found the residents and staff most helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. We were impressed by the commitment and enthusiasm of the Manager and of the staff group and of the quality of the services being provided at Wilhelmina House. The Manager told the Inspector that the cost of a placement at Wilhelmina House starts from £435 per week. What the service does well: The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their relatives and friends are able to visit and to assess the quality, facilities and suitability of the home. The health care needs of service users are being well met. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 6 Service users are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Service users generally presented as well settled in their environment, and very satisfied with the communal and personal facilities provided. What has improved since the last inspection? What they could do better: Specific areas needing improvements and that are identified in this report are as follows: 1. The Manager must ensure that a new “Controlled Medicines” book is drawn up and that staff make clear and accurate recordings to do with the administration of controlled drugs to residents. Staff who administer medicines need to be briefed on the method and practices of recording including that of the second signatory. 2. CRB checks should be renewed every 3 years. 3. An inventory of the resident’s valuable belongings should be drawn up and held on file for each resident and updated annually. This will help to ensure the protection of resident’s possessions. 4. A training matrix should be drawn up that identifies all the training that staff have received in the last 3 years and therefore where training gaps exist. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 7 5. The frequency of the staff meetings should be increased to once every 2 months. 6. The frequency of residents meetings needs to be increased to 5 or 6 times annually so that the access for residents for discussing issues is improved 7. A training matrix should be developed that identifies all the training that staff have received in the last 3 years and therefore where training gaps exist. 8. The Quality Assurance process as described in this report must be fully implemented in 2009. 9. Areas of discussion in supervision with staff need to be expanded. 10. Frequency of supervision remains an issue and records seen by us indicate that the frequency of staff supervision still needs to be improved. The standard requires staff supervision every 6 – 8 weeks or 6 times per annum. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wilhelmina House DS0000025870.V373229.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 Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Standard 6 is not applicable to this home as it does not provide intermediate care. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents may be assured that their needs will be thoroughly assessed and reviewed by their referring agencies, they may also be assured that their needs will continue to be fully assessed at Wilhelmina House and that fully completed documentation will always be held on their files. EVIDENCE: Standard 3 – We inspected 4 of the 20 resident’s files and on each of these files a comprehensive needs assessment was seen. Information on each of these residents and their needs had been provided by the referring authorities and there was also evidence of the home’s own thorough in house assessment of the resident’s needs prior to a decision being taken regarding admission. It included an assessment of the person’s health, risk factors, mobility and the compatibility of the person to ‘fit in’ with the current residents. The assessment Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 10 is completed together with the resident, his/her relatives or representatives and with the relevant professionals that have been associated with the referral. Evidence on the files inspected showed that residents had signed the assessments and care plans in agreement to the content being appropriate to them. Religious and cultural needs are a part of the needs assessments seen in the resident’s files and all care plans are based on the information contained in the needs assessments. A review of the needs assessment is carried out every 6 months and evidence of this was also seen together with revised care planning documentation. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their health, personal and social care needs will be the central focus of their care plans and that these plans will be appropriately reviewed as and when required. Service users can also be assured that their healthcare needs will be met at Wilhelmina House. Medication administration and recording needs to be reviewed and revised so as to ensure it is being appropriately managed and properly recorded and stored. It is important that the residents are being protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Standard 7 – On the 4 residents’ files inspected we found that appropriate needs assessments had been drawn up for each resident. Service user plans / care plans had been constructed from these needs assessments and we were impressed with the detail covered in these plans. All the care plans inspected Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 12 were seen to be reviewed regularly, the date of the review being recorded on file. It was clear from the care plan records held on the files that all the appropriate people are usually involved in the care plan reviews including the resident and their relatives where appropriate or their representatives. At this inspection we spoke to 2 relatives of 2 of the residents who confirmed that care plans are being reviewed and that they, or a member of the families are normally involved in the process. One relative said, “My father and I are very happy with the care provided to him by staff at Wilhelmina House, the care plans are a useful way of setting out what will care will be carried out to meet his needs. We were involved in the planning and I am invited to reviews”. Another relative told us, “Yes we have been invited to care planning meetings and we do go because we like to know of there are going to be any changes in Mum’s care”. The Manager informed us that after the initial placement of a new resident an intermediate care plan is now being drawn up before the 6-week review. After the 6-week review, the care plan is revised and then reviewed. All the documents required under Schedule 3 were seen on the residents files inspected. Standard 8 – This standard concerns the healthcare of each of the service users. The Registered Manager informed us that all the residents do have access to a GP. The Registered Manager also said that all residents have access to the following health care professionals who visit Wilhelmina House on a regular basis. The optician visits every 3 months, the dentist every 6 months and the chiropodist also visits on a regular basis. This information was supported by 4 residents who we spoke to over the course of this inspection. The Manager told us that dietary needs are assessed for each prospective resident at the time of their admission and then re-assessed as required this includes a nutritional assessment. Evidence of this was seen by us on the resident’s files and staff also said that this was the usual practice as a part of the assessment process for prospective residents. Standard 9 – We were provided with the agencies policies and procedures manual by the Registered Manager and this file included an appropriate medication policy for the unit. The Registered Manager told us that the usual practice for the administration of medicines at Wilhelmina House is for staff to give the residents their medication. All staff receive appropriate training to ensure that this is done safely and the residents are protected by safe and appropriate practices. Training records were presented for the care staff and it was clear that regular training is provided on the safe handling of medicines. 2 staff interviewed confirmed this. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 13 Some residents administer their own medication. At the last inspection it was required that the Registered Manager arrange for detailed risk assessments to be carried out for those residents and to ensure that they are reviewed as the persons needs and abilities to self medicate may change. Evidence that this has since been completed was seen on the resident’s files inspected and so this requirement has now been met. Appropriate records (MAR sheets) were seen to have been completed properly for the administration of medicines to service users. Together with the Manager we carried out a random stock take check of the medicines held in the home’s “controlled drugs” medicine cabinet and the numbers indicated on the MAR sheets. The “controlled drugs” record book being used to record which medicines had been administered to whom and when was seriously muddled and the recordings in the book did not match the stocks held in the cabinet. Stocks of controlled medicines held in the cabinet exceeded the levels recorded in the book. This is a serious matter especially for “controlled drugs” and so it is required that the Manager ensures that a new book is drawn up with clear and accurate recordings for the administration of controlled drugs. Staff who administer medicines need to be briefed on the method and practices of recording. Staff who act as a second signature need to be reminded of why they are signing and of their responsibilities to ensure that administration of medicines and the subsequent recording of information in the book needs to be checked for accuracy at each entry and second signatures should not be given until they are satisfied this is so. Standard 10 - We spoke with 6 of the residents at Wilhelmina House and 2 relatives of residents about the quality of the care they receive to meet their needs. On the whole we were impressed with the positive remarks made about the care and support that residents receive from staff at Wilhelmina House including maintaining the dignity and privacy of the residents wherever and whenever possible. All the residents receive personal care and some are helped with washing and bathing, dressing and toileting. Care staff who we interviewed showed by their responses their caring attitude towards the residents and service users in their comments about staff also reflected this. All of the bedrooms have en suite toilet and bathing facilities and this also helps residents to maintain a level of privacy that they welcome. All residents have their laundry done individually by their key workers and this systematic method ensures that residents are able to wear their own clothes when they like. The Manager told us that the staff induction programme covers the core standards of privacy, dignity, independence, civil rights, fulfilment and choice. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 14 Evidence was seen by us on the staffing files inspected. This is discussed later in the report. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users do feel that they are treated with respect and their rights to privacy are upheld. Residents are also likely to find that the lifestyle they experience at Wilhelmina House matches their expectations and their preferences and satisfies their social, cultural, religious and recreational interests. Residents are encouraged to maintain contacts with their friends and families and service users are helped to exercise choice and control in their lives wherever possible. The meals and food provided to residents is well balanced, healthy and varied EVIDENCE: Standard 12 – Over the course of this inspection we were shown a programme of entertainment and events, which are provided for the residents. The Manager informed us that the home continues to employ the activities officer who works every week at Wilhelmena House from Tuesdays to Fridays and who organises a varied and interesting social calendar for the residents including exercises and appropriate activities. The Manager told us that a new Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 16 computer has been provided for the resident’s use and some training is provided to enable them to use this opportunity. At this inspection we spoke to 6 of the residents and asked them all whether they enjoyed the different forms of entertainment offered to them. All the residents said that they do enjoy what is offered. A relative also said, “Wilhelmina is lucky with the calibre of the activities officer, residents enjoy a high level of activities and recreational activities”. The Manager informed us that the resident’s religious and cultural needs are assessed as a part of their initial assessment and placement at Wilhelmina House. Residents are encouraged to attend church if they wish to and staff will assist them to do so. Standard 13 – We were told by the Manager and the staff that there are no specific visiting hours and that as long as a resident wishes to see a relative then visitors are welcome at most times of the day. A record of visitors was seen and visitors may be entertained in communal areas as well as the resident’s own bedrooms where relatives, families and friends can be seen in private if they wish. Residents confirmed this with us. Standard 14 – This standard explores issues relating to: managing financial affairs, advocacy, respecting of the right to personal possessions, and enabling access to information kept concerning a service user. A number of residents still have some control over their own affairs and this is encouraged, where appropriate and assessed on admission to the home. Permission is given positively to residents who wish to bring in items of furniture or other familiar items when entering the home; the only proviso is that these items be safe from the point-of-view of fire and soundness. Standard 15 – There is a 4-week rolling menu planner and the Chef draws this up after consultation with the residents at the Residents meeting forum where residents are asked for their comments on the menu provided and whether there are any special requests. Any special dietary requirements are taken into account and provision is made in the menu plan. We saw both the 4-week menu plan and the daily menus and these menus provide a wide and healthy range of food for the residents. We were present for lunch and was able to speak to the residents about the food. All the residents who were asked by us said that they like the food on offer to them and they confirmed that they do have a choice. Menus are displayed in the dining room and this enables the residents to see what they will have to eat and what choices they have on a daily basis. Care staff was seen to provide assistance to the residents when this was necessary and staff were seen to ask the residents before they offered any help to them. Meal times were seen to be unhurried and any resident who chose to eat in their bedrooms was enabled to do so. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 17 The Manager informed us that a nutritional assessment is undertaken as a part of the residents needs assessments and any special needs are catered for in the menu planning. Where necessary and where there are special dietary requirements a daily record of the resident’s food intake is kept together with weight charts and this information is used by care staff to help support the resident appropriately. The kitchen was again seen to be in very good order by us and the menus offer residents a healthy, varied choice of food that they all said they enjoy. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home will deal with complaints appropriately; information about the complaints procedure is readily available to all who may wish to express an opinion about the service. Service users can be assured that the processes in the home will protect them from potential abuse by staff or others. However staff training needs to become more regularised for all staff working in the home. EVIDENCE: Standard 16 – The Registered Manager showed us the complaints policy and procedure for Wilhelmina House. This policy covers all the essential areas required for a complaints policy including a staged process with timescales and contacts for other agencies. The Registered Manager maintains a record of complaints and we saw this. 1 complaint had been recorded since the last inspection. Records show that this complaint was dealt with according to the home’s policy and also to the satisfaction of the resident who had complained. We also spoke to the resident concerned who told us that they had been satisfied with the way the complaint had been dealt with and the outcome. Standard 18 – Wilhelmina House has an Adult Protection policy and the Registered Manager showed us a copy of it. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 19 The Manager told us that it is policy to ensure that all care staff receive training for the protection of vulnerable adults (POVA). Members of staff are also made aware of the policy via induction training. The Manager said that all the home’s staff have now received POVA training over the last 2 years from L.B Croydon’s POVA training programme. Evidence on 6 staffing files inspected, demonstrated that they had received POVA training in the last 2 years. This means that staff should be better able to protect residents from abuse. The home’s policies and procedures cover all essential areas of guidance, including physical intervention, service user’s finances, insurance and such issues as gifts gratuities and bequests. There are sufficient organisational policies to safeguard the residents’ welfare e.g. dealing with abuse and a whistle blowing policy. It is recommended that an inventory of the resident’s valuable belongings should be drawn up and held for each resident and updated annually. This will help to ensure the protection of resident’s possessions. The Manager told us that all staff members are all thoroughly vetted and recruitment assures that nobody starts at the home until their credentials with regard to the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults Register have been checked. At this inspection we inspected 6 staffing files and found that although CRB checks had been carried out for all the staff these checks are now out of date and they now need to be renewed. CRB checks should be renewed every 3 years and this is required so that the Manager can remain assured that staff continue to have appropriate CRB records. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to pleasant and comfortable facilities. Residents generally presented as well settled in their environment, and as being very satisfied with the communal and personal facilities provided. EVIDENCE: Standard 19 – We undertook a tour of the premises and the home was seen to be clean and tidy in all areas. All areas of the home are accessible to wheelchair users and there is a lift that provides access to all floors of the building. There are at present no residents who use a wheelchair living at Wilhelmina House. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 21 The general condition of the home and the facilities is consistently good; communal areas and bedrooms are kept clean and odour-free. The Manager and staff provide a ‘homely’ touch through supplementary decoration and ornaments / flower decorations and pictures hanging on all the walls. There is a conservatory at the back of the house which has a commanding view over the garden and which some residents said they really enjoyed sitting in at any time of the year. At the time of this inspection the conservatory was beautifully decorated for Christmas. The LFEPA last visited Wilhelmina on 9.7.08. 2 requirements were made as a result of this inspection, one for the need of a revision of the fire risk assessment for the home and another for the development of an emergency plan. The Manager told us that both these requirements had been met and a letter from the LFEPA seen on the files confirmed that both requirements have since been met. At this inspection the Manager told us that there is a system for ensuring hot water outlets are checked monthly. Records were shown to us that demonstrated how the checks are carried out and the monthly recorded temperatures for each hot water outlet were shown to us. These demonstrated that all the hot water outlets are tested monthly and that the hot water is within the accepted temperature range. This helps to ensure the safety of the residents and reduce the risk of scalding or burning. Bathing equipment - such as bath seats and non-slip mats at this inspection were noted to be clean and in good working order. Standard 26 –The home was found at this inspection to be clean, hygienic, tidy and free from offensive odours. We toured the unit and inspected all areas of the home. 5 of the resident’s bedrooms were seen and were found to be clean and tidy and those residents spoken to by us said that their bedrooms are decorated and furnished as they wish. We saw the home’s infection control procedure, a copy of which is available in the staff room for information, this seems to be effective. The laundry area is well laid out and there is an impermeable floor laid down to prevent water ingress and easy cleaning. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s needs are being met by the numbers and the skills of the staff. They are being protected and kept safe by the use of appropriate recruitment policy and procedures. Records are being maintained as required. Staff are being provided with the necessary induction and training with which to competently perform their work duties. EVIDENCE: Standard 27 – We asked for a copy of the staffing rota for Wilhelmina House. The rota shows exactly who is working for the week. The Manager informed us that there are usually 3 care staff on duty for both the am and pm shifts. There is a manager on duty during the day and on call at nights. There are always 2 waking night staff on duty. The rota provided supported this statement. Given that that there are 20 residents living at Wilhelmina House at present the staff: resident ratio mix seems adequate to meet the needs of the residents. The Manager told us that a small number of agency staff are being used at present at Wilhelmina House. Standard 28 - At the time of this inspection and according to the staffing rota there are 14 care staff in total including senior carers, the Manager and Deputy Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 23 Manager. Of these 14 care staff 10 now hold an NVQ at level 2 or above. Both the Manager and the Deputy Manager hold NVQ level 4 qualifications. On the 6 staffing files inspected NVQ certificates confirming these qualifications were seen. This means that residents are in safe hands at all times. Standard 29 – Wilhelmina House does have a recruitment procedure that was inspected and seen to be appropriate for it’s purpose. As a part of this inspection we reviewed 6 of the staffing files. It could be seen that applicants are interviewed, application forms completed, two written references gained, enhanced Criminal Record Bureau checks undertaken and documentation regarding all these parts of the recruitment process are held on staffing files in the office at Wilhelmina House. On the files inspected we saw evidence that this process is being properly implemented. During the course of this inspection the Head Office of the Whitgift Foundation assured us that copies of contracts with staff would be sent over from the head office and will be held on the home’s staffing files and the Manager confirmed that she would ensure that copies of all staff contracts following this inspection would be placed on the home’s staffing files. Standard 30 – The home has a programme of induction in place. This covers staff roles and responsibilities, and key policies and procedures. Induction is ongoing for up to 4 – 6 weeks with observation, shadowing from an experienced staff member and ongoing assessment. The Manager told us that the staff induction training does include fire, manual handling, food hygiene and health and safety. With regards to staff competency it is important that all staff are familiar with the home’s policies and procedures. At previous inspections a requirement was made to ensure that all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions. They were then to sign to say that for each individual key policy and procedure that they have read and understood it and had the chance to discuss it with their supervisor. At this inspection the Manager told us that this work has been continuing with the care staff and signatures were seen by us confirming that the process of raising the awareness of staff of the home’s key policies and procedures continues. Therefore the previous requirement is now being met and at the next inspection we will review the whole process to see that it has been completed. The Manager explained that there is an extensive training programme provided for the staff group. Certificated evidence was seen on the 6 staffing files inspected that confirmed these staff had attended the following training courses: 1. Medication administration, Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 24 2. 1st Aid, 3. Infection control, 4. Health and safety, 5. Fire safety, 6. Manual handling, 7. Food hygiene, 8. POVA, 9. Staff supervision, 10. Understanding dementia, 11. Diabetes, 12. Activities management, 13. Continence Management. It is recommended that the Manager develops a training matrix that identifies all the training that staff have received in the last 3 years and therefore where training gaps exist. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Prospective residents may be assured that the home is well run and managed by a person who is fit and able to be in charge of the day-to-day operations of the unit. It is run in the best interests of service users who will benefit from the leadership and management approach taken in the unit. Resident’s financial interests are being safeguarded. Staff are supervised regularly however the process being used still needs some regularisation and improvement. The health and safety of staff and residents is being promoted and protected. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 26 EVIDENCE: Standard 31 – The Manager has operated in the management role at Wilhelmina House now for several years and holds the necessary experience to undertake this role. The Manager informed us that she holds the NVQ at level 4 in management and care. The Manager works hard to maintain the high standards already achieved in this home. At the last inspection it was recommended that some additional administrative support be provided so that the Manager be freed up to develop those areas that still needed raising in quality. Since the last inspection a new administrative post has been established and the Manager said that this additional support has greatly assisted with the management of the home. We spoke with the post holder who confirmed with us her role in the home’s administration. This all means that residents 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 carry out her responsibilities fully. Standard 32 – We inspected the records of the staff meetings at this inspection because at the last inspection it was recommended that the frequency of these meetings be increased. Records on file were seen for staff meetings held on 30.10.07; 22.1.08; 12.5.08; 21.7.08. Staff meetings are supposed to be held every 2 months in order to ensure that service users benefit from the ethos, leadership and management approach that may be instilled in them at team meetings. Whilst the frequency has been improved a little it continues to be recommended that the frequency of these meetings is increased to once every 2 months. Standard 33 – The home does have an appropriate quality assurance process although it has not been fully operationalised since the last inspection. The Manager explained that when the process is fully implemented, the monitoring of this agency or quality assurance [QA], is carried out through formal and informal consultation with service users and from visiting relatives and professionals. Feedback forms are issued and questions asked focus on the key principles of the service e.g. privacy, dignity, independence, choice, rights and fulfilment. The information and feedback gathered from these sources is then analysed and forms the basis of the annual development plan that includes implementation targets, with dates as milestones that can be measured and monitored. Residents are provided with information about all aspects of this process via residents meetings and newsletters. In the last inspection report we reminded the Manager that this needs to be an annual process and a recommendation was made supporting this. This recommendation now becomes a requirement given the lack of progress made since the last inspection. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 27 Minutes of resident’s meetings were inspected. 2 meetings were held with staff and the resident’s representatives in 2007 and in 2008. 2 meetings were also held directly with the residents in 2008 and 1 in 2007. Together this means that residents have a forum for discussing issues 2 or 3 times a year. It is recommended that the frequency needs to be increased to 5 or 6 times annually so that the access for residents for discussing issues is improved. The general feeling within the home was warm and congenial; both staff and management were open and communicative and little sense of anxiety was apparent with service users. Standard 35 – The Manager told the Inspector that Wilhelmina House does not look after residents monies directly and that if a resident does need something to be purchased the Manager might make the purchase but only after speaking with the resident’s relative or representative who then will repay Wilhelmina House Standard 36 – At a previous inspection a requirement was made to ensure that for supervision all care staff receive: • A single supervision-recording format that covers the areas outlined above in sufficient detail to ensure a useful record is maintained for both the staff and the management if the need arises in the future. • That all senior staff who provide supervision should receive staff supervision training and that this should be completed within the next 6 months. This should help to ensure consistency in the delivery of supervision. • That all staff should be given a copy of their supervision record following the supervision meeting. Evidence seen by us in the supervision notes held on staffing files indicates that the new supervision format is being used and that staff are routinely being provided with copies of their supervision notes. Staff interviewed by us told us that they do receive copies of their supervision notes routinely. It is also clear from certificated records that we saw on staffing files that those senior staff who provide supervision have received supervision training. 2 staff who we spoke to said this training had been useful in helping them carry out their supervisory roles more effectively. However inspection of the supervision records showed that the level of discussion held with staff needs to be expanded. It is recommended that areas of discussion should include: • Resident’s issues • The key working process • Monthly reports on progress made by key workers with care plans • Daily activities and outings for residents • Employment and training needs Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 28 • • Holidays and leave Work performance issues. Frequency of supervision remains an issue and records seen by us indicate that the frequency of staff supervision still needs to be improved. Records indicate that one member of staff received supervision twice in 2008 and 2 others three times in 2008. The standard requires staff supervision every 6 – 8 weeks or 6 times per annum. This is a requirement. When these issues have been fully addressed it will mean that all the key and important areas for the review and monitoring of the work being done to meet the needs of the residents and staff in the home will be properly met. Standard 38 - The policies and procedures manual that we saw includes appropriate policies on health and safety, risk assessment, moving and handling and fire. Certificates were checked and seen by us for the following services that are installed in the home, certificates which state that these systems have been checked by appropriate professionals since the last inspection and found to be satisfactory and fit for purpose. 1. Boiler / gas – 13.6.08 & 29.10.08. 2. Electrical system check – 5.06 (tested every 3 years). 3. Lift – 20.8.08 4. Fire alarms – 15.12.08 5. Fire equipment – 8.08 6. Emergency lighting system – 24.10.08 7. Fire fighting equipment – August 06 8. Water check for legionella organisms – 17.11.08 9. Portable electrical appliances – 10.10.08 Records were also seen and checked by the Inspector as satisfactory for: 1. Weekly fire alarm tests – last tested 15.12.08 2. Staff fire drill – last 19.5.08 a new drill is needed every 2 months 3. Fire extinguishers visually checked monthly A fire risk assessment covering all potential risk areas was carried out in January 2008. Personal emergency evacuation plans (PEEPs) have been drawn up for 18 residents who would be considered at risk were a fire to break out. The fire risk assessment and the PEEPs were required by the LFEPA at their visit in 2008 and both have since been approved by the LFEPA. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 29 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 X X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 13 14 15 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 4 3 3 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 1 X 3 2 X 3 Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 12 Requirement The Manager must ensure that a new “Controlled Medicines” book is drawn up and that staff make clear and accurate recordings to do with the administration of controlled drugs to residents. Staff who administer medicines need to be briefed on the method and practices of recording including that of the second signatory. CRB checks should be renewed every 3 years so that the Manager can remain assured that staff continue to have appropriate CRB records. That all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a period of time and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. The Quality Assurance process should be implemented this DS0000025870.V373229.R01.S.doc Timescale for action 01/02/09 2. OP18 19 01/02/09 3. OP30 18 01/12/09 4. OP33 24 01/11/09 Wilhelmina House Version 5.2 Page 31 5. OP36 18 year. Frequency of supervision remains an issue and records seen by us indicate that the frequency of staff supervision still needs to be improved. The standard requires staff supervision every 6 – 8 weeks or 6 times per annum. 01/02/09 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. 2. 3. 4. 5. Refer to Standard OP18 OP30 OP33 OP32 OP36 Good Practice Recommendations An inventory of the resident’s valuable belongings should be held for each resident and updated annually. This will help to ensure the protection of resident’s possessions. A training matrix should be developed that identifies all the training that staff have received in the last 3 years and therefore where training gaps exist. The frequency of residents meetings needs to be increased to 5 or 6 times annually so that the access for residents for discussing issues is improved. That the frequency of staff meetings be increased to once every 2 months. Areas of discussion in supervision with staff need to be expanded. Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wilhelmina House DS0000025870.V373229.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!