Inspection on 31/08/05 for John Wills House

This inspection was carried out on 31st August 2005.

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 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

John Wills House 19/04/07

John Wills House 01/02/06

John Wills House 15/03/05

John Wills House 31/07/04

John Wills House 24/02/04

Similar services:

Manor Lodge

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE John Wills House Jessop Crescent Westbury Fields Westbury on Trym Bristol BS10 6TU Lead Inspector Vanessa Carter Unannounced 31 August 2005 09:30 st 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 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. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service John Wills House Address Jessop Crescent Westbury Fields Westbury on Trym Bristol BS10 6TU 0117 3773700 0117 3773725 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) St Monica Trust Mrs Angela Rosalind Healey Care Home with nursing 60 Category(ies) of PD Physical disability (3) registration, with number DE(E) Dementia - over 65 (15) of places OP Old age (45) John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Fifteen older persons with dementia who require personal care only to be accommodated in `The Orchards` wing. Up to fifteen older people including two adults (aged forty years and over with a physical difficulty) requiring planned short-term care may be accommodated in the respite care wing. Of the fifteen, up to eight Service Users entering the Beeches Unit may be accommodated for a period of time not exceeding twelve months. This may include respite, intermediate and nursing care. Up to thirty older persons requiring nursing care to be accommodated in `The Willows` on the first floor. This may include one named person aged forty-six onwards, with a physical disability. This placement is specific for one individual and the condition will lapse if the placement ceases. Date of last inspection 15-March-2005 Announced Brief Description of the Service: John Wills House is a purpose built care home, built and owned by St Monicas Trust. It is registered with the Commission for Social Care Inspection (CSCI). The home is situated in Westbury Fields Retirement Village. In addition to the home there is a complex of sheltered housing, retirement apartments and bungalow - these do do fall under the remit of CSCI. John Wills House is registered to provide different levels of care in each of the three units : The Willows provides placement for 30 residents, both male and female who require nursing care. All rooms are for single occupancy, with ensuite facilities and ceiling fitted hoist mechanisms. The Orchards provides placement for 15 residents, both male and female with personal care and dementia care needs. The Beeches, is again for 15 male and female residents, but only on a short term/respite basis. A number of the beds are block booked by South Gloucestershire Council and Bristol City Council. The home is well appointed and shares its building with a purpose built pub the Cricketers. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection to the home that took place over one day. This was a focused inspection and not all standards were assessed – only care planning documentation and delivery of the care service. This brief report should be read in conjunction with the report of 17/18 March 2005, when a full announced inspection was undertaken. Evidence was gained from a tour of the home, speaking with a number of the residents, the manager and briefly, some of the care staff. What the service does well: What has improved since the last inspection? The home continues to provide a high standard of care and personal service to those who reside at the home. No requirements were made at the last inspection. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 6 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. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6 Residents are given clear information regarding the service, enabling them to make an informed before considering a move there. The home needs to ensure the pre-admission assessment process is appropriately followed. EVIDENCE: On the day of inspection the home had a number of planned admissions to the home. A welcome pack of information about the home and St Monica’s Trust was placed in each room. This includes a summary of the homes statement of purpose and information regarding the complaints procedure. A copy of the last inspection report was displayed in the main reception area of the home. The relative of one of the new residents stated she had been provided with all the necessary information, when she visited the home to make the arrangements. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 9 The home has introduced the ‘easycare’ assessment tool for new admissions. This is a comprehensive document that covers all aspects of a person’s personal care needs, daily living, health and social care. The homes policy is that all new residents will have been assessed prior to being offered placement. This is to ensure that the home is able to meet the person’s needs. The assessment for the most recently admitted resident was not signed by the assessor or dated. It was therefore not evident that the assessment had been completed prior to admission to the home and for this reason this standard is only partially met. One of the units, The Beeches, is an Intermediate Care Unit. It has separate communal facilities from the rest of the home. The staff team are supported by Intermediate Care Staff from South Gloucestershire Council and Bristol City Council, who have ‘block purchased’ a number of the beds. The unit has a rehabilitation kitchen and a physiotherapy department. Most residents length of stay is around the six weeks, however the home does have a condition of registration that states that up to eight residents are able to remain on this unit for a maximum period of up to one year. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 11 Residents are well cared for in respects of their health, personal and social care needs. Care planning documentation provides a detailed picture of each person so residents know that their individual needs will be met. EVIDENCE: Six plans were looked, two from each unit. The plans were person- centred and had obviously been written in conjunction with the resident and any of their family. They included the preferred name to be used and any information regarding the family and specific needs. One person’s plan stated “ must have her black bag with her at all times”. The identified needs were clearly set out with instructions for the staff in how these needs should be met. There were two examples where the information was a little unclear and this was discussed with the manager during the inspection and the plans will be amended accordingly. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 11 Daily communication sheets are maintained and completed by both the health care assistants and registered nurses. This is good practice and ensures that the person who delivered the care, then makes a record of that care given. Each entry was signed in line with good record keeping guidelines. These records showed that the residents are able to access other health care professional such as the GP, psychiatric services and chiropody. A recommendation was made following the last inspection for training to be arranged in the ‘care of the dying person’ and a course has been set up for five staff to attend this. The manager explained that the home is currently amending their Sudden and unexpected death policy. Following discussion, the home also needs to look at other policies in respect of resident’s wishes not to be actively resuscitated in the event of a sudden illness. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The residents have the option to participate in a stimulating and varied life. The meals provided are of a very good quality. EVIDENCE: The home met all these standards on the previous inspection, but these standards were not a focus of this inspection. However during the course of the inspection visit, residents made the following comments: “you are able to come and go as you please”, that “there is always plenty going on” and “the trips out are really enjoyable and good fun”. Several residents mentioned the recent garden party they had attended at another of the St Monica sites and the visit by the Princess Royal in May. Compliments were made about the standards of food and the choices available. Meals can be taken in the pleasant dining rooms on each of the units or in the resident’s own room. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The complaints procedure is made available to the residents and visitors, and any complaints are listened to and acted upon. EVIDENCE: The complaints procedure is contained within the homes Statement of Purpose and the Welcome Pack placed in each person’s room. Each resident spoken to was aware that the home had a complaints procedure, but none had had reason to make any complaints. One stated that they had raised issues with the manager but did not feel they were making a complaint – they said they had been listened to and their concerns had been acted upon. One health care assistant spoke knowledgeably about adult abuse issues and stated what she would do if she witnessed any unacceptable care practices. The manager stated that all new staff are issued with documentation about adult protection protocols (No Secrets) and all staff are expected to undertake adult abuse awareness training at the organisations training department. The training records were not inspected on this occasion. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21 and 26 Residents are cared for in a superb, comfortable and safe environment. It is well equipped and maintained throughout to a very high standard. Access to the home needs to be improved. EVIDENCE: The home was first opened in 2003 and complies with all the regulations for newly built care homes. A tour of the building showed that the home has been tastefully decorated and furnished throughout. The home was clean, tidy and odour free in all areas. Residents are encouraged to bring in their own possessions and furniture. Each resident’s room is spacious, with ensuite bathroom facilities, and fitted ceiling hoists in all “nursing care rooms”. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 15 The closure of some bedroom doors, (fire doors), are currently not functioning correctly. However the home have already taken action and a contractor was in the home rectifying the problem. This evidences that the home takes prompt action to deal with any maintenance issues that may have the potential to affect the safety of the residents. A recommendation was made following the last inspection for the home to improve the access at the main front gates to the village. Whilst the situation remains the same, the home and senior management team for St Monica’s are actively exploring solutions. This good practice recommendation will therefore be carried forward in this report John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed as part of this focussed inspection, however the home met all standards at the previous inspection in March. Then, the home exceeded the minimum requirements for standard 28, in respects of the numbers of trained members of care staff with at least, an NVQ Level 2 qualification. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed as part of this focussed inspection. The home met all standards at the previous inspection in March. Then, the home exceeded the minimum requirements for standard 31, in that the registered manager and the management team provide clear leadership, thereby ensuring that the standards in all respects are consistently high and that the residents are well cared for safe. John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 19 NO 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 OP3 Regulation 14(1) Requirement Pre-admission assessments must be signed and dated by the person who has completed them to validate when it was undertaken. Timescale for action From 31 August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP11 OP22 Good Practice Recommendations St Monica Trust should expand the policy on resuscitation in the event of sudden death and include a nonresuscitation protocol in order to respect residents wishes St Monica Trust should investigate ways of making the enterance panel in use at the main gates of the village, accessible to any resident or visitor to John Wills House (as a resonable adjustment under Disability legislation) John Wills House D56_46239_JohnWillsHse_227065_230505_Stage2.doc Version 1.30 Page 20 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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