Inspection on 22/02/06 for The Willows

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Willows 24/06/09

The Willows 21/10/08

The Willows 24/10/07

The Willows 07/02/07

The Willows 17/10/05

The Willows 28/01/05

The Willows 11/08/04

The Willows 19/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Willows 1 Murray Street Salford Manchester M7 2DX Lead Inspector Richard Dankwa Unannounced Inspection 22 March 2006 11:00 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 The Willows DS0000006730.V281671.R01.S.doc Version 5.1 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. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Willows Address 1 Murray Street Salford Manchester M7 2DX 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) 0161 792 4809 0161 708 9481 Unity Homes Limited Mrs Mary Tennant Lunnie Smith Care Home 108 Category(ies) of Old age, not falling within any other category registration, with number (107), Physical disability (1) of places The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 43 service users requiring nursing care or personal care only may be accommodated within the original premises. Of these, one named individual is under 65 years of age. When this person leaves or reaches the age of 65, the category will revert to OP. Up to 14 service users requiring personal care only may be accommodated within the newly built extension. Up to 51 service users requiring personal care only due to dementia may be accommodated in Bluebell Court. The care staffing levels on the units providing accommodation for service users requiring personal care only shall not fall below the minimum levels as specified in the Residential Forum Guidance for Staffing in Care Homes for Older People. Minimum nursing staffing levels as specified in the Notice issued in accordance with Section 25(3) of the Registered Homes Act 1984 on 12 April 2001 shall be maintained within the original premises regardless of whether some service users are accommodated who do not require nursing care. The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 17th October 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: The Willows is a detached property providing accommodation for up to 57 older people of whom 14 may receive personal care only and 43 may receive nursing or personal care. In addition, up to 51 service users requiring personal care only due to dementia may be accommodated in Bluebell Court. Unity Homes Limited owns the property. The responsible individual is the proprietor, Mr Sandher, and the registered manager is Mrs Mary Smith. The home is situated in a residential area of Broughton on the major bus routes and within ten minutes drive of Manchester City Centre. Accommodation and facilities are on three floors, including the basement area. All service users receiving personal care are located in the new extension with all nursing clients in the older part of the building. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 22 March 2006. The registered provider and the manager were present during the inspection. The opportunity was taking to speak some of the staff, residents and a relative. The staff were observed as to how they supported and cared for the residents. The general condition of the home was inspected and some of the paperwork that is kept at the home was examined. The majority of the areas identified as needing improvement during the last inspection had been carried out. Other areas needing improvement were identified during this inspection. This report should be read together with the previous one as the Commission for Social Care Inspection only looked at some of the standards. Doing so will give one a better picture of the services being provided by the home. What the service does well: What has improved since the last inspection? What they could do better: The Service User Guide must be up dated to include the terms and conditions of the home. A complaints logbook must be put in place for the recording of all complaints received by the home. The home should ensure that there is a programme in place to train all staff to achieve NVQ Level 2. The home must find out from the people that use the service what they think of it. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 6 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 Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 7 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 The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 6. The home had all the necessary information required by prospective residents to help them make a decision whether to use the services of the home. However, some improvements are required in this area. EVIDENCE: The home issued all prospective residents with a Service User Guide and the Statement of purpose. Representatives of prospective residents are also issued with these documents. They also visit the home to meet other residents and staff to have a feel of the home and the service they provide. However, these documents did not contain the terms and conditions of the home and this must be addressed. The home does not provide intermediate care. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. The changing needs and the personal goals of the residents were documented in the care plans, which allowed the staff to meet the assessed needs of the residents. EVIDENCE: The care plans were detailed and were being up dated on a regular basis. They included individual risk assessments that allowed the residents to participate as much as possible in daily activities. The care plans were up dated on a monthly basis. The care plans are kept in individual residents’ rooms. The care plans were divided into sections and included maintaining safety, communication, nutrition, personal cleansing, mobility, socialising, spiritual/cultural and orientation. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. The lifestyles of the residents are met and the home continues to support them to pursue their social, cultural, religious and recreational interests. EVIDENCE: There is an activity organiser in place who organises bingos, drawing, dominoes, knitting, art and playing ball. The home has an art room and a sensory room. The residents are supported to use the local shop when required. The home also receives all the major newspapers on a daily basis including magazines. The planned activity was displayed. An entertainer visited the home on a monthly basis. All activities participated by the residents were documented in the activity file. All birthdays are celebrated. A Catholic and a Church of England minister visited on a monthly basis to perform a service. Their services were available through the month when they are needed. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The home had the necessary information available for dealing with complaints and the people who use the service are aware how to make a complaint. EVIDENCE: The home had policies and procedures in place for managing complaints. A complaint received by the home was dealt with satisfactory on the day of the inspection. The families and the relatives spoken to were aware how to make a complaint. Nevertheless, the home did not have a complaints book in place for the logging of all complaints received by the home. The home must ensure that one is put in place. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 24. The residents enjoyed safe and comfortable communal facilities and lived in comfortable bedrooms with their own possessions around them. EVIDENCE: The home was very spacious and allowed the residents to enjoy the communal facilities available. There was a smoke room, a television room, a dinning room and a big lounge with a music facility. The residents chose whether to go to the television room to watch television or to the big lounge to listen to some music. The communal areas were well planned, bright and well decorated. All residents’ bedrooms had an en-suite facility. They were well decorated and personalised with their own possessions around them. Each bedroom had a comfortable chair in it. All bedrooms had adequate furniture for the residents’ use. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28. The home does not have the minimum ratio of 50 trained members of care staff in NVQ Level 2. EVIDENCE: The home ensured that all staff received induction training at the start of their employment. 4 staff members had obtained NVQ Level 2 and 2 members of staff are undertaking it. The home should ensure that all staff achieve NVQ Level 2. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 37 The home did not find out from the people who use the service what they think of it. The home’s record keeping and the policies and procedures safeguarded the rights and best interest of the residents. EVIDENCE: Although the manager and the provider of the home speak to the residents and their representatives on a regular basis there was no evidence that they seek the views of the people who use the service. The home must seek the views of those who use the service and find out what they think of it. The home had policies and procedures in place to safeguard the rights and best interest of the residents. These and other records are kept in the office that is locked when not in use. The office can be accessed using a digital lock. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 15 The residents’ care plans are kept in their individual rooms and are able to access their records at any time. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X 3 X X X 3 X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X X The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 17 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 OP1 Regulation 6 Requirement The registered person must review the Service User Guide to include the Terms and Conditions. The registered manager must put a complaints logbook in place for the recording off all complaints. The registered person must ensure that residents and their representatives are consulted on a regular basis to establish whether the home is providing a good service (previous timescale of 31/03/06 not met). Timescale for action 15/04/06 2 OP16 22 15/04/06 3 OP33 24 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations The home should ensure that there is a programme in place to train all staff to achieve NVQ Level 2. The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows DS0000006730.V281671.R01.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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