Inspection on 24/10/07 for The Willows

This inspection was carried out on 24th October 2007.

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

The inspector 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 07/02/07

The Willows 22/02/06

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Willows 1 Murray Street Salford Manchester M7 2DX Lead Inspector Adele Berriman Unannounced Inspection 24th October 2007 10:00 X10029.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.V353508.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 and Care Homes for Adults 18 – 65*. 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.V353508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 1 Murray Street Salford Manchester M7 2DX 0161 792 4809 0161 708 9481 msandher@aol.com 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) Unity Homes Limited Mrs Mary Tennant Lunnie Smith Care Home 124 Category(ies) of Dementia (15), Dementia - over 65 years of age registration, with number (67), Old age, not falling within any other of places category (57), Physical disability (5) The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 43 service users requiring nursing care or personal care only by reason of old age may be accommodated within the original premises. At any one time, up to 5 of these service users may be below 65 years of age but over 50 years of age. Up to 14 service users requiring personal care only by reason of old age may be accommodated within the newly built extension. Up to 67 older service users requiring personal care only due to dementia may be accommodated in Bluebell Court. At any one time up to 15 of these service users may be below 65 years of age, but over 25 years of age. 7th February 2007 2. 3. 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 and internally the buildings are accessible to all. Accommodation and facilities are on three floors, including the basement area. Tow car parks provide adequate parking for residents and visitors. The cost of the service is between £364.41 and £503.41 per week. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two visits were undertaken as part of a key inspection, which also includes analysis of any information received by the Commission for Social Care Inspection in relation to this visit taking place. Both visits were unannounced and took place on Thursday 11th October and Wednesday 24th October 2007. The visit on Thursday 11th October started at 9.00am and finished at 8.30pm. During the visits time was spent talking to several residents, staff on duty and the registered manager of the service. Time was also taken to assess records and the policies and procedures of the home. General observations were also made of the general day to day activities of the home. One spent time in The Willows area of the home and one inspector spent time in the Bluebell Court area of the home. Prior and during the visits survey forms were distributed to residents, their relatives and staff. A member of staff assisted in distributing the survey forms. Eight completed survey forms were received from residents, a further six survey forms were completed by relatives of residents and twelve completed staff surveys were completed and returned. Some time before the visits took place the management of the service were sent an Annual Quality Assurance Assessment to complete. This document requested information about what the service does well, what the service could do better, how the service had improved in the last twelve months and plans for improvement over the next twelve months. The document was returned to the Commission containing detailed information, however, the document was returned late and arrived only after both visits to the home had taken place. The majority of residents who completed a survey form stated that their healthcare needs were always met by the home. All residents who responded to the survey stated that they knew how to make a complaint about the service. Three relatives who completed survey forms stated that they knew how to make a complaint about the service. All relatives who completed a survey stated that they knew how to make a complaint about the service if needed. All but one member of staff who responded to the survey stated that they knew what to do if a resident/relative or friend had concerns about the home. The majority of residents stated that they always received the care and support they needed and that staff were available when they needed them. One resident wrote “staff are very attentive, if you have any problems. Will help you in anyway they can.” Anther resident commented ‘I am happy with my life at the Willows and I am given daily choices for the meals I eat to what The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 6 I wear. I can also voice my opinions on anything I feel can improve my life at the resident’s committee meeting.’ Four relatives commented that they felt that the home always met the needs of their relative and two people stated that they usually did. The majority of relatives who commented about the service stated that they felt that staff usually had the right skills and experience to look after people properly and one relative stated they always did and one relative stated that they sometimes did. At the time of the visits the home was clean and tidy. The majority of residents who responded to the survey forms stated that the home was always fresh and clean. One resident wrote “the home is kept on very high standards as far as cleanliness is concerned.” At the time of this inspection, several concerns were being investigated under Salford Social Services Safeguarding Adults procedure. What the service does well: What has improved since the last inspection? Improvements had been made to the management of medication and the practice of clinical decisions being made by staff not qualified to do so has ceased. Improvements had been made to how staff were recording accidents that had occurred in the home. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 7 It is now the general practice of the home to inform the Commission of all situations that occur in the home that has or has potentially put the welfare of a resident at risk from harm. Some improvements have been made to the content and detail of the care plans in use. However, further development of these documents is required. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed prior to moving into the home. However, failure to record detailed information gained about the person may result in their needs not being fully met. EVIDENCE: The home had statement of purpose available. A separate statement of purpose was available for the Bluebell Court area of the home that provides care and support to people with dementia. The document contained detailed information about the rights and choices of residents living at the home. However, some of the information contained in the document was in need of The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 10 review as it was inaccurate. For example, information relating to the admission criteria for Bluebell Court refers to a “nursing needs assessment” and “the nursing home.” It is essential that the statement of purpose for the service clearly states that Bluebell Court offers personal care only to ensure that people are fully aware of what support is available. The document also fails to demonstrate what actual arrangements are in place to promote the privacy and dignity of individual or specific arrangement for residents to engage in social activities, hobbies, therapeutic and leisure interests. There was no evidence on younger residents files that they had been supplied with a written contract or a statement of terms and conditions. The registered manager of the service confirmed that these documents were not available. Prior to a person moving into the home a pre admission assessment is carried out. The purpose of this assessment is to ensure that the service is able to meet the person’s needs and wishes. A senior member of staff from the home carries out these assessments and a set pro forma is available for peoples needs and wishes to be recorded, however, the pro forma gave little opportunity to record people’s likes and dislikes or individual recreational, therapeutic or educational needs. Completed pre admission assessments were present on all of the resident’s files that were assessed. However, some of the assessments had not been fully completed and did not contain sufficient information about the individuals’ needs and wishes. It is essential that prior to a person moving into the home their needs are fully assessed to ensure that the home has the facilities and services to meet the persons needs. The Willows does not offer intermediate care facilities. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP7,8,9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Failure to identify and record detailed information about a persons needs and wishes may result in their needs not being met. Residents healthcare needs are met by healthcare professionals. EVIDENCE: The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 12 At the time of the visits the service was in the process of implementing a revised format of a care plan to document peoples assessed personal and social care needs. A selection of the newly revised care plans were assessed along with the contents of the previous format. Each resident had their own individual care plan that was recorded on a set format and gave the opportunity to record a persons needs relating to personal care. However, neither of the formats in use gave the opportunity to record the personal assessed needs and wishes relating to finances, recreational, social and therapeutic needs. Also, there was no opportunity to record individuals’ personal goals. The detail and quality of information contained in care plans varied throughout the home. Some care plans contained detailed information about the needs and wishes of the person and how their needs were to be met. However, many of the care plans that were assessed during the visit contained limited information about the person needs and few gave detailed information about how staff needed to deliver the specific care and support needed to ensure that resident’s needs were fully met. For example, one care plan stated ‘he is able to perform some hygiene tasks by himself, staff to help maintain a high standard of hygiene’ but there was no guidance or record of how/what and when staff needed to support the resident with their personal hygiene. Another care plan for a resident receiving personal care only stated ‘please monitor chest status daily’, however, there was no further information on what and how this monitoring was to be done. A further example was that one resident’s care plan stated that they always worry about their account card, however, no information was recorded to how the resident was to be supported with their finances. Several care plans for residents requiring nursing care were assessed. Some of these documents contained detailed information about the care that was needed to support the individual. However, the care plans had no ‘triggers’ to show that when a need is identified that a risk assessment should be put in place, for example, for a resident with diabetes the care plan should contain information about what action to take in the event of a hypo/hyper glycaemic episode. There was evidence on some peoples care plans that they had the use of pressure relieving mattresses. Care plans must specify what mattress is required to meet the individuals’ assessed need. There was evidence that care plans were being reviewed on a regular basis. However, not all care plans assessed contained the changing needs of individuals. For example, one residents’ care plan clearly stated that he had recently been diagnosed with a specific mental health issue but his care plan did not reflect or consider what actions needed to be taken to support the resident. Another care plan did not reflect that a resident’s mobility had improved and that they no longer required the use of a hoist. It is essential The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 13 that residents changing needs and wishes are recorded on their care plans to ensure that they receive the care and support they require at all times. There was evidence that local health care professional visited the service on a regular basis. Each resident was registered with a local general practitioner. A record of visits from healthcare professionals was maintained. The majority of residents who completed a survey form stated that their healthcare needs were always met by the home. Risk assessments formed part of individuals’ care plans. The main focus of these risk assessments was on falls, smoking and pressure care, however, not all assessments had been completed in full by the assessor. It is essential that detailed risk assessments are devised and reviewed on a regular basis of all identified risks involved in a persons day to day life and when promoting a resident to maintain an independent lifestyle. Daily records were maintained for all residents. Several of theses records were assessed and some contained detailed information about what the resident had experienced and their wellbeing for that day. However, some records contained little information, for example, one record stated ‘X had a settled day, enjoyed all meals today. Smoked in designated area, spent time in TV lounge’, daily records must reflect what care, support, recreational or therapeutic activities the person had experienced. One residents tissue viability risk assessment stated that they were very high risk; the record for one day stated “fairly settled day”, it is important that records reflect on the care given. The medication policy for Bluebell Court was assessed. The policy contained some detailed information to guide and advise staff on how administer medication. However, the policy stated that “treatment sheets should be reviewed monthly by the GP”, there was no evidence that this was taking place. The policy failed to include guidance for residents who are able to fully or partially self administer their own medication to maintain independence. Medication Administration Records (MAR) sheets were in use throughout the home to record medication administration. The majority of the records were completed appropriately, however, staff were failing to record the date that the medication was received on the Bluebell unit and at the Willows staff were just ticking the box where the date should be recorded. All medication was stored in secure environments throughout the building. Staff stated that they had been trained by the local pharmacist and the registered manager in the administration of medication. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service fails to support people with their personal development, social interactions and recreational activities and this may result in their needs not being fully met. EVIDENCE: An activities co-ordinator was employed for thirty hours a week and was based at Bluebell Court, there was no formal provision for activities at the Willows. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 15 The manager stated that occasionally outside entertainers visited the home. A quiet room with alternative lighting and music was available on the first floor and several objects including a shopping trolley and telephones from previous decades were apparent around the building. An activities room, equipped with craft and art materials was also available on the first floor of Bluebell Court. During the visit on the 23.10.07 one resident was seen alone in the craft room working with beads and also demonstrated a picture that they had painted earlier. The resident confirmed that she could access the room at all times. Three residents who responded to the survey stated that there were always activities arranged by the home that you can take part in and three people stated that there usually were. However, records and general observations during the visits did not demonstrate that residents needs and wishes relating to maintaining social inclusion, community contact, personal development, educational and leisure activities had been assessed or were being promoted. A resident who was being cared for in bed said that they did not see anyone from teatime till suppertime and a relative wrote that the service should “maybe take more interest for the people who are in bed more, it must be lonely in their rooms without visitors.” One relative of a resident wrote “I think that there should be more activities and therapies to stimulate residents of the home” and another relative wrote that since the transfer of the activities co-ordinator to the Bluebell unit “there are no longer any activities in the Willows. Clients that are able to participate are now bored with nothing to stimulate them. Need to have an organised and regular activities schedule for the Willows just like Bluebell.” During one visit two residents commented to the inspector that they were bored. It is essential that the needs and wishes of all residents are assessed in full and that residents have an opportunity to access recreational, social interaction, education and stimulating activities. Relatives and friends were seen entering the home throughout the day. One relative commented about the “pleasant and welcoming manner staff show to relatives.” Four relatives commented in their survey forms that they are always kept up to date with important issues affecting their relative And two people stated that they usually were. The majority of residents stated in their questionnaires that staff listen and act on what they say. However, one resident wrote “sometimes I get the answer before I ask the question.” During one visit a resident were seen asking for private information about their finances. This conversation took place with the resident stood on one side of the glass reception window talking to a member of staff in the office. The resident was talking about their personal affairs and the conversation could be heard by people walking past along with visitors entering and leaving the The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 16 home. It is essential that residents are supported to and have the opportunity to discuss their personal affairs in private and information about what support an individual needs must be recorded on their care plan. Meals were served in several dining rooms around the building. Residents were observed enjoying their meals. Discussion took place with the cook for the Bluebell unit. The cook demonstrated several weeks’ menus containing varying meals. The menus contained only the choices for the lunchtime and teatime meals. It was strongly advised that the menus contain what foods were on offer at breakfast and suppertime. The cook stated that she had recently attended a course on nutrition for older people with dementia and that following this course she intended to review the menus to include more buffet style finger foods to offer an alternative for residents. During one of the visits the lunchtime meal was bacon ribs, cabbage, mashed potatoes and gravy with cheesecake for dessert. This meal was known by the cook to be popular with all residents, however she said if someone did not like it they could have an alternative without a problem. Residents were seen to enjoy the food that was served. Tea served on the day was home made vegetable soup and bread and butter, which was served at 4.10pm. One resident who did not want soup was given a sandwich. Staff stated that residents were also given a sandwich at 8.00pm or 9.00pm. It is strongly advised in this report that residents are consulted about their choices of foods served around the home and the times that they are served. All of the resident who completed a survey form stated that they always enjoyed the meals at the home. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are aware of the homes complaints procedure. The service would benefit from all staff having awareness training in safeguarding adults. EVIDENCE: A complaints policy was readily available around the home. A ‘log’ was maintained of all complaints received that recorded the date, name of complainant, nature of the complaint, who the complaint was received by and action taken. However, information under the action taken section was not very informative and outcomes of complaint investigations were not fully recorded. All residents who responded to the survey stated that they knew how to make a complaint about the service. Three relatives who completed survey forms stated that they knew how to make a complaint about the service. All relatives who completed a survey stated that they knew how to make a complaint about the service if needed. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 18 All but one member of staff who responded to the survey stated that they knew what to do if a resident/relative or friend had concerns about the home. A policy for protecting vulnerable adults was available at the home. The policy contained detailed information, however, it is strongly recommended in this report that the full contact details of Salford Social Services Safeguarding Unit are added to the policy and that staff are aware that they are able to contact Salford Social Services at any time with a concern/allegation. There was evidence on some staff files that they had received ‘in house’ awareness training on safeguarding adult’s procedures. However, when asked about the procedures two staff demonstrated little awareness of Salford SSD’s safeguarding adults procedures. Training relating to Safeguarding Adult procedures is planned to be delivered by a healthcare professional from Salford PCT. It is essential that all staff attend this training opportunity to ensure that everybody working at the home is aware of the appropriate actions to take in the event of them having a concern. At the time of this inspection several concerns about the service were being investigated under Salford Social Services Safeguarding procedures. A policy was in place for the ‘management or service users’ money, valuables and financial affairs’ which gives information about the safe storage, management and recording of monies/valuables. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean and spacious environment for residents to live. EVIDENCE: All internal areas of the home providing bedrooms and communal areas for residents were accessible to all with the support of passenger lifts around the building. Several bedrooms were visited that contained furniture to meet the The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 20 needs of the resident. Several bedrooms had been personalised with residents’ personal effects. One resident demonstrated their extensive music collection in their room. CCTV cameras were in use around the entrances of Bluebell Court for security purposes only. One area of Bluebell Court that was accessed by a ‘key coded’ door was home to several residents. The area contained lounge areas and small dining areas on two floors. Several large lounges/dining rooms were available around the buildings. Several lounges were pleasantly furnished, however, the conservatory area of the home was described by one person as ‘a bit sparse.’ Bathrooms and toilets around the home were spacious, however, several of the bathrooms were not ‘homely’ as they contained laundry trolleys, several bathrooms had signs up regarding ‘net knickers’, one bathroom had no mirror and one bathroom had a stool chart on the wall. An inspector discussed with staff how these rooms could be made more homely. Paper towel and soap dispensers were seen in some bathrooms as being too high for people unable to stand up to access. It is strongly recommended in this report that the environment of the home is made as homely as possible and that soap and paper towels are accessible to all. At the time of the inspection the home was clean and tidy. The majority of residents who responded to the survey forms stated that the home was always fresh and clean. One resident wrote “the home is kept on very high standards as far as cleanliness is concerned.” The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29 & 30. YA 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff must be fully trained to meet the needs of the residents. EVIDENCE: A team of care, senior care, nurses, ancillary, administration staff and the manager of the service were on duty at the time of the visits to meet the needs of the residents. Agency staff were also working at the home to cover for current staff vacancies. Rotas were available demonstrate the names of staff that were on duty, however, the rotas did not give the names of the agency staff on duty nor did they demonstrate the working hours of the registered manager. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 22 A selection of files for the most recently recruited staff members were assessed. These files demonstrated that appropriate checks and references had been carried out by the home prior to the staff member commencing employment. No formal recruitment policy or procedure was available for the recruitment of staff to the home. An ‘in house’ induction programme is in operation for all newly recruited staff. Information supplied by the registered manager stated that it is planned to improve the induction plan within the next twelve months. It is strongly recommended that when developing the induction programme that the Key National Induction Standards are considered. The majority of staff stated on their survey forms that their induction programme covered very well or mostly all of what they needed to know about the job before they started, however, one staff member stated that it only partly covered the role and another staff member stated not at all. Some, but not all staff had received training in meeting the needs of people with dementia. At the time of the inspection the registered manager stated that the service was searching for a relevant training course in dementia for all staff to attend. Staff confirmed that regular ‘in-house’ two hourly training sessions took place. Records demonstrated that these sessions covered subjects including room management, daily evaluations and managing challenging behaviour. One nursing member of staff stated that they had attended external training courses on incontinence, peg feeding, Parkinson’s Disease and flu vaccine training. The majority of completed staff survey forms stated that they are being given training that is relevant to their role. However, two staff members stated that they were not receiving training that helps then understand the needs of the residents or that keep them up to date with the new ways of working. Seven staff stated that that they had the right support, experience and knowledge to meet the different needs of people who use the service and five staff stated that they usually did. Staff were observed in Bluebell Court assisting residents. Several staff were observed supporting residents in positive, supportive manner using touch and verbal communication. It was evident from the verbal and non verbal responses from residents that they felt safe and were comfortable with the interactions from these staff members. However, several interactions between some staff and residents also demonstrated a lack of awareness from the staff about the specific needs of the residents. It is essential that all staff who The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 23 support residents in their day to day life receive appropriate training in all aspects of their role to ensure that they are able to meet the needs and wishes of the residents and be able to manage situations effectively in the event of a resident challenging the service. During one visit, two staff were observed carrying out an inappropriate moving and handling technique. This observation was raised immediately with a senior member of staff. Records demonstrated that 90 of catering staff and 50 of care staff had received training in safe food handling. The home is a member of Salford Training Partnership and is also a facility for the overseas nurse programme for Manchester University. Half of the care staff team have achieved their NVQ level 2 award and the other half are working towards their qualification. Several staff commented on what they felt that the service does well, these comments included “promote good care to all service users”, “meet the needs of residents”, “giving the resident good and nourishing diet” and “meets the changing need of resident with a friendly and clean environment.” Several staff commented on what the service could do better, these comments included “arrange more activities and outings for residents” and “to listen to staff concerns.” The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35, & 38. YA 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures did not support the needs of the people using the service. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager of the home is a registered nurse with sixteen years experience in managing the home, has obtained the registered managers award, is an NVQ assessor and is a co-mentor for Manchester University’s overseas nursing programme. The registered manager meets daily with senior staff from all areas of the home to discuss residents care needs. Records to demonstrate that the registered manager undertakes periodic training and development to update their knowledge were not stored at the service. It is strongly recommended that a record/evidence of all training and development undertaken by the registered is maintained at the service. People living in the Willows section of the home have a residents committee that they are able to access. Information supplied by the registered manager also stated that it was intended that a residents committee would be developed for people to access who live in Bluebell Court and that the home is looking to develop a quality assurance system in the near future. It is essential that feedback from residents and their families and friends have the opportunity to feedback about the service delivered in the home to ensure that the service is developed and delivered in a manner that meets their needs. Accidents were recorded in appropriate accident registers. Records at the Willows demonstrated that copies of all accident reports were placed in residents care plans. Other accidents records were stored in a central file. An improvement had been made to the content of these records since the previous inspection. Records demonstrated that weekly maintenance checks were carried out around the building along with weekly tests of the fire detection system. However, the most recently recorded weekly check of ‘means of escape’ took place in 21.09.07; the manager was informed of this during the visit. It is strongly recommended in this report that the person who carries out fire detection and maintenance checks signs the record. There was evidence that risk assessments relating to health and safety had been carried out. However, several of these risk assessments had not been reviewed for sometime. For example, the risk assessment relating to the Control Of Substances Hazardous to Health (COSHH) last recorded review date was 10.06.03 and the homes fire hazard analysis was last reviewed in August 2006. It is essential that all risk assessments are reviewed on a regular basis to ensure that any changing information/legislation is concerned when assessing the risk. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 26 Policies and procedures to support staff in their role were available in the staff office at Bluebell Court. These included health and safety at work, manual handling, referral and admission, infection control, sharps, security, smoking and accident recording. A policy for the management and promotion of continence was available, however, the policy stated “the trained nursing staff should enable residents to maintain continence” and “on admission an individual continence chart and profile should be commenced. From this information the nurse in charge shall implement the management for promotion or dealing with the residents continence.” This policy did not meet the needs of the residents living at Bluebell Court as there are no nursing staff working in that area of the home. A policy on Physical Restraint was available. The policy describes the use of minimum restraint, however, this policy needs reviewing to include information about mechanical restraint. Also, there was no evidence on training records that staff had received any training in restraint. During the visit on the 23.10.07 the registered manager confirmed that staff had not received any training on restraint. It is essential that all policies and procedures relating to the health, safety and wellbeing of all reflect the needs of the residents and the service delivered and that the documents are reviewed and updated on a regular basis. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 27 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 2 2 3 2 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 2 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 2 The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 28 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement A full audit of the services Statement of Purpose is required to ensure that it contains up to date information about what services are available at the home. All residents must be issued with a contract or statement of terms and conditions when they move into the home to ensure that they are aware of any conditions that form part of their placement. Timescale for action 30/11/07 2. YA2 15 30/11/07 OP3 3. 14 4. OP7 15 Residents must benefit from 30/11/07 having all their needs and wishes assessed for all aspects of their life prior to moving into the home to ensure that that the home has the resources to meet these needs. 30/11/07 Residents care plans and assessments must contain detailed up to date information to ensure that staff are aware of what care and support the person needs at all times Requirement not met from 10/08/07 DS0000006730.V353508.R01.S.doc Version 5.2 Page 29 The Willows Detailed records must be maintained of all care and support received by residents Individual assessments relating to specific risks to individual residents must be completed in full and reviewed and updated on a regular basis. 5. OP9 13 The medication policy needs to be reviewed and updated to ensure that it contains information that is relevant to the residents needs. He document also needs to include information on how to support a resident who is able to partially/self administer their own medication. Residents must benefit from a service that provides opportunities for resident personal development and education. Residents must benefit for being cared for by staff who have the appropriate training and knowledge to meet their specific needs. The health, safety and wellbeing of all must be protected by up to date policies, procedures and risk assessments that minimise the risk of harm to people living, working and visiting the home. 30/11/07 YA11 6. 12 (1) (b) 30/11/07 7. OP30 18 (1) (c) (i) 30/11/07 8. OP38 12 & 13 30/11/07 The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations A formal procedure for notifying resident families or other next of kin of any accidents or illness relating to the resident should be developed. The agreed procedure should be documented in the residents care plan and delivered to all staff in an awareness session. It is strongly recommended that a residents are given the opportunity to take part in activities that satisfies their social and recreational interests and needs. It is strongly recommended that the menu available and that times in which food is served to residents are reviewed on a regular basis. It is strongly recommended that the investigations and outcomes of complaints are recorded in full. It is strongly recommended that the services adult protection procedure contains the full contact details of Salford Social Services Safeguarding Adults Unit and that staff are aware that they can contact the unit directly at any time. It is strongly recommended that actions are taken to promote a more ‘homely’ environment for residents to live in when any decoration around the building takes place. It is strongly recommended that the staff rota contains the full names of all staff on duty and the working hours of the registered manager. It is strongly recommended that a formal recruitment policy is devised and implemented to ensure a consistent approach to recruitment. It is strongly recommended that the services induction programme be revised to ensure that considers the national key induction standards. It is strongly advised that evidence of the registered managers continual development for the role is available at the home DS0000006730.V353508.R01.S.doc Version 5.2 Page 31 2. OP12 3. OP15 4. 5. OP16 OP18 6. OP19 7. OP27 8. OP29 OP30 9. 10. OP31 The Willows OP33 11. OP38 12. It is strongly recommended that a robust Quality Assurance programme is developed and implemented to ensure that residents and their families and friends have the opportunity to comment on the service provided and that any information gained through the process is acted upon. All bathrooms and toilets must contain soap and towels that are accessible to all. The Willows DS0000006730.V353508.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Central Registration 9th Floor Oakland House Talbot Road, Old Trafford Manchester M16 0PQ 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. The Willows DS0000006730.V353508.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. 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