Inspection on 11/10/06 for The Willow

This inspection was carried out on 11th October 2006.

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 Willow 08/12/05

The Willow 16/09/04

The Willow 06/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Willow 110 Chartridge Lane Chesham Bucks HP5 2RG Lead Inspector Nichola Cahill Unannounced Inspection 09:30 11 October 2006 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 The Willow DS0000023058.V309848.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. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willow Address 110 Chartridge Lane Chesham Bucks HP5 2RG 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) 01494 773451 woodstockconkers@aol.com Mrs Lynne Woodstock Mr Mason David Duke Mrs Lynne Woodstock Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: The Willow is a privately owned care home providing personal care and accommodation for up to ten older service users. The home is located on the outskirts of Chesham and is a short distance from local amenities. The Willow is a domestic type residence, which is situated in a residential area of Chesham and has been sympathetically extended and refurbished to meet the needs of service users. Service users accommodation is situated over two floors and communal space is situated on the ground floor in the sitting room, which has been extended into the conservatory. There is a large domestic type kitchen/diner adjacent to the lounge. The dining area in the kitchen appears to be a key area within the home as it is centrally placed and appears to be a common meeting place for service users, staff and visitors. All bedrooms provide single room accommodation. With the exception of two rooms all are fitted with en-suite facilities. There is no passenger lift between the ground and first floors therefore service users who are considering moving into the home must have some mobility. The home has a small driveway at the front with adequate parking for a number of vehicles. At the rear of the building there are beautifully landscaped gardens. Information regarding the services offered is available from the home on request. The fees for care provision are £550.00 per week. Items not covered by fees include, chiropody, hairdressing, visits from the beautician and newspapers. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the unannounced Key inspection visit carried out by Nicky Cahill (inspector) on 11th October 2006. The inspection took place over a period of 10 hours, this included the pre-inspection planning. The inspection consisted of the case tracking of three service users currently living in the home, service user and staff discussions, observations, a tour of the building, viewing of documents and meeting with the manager and deputy manager. An assessment was also carried out of any information received by the Commission since the previous inspection visit. The Commission received feedback from three service users, seven relatives / representatives and one heath care professional prior to the inspection visit. An assessment was made against all key standards. One requirement was made during this visit. There is one outstanding requirement from the inspection in December 2005. From the evidence seen and comments received, it is considered that this service meets the individual cultural, religious and diverse needs of all service users. What the service does well: Service users are appropriately assessed prior to admission. Service users are assured that the home can meet their needs. Service users are treated with dignity and their right to privacy is upheld. The home has an activity programme in place to ensure that service users’ social and recreational interest and needs are catered for. Service users are supported to exercise choice and control over their lives. Visitors are welcome to visit at any time this ensures that service users maintain contact with their families and friends. Service users receive a varied and appealing diet and are supported in their choice of meals in accordance with their assessed needs. A complaints policy is in place and service users are empowered in airing their Concerns and complaints. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 6 Robust policies and procedures are in place to ensure that service users are protected from abuse. The home is suited to its stated purpose. Service users are able to live in a warm, comfortable, safe and hygienic environment. Care staff receive appropriate training in order to meet ensure the safety of service users. Staffing allocation is adequate to continue to fully meet the needs of the service users. The home is well managed and run in the best interests of the service users. Service users are able to live in a home that provides a quality service throughout. Service users are protected from financial abuse by the homes policies and procedures in place. Health and safety systems are in place to ensure that service users are protected from harm. What has improved since the last inspection? What they could do better: Service users do not have an appropriate plan of care, this does not ensure that their care and health needs will continue to be met. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 7 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 Willow DS0000023058.V309848.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 The Willow DS0000023058.V309848.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users are appropriately assessed prior to admission. Service users are assured that the home can meet their needs. EVIDENCE: Two of the three service user records viewed showed an appropriate preadmission assessment. The manager carries out the majority of assessments. Service users are offered the opportunity for a four-week trail visit to the home. This was confirmed through documentation viewed. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users do not have an appropriate plan of care, this does not ensure that their care and health needs will continue to be met. Safe systems are in place for the safe handling, storage and administration of medication ensuring the safety of service users at all times. Service users are treated with dignity and their right to privacy is upheld. EVIDENCE: Three care plans were viewed and care needs were discussed with service users and care staff. It was clear through observations made and discussions that service users care needs are fully met. However, care plan information did not, in all cases, reflect the current and ongoing needs of service users. Areas of care had been highlighted under areas such as, eating and drinking, personal dressing and hygiene and communication. However, information was limited and did not detail how the The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 11 home would assist service users in ensuring that these needs were appropriately met. It was unclear whether service users had been consulted when drawing up individual plans. Reviews had been carried out, however, it was difficult to track any changes within the care plan document. Care plan files were not easy to follow and did not include an appropriate profile of individuals. Health and medical interventions were appropriately recorded, however, health needs were not identified as part of the care planning process. Requirements have been made for improvement in this area. The home uses the Nomad monitored dose system. Medication was secured in a metal cupboard attached to a wall. There were no gaps noted on the Medication Administration Records (MAR) sheets. It was noted through observations made that medication is administered according to the homes policies and procedures in place. All staff responsible for the safe handling of medications have received training in this area. Observations were made throughout the day of excellent practices regarding the protection of service users privacy and dignity. Service users also reported that staff were, ‘Very respectful’. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home has an activity programme in place to ensure that service users’ social and recreational interest and needs are catered for. Service users are supported to exercise choice and control over their lives. Visitors are welcome to visit at any time this ensures that service users maintain contact with their families and friends. Service users receive a varied and appealing diet and are supported in their choice of meals in accordance with their assessed needs. EVIDENCE: Daily life and social activities were assessed through discussions with service users and staff, through documentation viewed and from observations made during the inspection visit. A number of service users and relative questionnaires were also received prior to the inspection. The home currently has an activities co-ordinator. All service users have received an assessment of their social interests and activities are planned with these in mind. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 13 The inspection visit was during a busy period were personal care was taking up most of the care staffs time. However, newspapers were given out, care staff engaged in appropriate conversations whilst carrying out other duties and it was pleasant to hear service users singing and socialising in small groups in the lounge. It was confirmed that visitors are always welcomed. The manager issues a ‘newsletter’ throughout the year. This informs service users of all that is happening in and around the home and highlights some of the forthcoming events, such as visits to ‘Bluebell Wood’ and visit by the ‘Sapphire Singers’. It was confirmed through discussions with service users that they are actively encouraged to maintain links with family, friends and the local community. Service users commented that they received visits from the local school children at key times through out the year and that their visitors were always made welcome in the home. This was also confirmed through comment cards received prior to the inspection. It was apparent from discussions, observations and through documentation viewed that service users are actively encouraged to exercise control over their lives. Through discussion with service users it was confirmed that they all have regular discussions with the cook regarding their likes and dislikes and the planning of the menu. Breakfast is taken at leisure from 7am onwards. Service users are encouraged to eat together in the homes dining area should they wish. From observations made this is clearly a social time for service users, which is greatly enjoyed. Staff are ready to offer assistance in eating where necessary with sensitivity and respect. Service users dietary and nutritional needs are catered for, this was apparent through discussions and observations made during the inspection visit. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. A complaints policy is in place and service users are empowered in airing their Concerns and complaints. Robust policies and procedures are in place to ensure that service users are protected from abuse. EVIDENCE: Complaints within the home were assessed through documentation, service users discussions and feedback questionnaires. The home has not received any complaints since the last inspection visit. A copy of the complaints procedure was in place in the main entrance of the home and clearly encouraged service users and visitors to share any concerns or suggestions for improvement with the manager / provider. The home has received many letters of thanks from friends and family for the quality service given to service users who have resided in the home in the past. Adult protection polices and procedures are in place and staff confirmed that they would feel empowered in ‘whistle blowing’ should the need arise. The home has not had any issues regarding the protection of vulnerable adults since the last inspection visit. It was confirmed that all staff have received up date training in this area. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 15 The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home is suited to its stated purpose. Service users are able to live in a warm, comfortable, safe and hygienic environment. EVIDENCE: All areas of the home viewed were well presented and had a homely, comfortable and warm feel. Permission was given from a number of service users to view bedroom areas, these were reflective of the individual personalities of the service users, they were well-furnished and kept in good repair. It was pleasing to note that all service users had their own comfortable armchair; these had been purchased according to individual needs and choices. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 17 All areas of the home were found to be spotlessly clean and free from offensive odours. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Care staff receive appropriate training in order to meet ensure the safety of service users. Staffing allocation is adequate to continue to fully meet the needs of the service users. The home operates a robust recruitment procedure; protecting the safety of service users. EVIDENCE: From observations and discussions made during the inspection and from documentary evidence viewed it would appear that there are an appropriate number of staff on duty at any one time to ensure that the needs of service users are met. The home is proactive in accessing training for all staff and has recently employed a training co-ordinator. Records were easy to assess and confirmed that most training is up to date. Two staff have completed their NVQ level 2 in care, with a further four staff currently training in this area. The assessment of staffing included sampling two personnel files. The home has robust recruitment procedures in place to ensure the safety of service users. Both staff files viewed confirmed that pre-employment checks had been carried out. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 19 The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home is well managed and run in the best interests of the service users. Service users are able to live in a home that provides a quality service throughout. Service users are protected from financial abuse by the homes policies and procedures in place. Health and safety systems are in place to ensure that service users are protected from harm. EVIDENCE: The registered manager of the home, Lynne Woodstock, is also the care provider. Mrs Woodstock is well supported by her deputy manager and a dedicated group of care and ancillary staff. Mrs Woodstock has many years of experience in the care field and is a registered nurse. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 21 It was confirmed through discussions that the manager and the assistant manager are currently completing their NVQ level 4 in management and care. It was clear from observations and discussions throughout the inspection that there is a positive and inclusive feel to the home and that it is run in the best interest of the service users. The home are regularly completing quality audits of which service users play a very active role. The results of the most recent audit had been published within the homes ‘newsletter’. It was clear that, in most areas, service users were 100 happy with the service provided. Action was being taken to ensure that all areas were to service users satisfaction. The home is not responsible for the safe keeping of any service users monies. All service users receive personal allowances. Health and safety systems viewed appeared to be in order, with the exception of the fitment of water temperature regulators to hot water outlets. The manager had identified this as a shortfall and had made arrangements for this work to be carried out. Adequate risk assessments were in place to ensure the safety of service users in the interim. During the inspection feedback it was agreed that the manager would confirm, in writing to the Commission, that this work had been completed. The accident and incident file was viewed. Any accidents and incidents had been reported appropriately and follow up action had been taken. It was noted that the manager had, where necessary, telephoned the Commission, as required, to report any accidents where injuries had been sustained. The manager was reminded that details must also be forwarded to the Commission in writing following the initial telephone call. The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 22 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered manager must ensure that the care plans are reviewed to include more detailed information regarding health and social care needs. This must be carried out in consultation with service users Timescale for action 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willow DS0000023058.V309848.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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