Inspection on 04/08/08 for Green Willow Residential Home

This inspection was carried out on 4th August 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Green Willow Residential Home 16/06/06

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Green Willow Residential Home 21-23 Vicarage Lane East Preston Littlehampton West Sussex BN16 2SP Lead Inspector Diane Peel Unannounced Inspection 09:50 4 August 2008 th 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 Green Willow Residential Home DS0000066141.V369157.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. Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Willow Residential Home Address 21-23 Vicarage Lane East Preston Littlehampton West Sussex BN16 2SP 01903 775009 01903 773320 gwrh@ukhome.net 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) Green Willow Care Limited Mrs Julie Alison Howard Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Green Willow Residential Home DS0000066141.V369157.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: Old age, not following within any other category - (OP). The maximum number of service users to be accommodated is 26. 2. Date of last inspection 16th June 2006 Brief Description of the Service: Green Willow is a care home registered to provide personal care and accommodation for up to twenty-six older people. It is situated in East Preston, West Sussex and is within a couple of miles of Rustington and 5 miles from Littlehampton and therefore close to all amenities including the sea. The premises have been undergoing a major building project, which has increased the number of bedrooms and improved the layout of communal and other private space. It is a two-storey accommodation with a lift to the second floor, which has four bedrooms. All bedrooms have en-suite facilities with some having bath en-suite. There are large gardens to the rear of the property and parking at the front of the home. The registered manager is Julie Howard and the registered providers is Green Willow Care Limited The fees currently being charged are from £600 per week. Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. On this unannounced visit to Green Willow our inspector, Mrs Diane Peel was accompanied by an ‘expert by experience’: An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. We use information from experts by experience to help us triangulate evidence and verify any issues. During this visit the intended outcomes for 29 standards were assessed; these included the key standards for care homes providing a service to older people. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home and this was used to address areas of improvements with the manager. Prior to the visit “Have Your Say” surveys were returned to us by nine of people living at the home, one relative completing a survey on behalf of a person living at the home, thirteen staff working at the home and one health/social care professionals who visits Green Willow. Everybody returning surveys had positive things to say about Green Willow praising the level of care and homely environment and commitment of the staff. During the course of the visit we met most of the people living at Green Willow, spoke with people over lunchtime when we joined people for the main meal of the day and then spoke with people in the privacy of their bedrooms. A case tracking exercise for three people living at the home was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. Staff were spoken with during the visit and observed during their interaction with people living at the home. Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 7 During our visit we discussed how improvements could be made to the softened diets provided at mealtimes for an individual person. Improvements to the environment continue in the building programme. 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. Green Willow Residential Home DS0000066141.V369157.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 Green Willow Residential Home DS0000066141.V369157.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): 3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed prior to them moving into the home and people have the opportunity to visit the home to look at the facilities and meet other people living at the home and staff so that they can decide if it the place for them. EVIDENCE: The AQAA returned to us in June 2008 told said “The home has a comprehensive pre- admission process starting from the initial telephone enquiry, inviting an unannounced drop in to the home at any time or day to suit the prospective service users. To complete a full and comprehensvie preGreen Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 10 admission profile, information is obtained from the prospective service users, hospital staff, social care managers, relatives and GPs and in all cases except those where location prohibits it, the prospective service user is met and assessed by the senior care team.” During our visit to Green Willow we spoke to people about the process of how they had come to live at Green Willow. One person told us that they had come to look at the home when they had been looking for a care home for their husband who had been already living in another Nursing Home. They had chosen the home and both lived at Green Willow. Another person told us that they were just staying at Green Willow for a short time until they decided if they could move back to their home but they thought that they might stay. They had lived nearby and knew of the home. Eight people out of the nine people living at the home who returned Have Your Say surveys to us told us that they had received enough information about the home before they moved in to help them decide if it was the right place for them. The other person told us that due to shortage of time they hadn’t had enough information but “information about the home was very soon given.” We looked at four peoples care records during our visit to Green Willow and observed that pre assessments were in place. Intermediate care is not offered at Green Willow. Green Willow Residential Home DS0000066141.V369157.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have person centred care plans, are respected as individuals and have their healthcare needs met by other healthcare professionals so that they know that the care that they receive is based on their individual needs. EVIDENCE: Information in the AQAA returned in June 2008 told us that all people living at the home had a care plan. It said, “These plans are reviewed monthly or more often if required, in response to staff everyday assessment of changes in SU wellbeing (at which time other professionals may also be informed and asked Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 12 for input e.g GP, DN). All staff have access to these plans to consult, keep up dated and contribute. Changes that have been made may also be noted in the day to day diary to ensure that all staff note all care plan changes.These individual care plans are discussed with each service user or their family if service user is unable to, giving them the oportunity to discuss any changes/amendments/decisions they feel are required.” During our visit to the home we looked at the care plans and other care records for four people living at Green Willow. They all included an admission information sheet which detailed information about each individual, recorded the people important to them, their hobbies and interests and what they had done prior to moving into the home for example what their employment had been. The care plans included procedures for care, which had been signed by the person receiving the care or a representative. The plans were individual and recorded people’s likes and dislikes and decisions about their lives and what they would like to happen when they died. The care records showed that the plans had been reviewed regularly and that the checking of blood pressure and weight monitors people’s health. Records of other health care professionals interventions were observed in the care records with additional notes being made in the daily reports completed by staff for each individual. Risk assessments were observed to be in place, which covered general risks, slips, trips and falls, handling assessments. All fourteen staff returning Have Your Say surveys to us told us that they are given up to date information about the needs of the people that they support or care for. Comments received were: “Care plans are constantly updated on a monthly basis and as and when any changes occur. These changes are reported at handover and recorded in daily report.” “The care plans are always kept up to date.” “Handover report at change of every shift. Regular updates on procedures of care every month and monthly updates on risk assessments. Any changes are always reported and implemented immediately, made known also with message book.” When asked the question “Do you receive the care and support you need?” in the Have Your Say surveys for people living at the home six people said “always” and three people said “usually”. Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 13 When asked the question “do staff listen and act on what you say?” all nine people returning surveys to us said “yes” and when asked “ Do you receive the medical support you need” most people responded “yes” and other commented that they got medical support from health professionals. A doctor returning a Have Your Say survey told us that people’s heath care needs are “always” met by the care service and that the service “always” supports people with their medication. During our visit we looked at the procedures for administering medication and observed medication being administered to people during lunchtime. We saw that a lockable metal trolley was being used to store medication and this was taken into the dining room at lunchtime People received their medication from a monitored dosage system prepared by the supplying pharmacist. When we looked at medication record sheets we saw that they had been completed up to the day of our visit and saw samples of signatures for staff that had administered medication. The registered manager told us that no one currently had controlled medication but they told us that they are aware that the home must have a controlled medication storage cabinet, which meets the Royal Pharmaceutical Society guidelines. A healthcare professional returning Have Your Say survey to us told us that the service respects individual’s privacy and dignity. A relative returning a Have Your Say survey on behalf of a person living at green willow also confirmed that the service respects individual’s privacy and dignity. The “expert by experience” said in their report: “The staff are very respectful of the privacy of the residents and as unobtrusive as possible.” All people living at the home have lockable rooms although we have been told that non-one has chosen to lock their rooms yet. Information provided in the AQAA returned by the registered manager told us that all bedrooms have phone points allowing people to have their own private phone line connected. People requiring to make or receive calls have access to the homes cordless phone system via the staff. Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The interests of people living at the home are recorded and they are provided with opportunities to take part in recreational activities and maintain contact with their family and friends so that they can continue to have a fulfilling lifestyle. EVIDENCE: The AQAA returned from the registered manager said “Service users are actively encouraged to participate in making choices, such as when they want to get up or retire, which clothes they want to wear, having music on or the TV and which programmes they want to watch. Service users are encouraged to personalise their rooms with pictures, ornaments and many have their own pieces of their own furniture. We practise person centred care treating service Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 15 users as unique individuals therefore the home will try to make the routines of daily living as flexible as possible.” When we arrived at Green Willow five people were gathering in the new garden room for an exercise activity, which we saw, advertised as taking place twice a week. After lunch people met in the garden room to share favourite songs, poems and hymns whilst a manicurist visited some individuals in their rooms. We saw monthly newsletters, which are distributed to people who live at Green Willow. They included, a list of activities for each month. Advertised for August were: aromatherapy, exercise classes, cookery sessions, residents circle meeting, garden quiz, flower arranging, patchwork quilting. The service also has a shop for people to make purchases from on a Friday morning. People who we spoke with told us that they could buy “allsorts of things from the shop” and gave examples of toiletries, chocolate and birthday cards. July activities had included a management clinic, a visiting clergy, a bubbly evening, bingo, high tea, mini sports, garden project, days gone by – reminiscence and a walk out to the village in addition to the shop, visits by the hairdresser and the exercises classes. We also saw activities advertised on a notice board in the dining area in large font and photographs of activities in a folder. Photographs of Pet Therapy visits showed people living at the home holding some unusual pets such as a snake and a bearded dragon lizard. Peoples individual care records which we saw recorded what activities they have taken part in contact with relatives and visitors. Examples of quarterly news letters distributed by the registered providers informed people using the service; their relatives and any other interested parties about events and activities which had taken place or were to take place, such as summer fetes, the progress of the garden, and the new facilities being built. The “expert by experience” reported “ There are a wide range of activities, many run by a former member of staff who comes in three afternoons a week to take craft sessions, pampering, reading stories, cookery, flower arranging and quizzes. Other activities include exercises classes, patchwork quilt making and a visit by the parish priest. People who wish can go out as a group to the theatre, walk along the seafront or visit a historic home or gardens.” Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 16 When staff were asked in Have Your Say surveys “What does the service do well? Comments received included: “Lots of choices in activities, meals are excellent.” “Residents enjoy good food with lots of choice. They have regular meetings where they can have their say about the home and what they think about the service. They are listened to and what they say is documented in the monthly newsletter.” People living at the home told us that visitors are welcome at any time and the visitor’s book currently being used showed many visitors to the home. The monthly newsletters given out to people living at the home were observed to include the menu for the coming month and showed lots of variety and choices. We noted that there was a place on the menu for people to comment on the food, which had been served. We joined people for the main meal of the day in the dining room. The meal advertised on the menu was, liver and bacon, seasonal vegetables and potatoes followed by blackcurrant sponge and cream. We saw other alternatives served. One person had fish in a sauce. This person told us told us that they didn’t eat liver. The expert by experience reported “ The food is excellent, not only because of the variety and it is well cooked but because of the little touches. For instance on the day we visited the dinner was liver and bacon, liver is notorious for having sinews in it, but none of the four people on our table had any at all. One of the people suffers from fructose intolerance, unable to have any sugar or fruit. All her meals are prepared with this in mind, so that when we had blackcurrant sponge and cream she had semolina with one –sugar sweetener. As a diabetic I had a suitable alternative which was delicious.” When asked the question “Do you like the meals at the home?” in Have Your Say surveys six people returning the surveys said “usually” one person said “sometimes” and two people said “always”. Comments received from people living at the home were: “ The staff have been very helpful as I am diabetic and have gone to a lot of trouble to see I have what I can eat.” “ I have an unusual condition. It is fructose intolerance. The staff have handled my diet excellently.” Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure so that people know that if they have any dissatisfaction they can voice their concerns. Safeguarding people form abuse and harm is taken seriously so that people can feel protected. EVIDENCE: The home has a complaints procedure, which we saw on display in the hallway along with a suggestions box. The AQAA returned to us by the registered manager said: “Policy and procedure are reviewed at least anually and are updated as required. Complaints are welcomed both in writing and verbally, this is documented and investigated. We have a suggestions box in the hall, and also a compliments book. All of these, particularly the complaints, form part of our quality assurance assessments.” The AQAA returned to us told us that the home had not received any complaints. The registered manager told us that there had been two Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 18 complaints since completing the AQAA and showed us the records of the complaints and how they had been responded to. All fifteen staff returning surveys to us told us that they knew what to do if a service user, relative or advocate has concerns about the home. One member of staff informed us “ I would be confident it would be dealt with.” Seven out of the nine people living at Green Willow who returned surveys told us that they knew how to make a complaint but the other two people didn’t respond to the question “Do you know how to make a complaint?” The AQAA returned to us by the manager told us “user questionnaires indicates that 100 of users know of the complaints procedures and who to complain to.” A relative returning Have Your Say survey on behalf of a person living at responded “always” when asked the question “Has the care service responded appropriately if you or the person using the service have raised concerns about their care.” During our visit we also saw minutes of the “Residents Circle” meeting for May and June 2008, which showed that, people living at the home are able to use this forum to bring informal concerns to the attention of the registered manager and staff. We also saw a “Management Clinic” advertised in the July 2008 Monthly newsletter for people living at the home to meet the registered manager if they wished. The home has its own safeguarding adults policy, which the AQAA informed us, had been last reviewed in April 2008. The service also has the West Sussex Multi Agency Safeguarding policy. The AQAA returned to us from Green Willow reported that there had been no safeguarding referrals and no safeguarding matters or complaints have come to our attention. The registered manager told us that staff are given training in-house using an accredited distant learning package and by a person who has attended a training the trainer course in safeguarding. The AQAA also informed us that “Staff have been issued with safeguarding adults leaflets and service users are given easy to read preventing abuse literature.” Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have a well-maintained, clean homely place to live so that they can continue to feel comfortable and safe in their environment. The gardens are well maintained so that people have a lovely outlook from the home and additional safe space to enjoy. EVIDENCE: Green Willow is in the final stages of a major rebuilding and extension programme. On the day that we visited we were able to see the improved Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 20 facilities and noted how areas still being worked on had been made safe to avoid risks to people living at the home and staff and visitors. The completed developments include four-day rooms, a dining room, conservatory, a hairdressing suite, a hydrotherapy spa, and additional bedrooms in a new wing, which in addition to four bedrooms on an upper floor has taken the homes available occupancy level up to twenty-six people. A call bell system is fitted in all rooms, a fire warning system is in place and under floor heating has been installed in the new wing. There is also one new assisted bathroom within the new wing in addition to the en suite facilities in the bedrooms. The furniture, décor, carpets and soft furnishings, which we saw in the already completed communal areas and bedrooms were above average standard and people who we spoke with, were pleased with their newly furbished areas. The four bedrooms on the upper floor, which have been refurbished and are accessed by a new passenger lift and stairs. We saw refurbished walk in shower rooms, a treatment room for visiting health care professionals and people living in the home to use. New doors had been fitted to all bedrooms, which had a locking facility, and new furniture in bedrooms had a lockable drawer for people to use. Grab rails were observed in all bathrooms and toilets. Rails run along walls in the corridors. The AQAA returned to us by the registered manager told us “ An assessment of the premises and facilities has been made by a qualified occupational therapist who has the knowledge of our service user group to ensure that we meet the needs of our service users.” Individual bedrooms were observed to have radiators, which were covered and fitted with thermostatic valves, and we saw that people had had personal effects in their rooms to personalise them and for some people they had small pieces of furniture. On the day of our visit the areas being occupied by people living at the home was exceptionally clean. Eight out of the nine people living at the home who returned surveys to us told us that the home was “always “fresh and clean one person said “usually.” The AQAA returned to us by the manager told us “ The home is clean, tidy and fresh. It is homely and well decorated as fed back from quality assurance questionnaires.” Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 21 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): 27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have a consistent, well-trained staff team to assist them to remain safe and as independent as they individually require. EVIDENCE: The AQAA returned to us by the manager said, “We have a stable staffing team and low turn over of staff resulting in no agency staff used. We have 2 staff on our bank register who can be called upon to fill vacancies and who have worked for the home and know it well. Staff take part in a quality questionnaire to ensure that we understand their needs and views The company recruitment procedure is robust and a high level of training is provided both mandatory and non mandatory.” On the day of our visit the registered manager told us that there are currently three care staff on duty in the morning, two in the afternoon and two staff at Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 22 night for thirteen people. In addition there are cooks, housekeepers, an administrator and a handyman/gardener. We saw that the monthly news letters distributed to people living at the home included a staff structure and some of the records of the meetings between people living at the home and staff included suggestion for training for staff. We also saw in samples of quarterly newsletters sent out by the registered providers information about staff training levels and achievements by staff. We looked at the recruitment documentation for three staff during our visit, which included someone who had just recently been employed. We saw that they had been asked to fill in an application form, and two written references had been obtained There was also a Criminal record Bureau (CRB) and Protection of Vulnerable Adults (POVA) clearance for all three people in place which had been carried out prior to them starting work at the home Staff training records, which we saw during our visit showed that people, have the opportunity to develop and maintain their skills regularly this included how to work safely. For the person who had been most recently recruited we saw the induction records being used based on the Skills for Care Common Induction Standards. Data in the AQAA returned to us told us that out of the fifteen permanent care staff eleven have an NVQ level 2 or above and that two other are working towards an NVQ level 2 or above” We were also told that two staff have completed an NVQ level 3 and that a cook is working towards NVQ level 2 in catering. Training records showed that staff have opportunities to attend a variety of training course to keep them up to date with the work in their roles. Course attended recently were: Safeguarding adults Fire safety, Infection control Dementia ASET course Some staff training records showed care planning, risk assessment, diabetes, pressure area care and staff supervision this year Comments from staff received in Have Your Say surveys about induction and training included: “ Very in depth induction. Made sure I was confident with certain things.” “ Sometimes seems almost too much training.” Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 23 “ Training is ongoing, very thorough and I have learnt a tremendous amount in the many years that I have worked here.” “Induction was very thorough and training and supervision is carried out regularly. ”Several of staff have just completed ASET level 2 in Dementia care and there are always many course of various subjects to attend which we are encouraged to do as many as possible.” All staff returning surveys to us told us that the employer had carried out CRB and reference checks before they started the job and that they were given the training relevant to their role, which helped them meet the needs of individual service users and keeps them up to date with new ways of working. Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 24 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): 31,33,35,37,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Willow Green is a well-managed service. People know that the registered providers and manager want to listen to their views so that the home is able to provide a service, which meets their needs and expectations. EVIDENCE: Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 25 Julie Howard is the registered manager and she has twenty years management experience. She holds the NVQ level 4 Registered Managers Award and is able to demonstrate that she continues to update her knowledge and skills. Staff returning Have Your Say surveys told us: “We have very capable management and staff.” “ The manager is excellent and always has time to discuss things.” “Our manager is very approachable and we can meet with her at any time to discuss problems”. “It’s a lovely environment to work in.” “It is an extremely well run place and the managers and owners are extremely caring people who treat you with respect and care about everybody as individuals.” “ This is a well run establishment.” During our visit we spoke to people living at the home who told us about the staff and management of the home. In general people felt that there had been disruption during the building work but commented upon how well the process had been managed. Everybody praised the staff and their dedication to their jobs. The manager holds regular management clinics for people to formally meet with her and staff tells us that she helps out with care duties if they are unable to replace someone who has phoned in sick. The AQAA returned to us by the registered manager told us: “Annual quality assurance work is collated to form an annual action plan for the home based on these results. Feedback is sought back from all to ascertain satisfaction and focus on areas of improvement.” “ Monthly Regulation 26 visits/ reports are carried out by the owners or area manager.” During our visit we saw minutes of the “residents circle” and samples of quarterly newsletters, which are distributed to people living at the home, their friends relatives and other people interested in the service. One of these newsletters had a section on quality assurance explaining the ways which the service gets feedback people using the service and how the information is used. In the entrance hall there is a suggestions box for people to put their comments and suggestion in. The “expert by experience reported “ One feature that particular impressed me was the monthly “residents circle” where residents meet with senior staff to discuss anything the residents wish to raise. This is impressive at two levels; the owners and staff try very hard to do all they can to make the home as Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 26 pleasant and comfortable as possible and the owners must be confident of the quality of service.” We were told that the catering staff also meet with the people who use the service once a month. The AQAA returned to us by the manager told said: “ We have reviewed our proceedures for service users whom we hold money. They have access to it at all times. A more thorough and detailed account is now avaiiable and copies are sent out to service users representatives frequently.” “Service users may manage their own money if they wish and there are lockable units in each room for those whose wish to. The home looks after small amounts of pocket money for several of its service users. Double signatures are required for transactions and audits are carried out monthly.” The AQAA returned form the registered manager reported: “Staff have suprvision and appraisals exceeding the standards x6 a year. This is carefully documented and recorded.” Staff returning Have Your Say surveys to us told us: We have yearly appraisals, monthly staff meetings and supervision sessions.” “We have our appraisals in which we can discuss any matters with our manager and we have our supervson and training , this is all done on a regular basis.” Apraisal records were seen in staff recruitment files and supervison record were offered for viewing but we didn’t take up the opportunity during this visit. During our visit we observed that action had been taken to ensure that people were not at risk from the ongoing building works and that contingency plans were in place for visitors accessing the temporay entrance to the building. Risk assessments for the home had been completed and we were told that these were updated annually. Data supplied in the AQAA returned to us by the registered manager showed us that equipment had been tested and serviced regulally. We looked at fire training records and fire equipment testing record during our visit and the fire alam was tested whilst we were at Green Willow. A member of staff told us about a fall that one person had had recently. When we looked at this persons care records we saw an accident report completed. Another member of staff told us in the survey that they returned: “Health and safety is to the highest standard.” Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 27 Staff training records showed that staff have had health and safety training. Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 28 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 4 4 4 4 4 3 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 4 X 3 Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Green Willow Residential Home DS0000066141.V369157.R01.S.doc Version 5.2 Page 31 - 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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