Inspection on 08/12/05 for The Willow

This inspection was carried out on 8th December 2005.

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

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

Other inspections for this house

The Willow 11/10/06

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 Joan Browne Unannounced Inspection 8th December 2005 15:30 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.V266786.R01.S.doc Version 5.0 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.V266786.R01.S.doc Version 5.0 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.V266786.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: The Willow is a privately owned care home providing personal care and accommodation for up to ten older residents . 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 residents . Residents 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 residents , 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 residents who are considering moving into the home must have some mobility. The home has a small drive-way at the front with adequate parking for a number of vehicles. At the rear of the building there are beautifully landscaped gardens. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home, which took place during the late afternoon and evening of Thursday 8th December 2005. The inspection consisted of meeting with residents and staff, examination of care documentation and records. A tour of the communal areas and some bedrooms was carried out. The serving of tea was observed. Residents spoken to were complimentary about the provision of care and made the following comments about their experiences of living in the home: ‘the manager and staff team are very kind’, ‘we are looked after very well’, ‘I could not have chosen a better place to live.’ The requirements and recommendations from the previous inspection were discussed. This was a good inspection for the home. All key standards were inspected. Feedback was given to the manager and deputy manager on the findings of the inspection. What the service does well: What has improved since the last inspection? The home’s pharmacist has carried out a medication audit. Medication when received into the home is now counted in and recorded on the medication administration record sheets. Staff have undertaken training in the protection of vulnerable adults and challenging behaviour. The extractor fan in the kitchen has been replaced The Willow DS0000023058.V266786.R01.S.doc Version 5.0 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. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 Care plans need to be reviewed to ensure that residents’ needs are known to staff. Arrangements were in place to ensure that residents’ health and personal care needs are fully met. However, residents on Warfarin treatments would need to have protocols developed to ensure that staff meet their needs adequately. Overall staff’s recording practice of medication is satisfactory but there are areas which need to be improved. EVIDENCE: Three residents’ care plans were examined. These pertained to the three residents who were recently admitted to the home. The plans contained information that had been gathered when residents’ needs were assessed, prior to admission. The standard of recording in some plans were noted to be at different levels and appear to be reflective on the staff members who completed the plans. Some care plans were also duplicated. The manager was aware of the anomaly of the standard of recording in the care plans and intends to put it right. It is being made a requirement in this report that the The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 10 care plans are reviewed to include more detailed information of the individual’s needs. Entries recorded in the daily report writing must report on the progress of needs identified in the care plan. Staff do themselves an injustice by not incorporating their evident good practice. All residents were registered with a general practitioner of their choice. Residents are able to access community based practices, either on a private basis or via their National Health Service (NHS) entitlements for all routine health care appointments such as dentists, opticians and chiropody. Several residents with continence problems were receiving support from the district nursing services. The necessary aid and equipment were being provided. The manager confirmed that there were no residents suffering with tissue ulcers at the time of this unannounced inspection. One particular resident was in receipt of daily Warfarin treatment. It is recommended that a Warfarin protocol be developed for the individual. The home uses the Nomad monitored dose system. Medication was secured in a metal cupboard attached to a wall. The medication administration record sheets were examined. There were no gaps noted on the Medication Administration Records (MAR) sheets however, some weaknesses in the recording of medication were noted. For example, handwritten entries recorded on MAR sheets were not signed and dated by two staff members. Some entries were scribbled over. Entries recorded in error must have a line drawn through and an explanation for the error recorded at the reverse of the MAR sheet. Some MAR sheets had as directed instructions recorded, which is not acceptable. It is recommended that the strength, dosage and frequency of administration should be recorded on the MAR sheets. It was noted that Movicol, which is a strong aperient was prescribed for a particular resident when necessary (PRN). It is recommended that a PRN protocol be developed. It was noted that the pharmacist had carried out a medication audit recently. However, at the time of the inspection the report of his findings were not submitted to the home. The manager was requested to forward a copy of the report to the Commission’s Aylesbury local office. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 11 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 & 15 Arrangements are in place to ensure that residents’ recreational interests are catered for. An appropriate range and variety of meals were on offer to residents. EVIDENCE: Residents enjoy varied social activities. On the day of the inspection six residents were invited to the local school’s nativity play, which they thoroughly enjoyed. One of the residents who attended the play used to teach at the school. He was recognised by some staff members and was given a VIP reception. Regular coffee mornings are held in the home. The home now keeps a record of the daily activities held in the home. It was noted that there was a planned activity programme arranged to cover the Christmas period. This included parties and entertainment from various singers including children from the local school. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 12 Residents confirmed that meals served at the home were well prepared and presented and that their needs were catered for. Drinks and snacks are available as and when required. Residents dine together in the dining area. The tables were noted to be appropriately set. Teatime seemed a relaxed and social activity with lots of interaction amongst residents and staff. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 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 the following standard(s): 18 Staff have undertaken adult protection training however, weaknesses in the home’s recruitment procedure has the potential to put residents at risk. EVIDENCE: The manager stated that all staff had undertaken training in the protection of vulnerable adults by an accredited trainer also dementia training. This was a requirement from the previous inspection. Some weaknesses were noted in the home’s recruitment procedure, which could potentially put residents at risk. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 24 & 26 The physical environment was well maintained, ensuring residents lived in safe, attractive and comfortable surroundings that were suitably equipped to meet their needs. EVIDENCE: The Willow is a privately owned care home, which is registered to accommodate and meet the needs of up to ten older residents. The home is situated in a residential area of Chesham. It is a detached house, which is presented in a domestic manner with traditional décor, carpeting and soft furnishings and domestic style lighting. Furniture is of a good quality and the standard of décor is excellent. The home has adequate toilet and bathing facilities to meet residents’ needs, which were well maintained. Residents living in the home have to be mobile because there is no lift. Call bells were fitted in all bedrooms and were accessible. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 15 All bedrooms are single occupancy and eight have en suite facilities. The remaining two bedrooms consist of a sink and toilet. Bedrooms were personalised with residents’ own furniture, family photographs and mementoes. Standards of cleanliness at the home were high and there were no offensive odours noted in the communal areas of the home during the inspection. The home’s laundry room is fitted with a range of domestic equipment. The walls and floors were clean and free from dust. It was noted that the clinical waste bin was, which is stored at the front of the building was not locked. The bin in a particular resident’s bedroom, which is used to dispose of incontinent aids needed to be replaced with the foot pedal type to prevent the spread of cross infection. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 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 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, 29 & 30 An appropriate number of staff were on duty to meet the needs of residents. Some weaknesses in the home’s recruitment procedure were noted, which has the potential to put residents at risk. Staff have undertaken training to ensure that they are competent to meet residents’ needs. EVIDENCE: On the day of the inspection the home was adequately covered with two carers and a senior member of staff. This was reduced to one carer and a senior member of staff after 6.00 pm. One carer who works a waking night provides cover during the night. There is a senior member of staff on call should an emergency occur. All care staff are multi-skilled and undertake general domestic and cooking duties. A part-time cook is employed Monday to Thursday and care staff cook from Friday to Sunday. The personnel files for the two most recently appointed members of staff were examined. It was noted that the application form for one member of staff was not available. However, references were in place and a ‘POVA’ first check and Criminal Record Bureaus clearance check was in place. For the second staff member there was only one reference in place, however, a ‘POVA’ first check had been obtained and the home was waiting to receive the The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 17 Criminal Record Bureau Clearance. There was no written documentation in place to confirm that an experienced member of staff was supervising the new member of staff until the full CRB disclosure had been obtained. However, the deputy manger stated that she was supervising the member of staff and the member of staff was not providing personal care to residents alone. The status of some referees was unclear. Whenever possible the home must ensure that references from employers have an official stamp to confirm their authenticity. The manager stated that all new staff had undertaken induction training, and mandatory training for staff had been updated. However, this information was not recorded in individual’s training records. The manager stated that this was because certificates of attendance had not yet been received. This will be followed up at the next inspection. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 18 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): 36 & 38 Arrangements need to be in place to ensure that all staff are appropriately supervised. The practice of wedging open bedroom doors must cease to ensure that residents’ safety and welfare is not compromised. EVIDENCE: The home does not appear to have a structured supervision framework in place. Staff appear to have supervision on an ad hoc basis. However, staff meetings are held quarterly. The manager and deputy manager stated that they carry out informal supervision with staff members because they tend to work hands on along staff members on a daily basis. Staff are also made aware that they can approach the managers at anytime if there was something worrying them. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 19 The fire records were examined and there was evidence that the panel is checked weekly. The fire risk assessment for the building was recently reviewed. The portable appliance test for all electrical equipment in the building was completed on 12 November 2005. It was noted during the tour of the building that two bedroom doors were kept opened with footstools. It is a requirement of this report that no article is used to hold open bedroom doors other than those approved by the Fire Officer. It was noted that radiators in the bedrooms and communal areas were not covered, which posed a safety risk to residents. The manager stated that she had been regularly risk-assessing radiators as advised by the local fire services. However, she has decided to have all radiators covered sometime in the New Year. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 20 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 3 X 3 X 2 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 2 The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 21 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 Timescale for action 28/02/06 2 OP26 16(k) 3 OP29 19(1) 4 OP36 18(2) The registered manager must ensure that the care plans are reviewed to include more detailed information. Daily report writing must reflect on the progress of individual’s needs identified in the care plan The registered manager must 31/12/05 ensure that the clinical waste bin is kept locked. The bin in a particular resident’s bedroom used to dispose incontinent aids must be replaced with a foot pedal type to prevent the spread of cross infection. The registered manager must 09/12/05 address weaknesses in the home’s recruitment procedure. An experienced staff member must supervise staff members commencing work without a full CRB clearance. (Previous timescale of 17/05/05 not met) The registered manager must 31/01/06 ensure that a structured supervision framework is introduced into the home to DS0000023058.V266786.R01.S.doc Version 5.0 The Willow Page 22 5 OP38 13(4) ensure that all are adequately supervised. The registered manager must ensure that bedroom doors are not wedged open with door wedges or other obstacles. 09/12/05 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 3 4 Refer to Standard OP9 OP9 OP8 OP9 Good Practice Recommendations It is recommended that the registered manager should ensure that handwritten entries recorded on MAR sheets are checked dated and signed for by two staff members. It is recommended that the registered manager should ensure that the strength, dosage and frequency of medication be recorded on the MAR sheets It is recommended that the registered manager should ensure that a Warfarin protocol be developed. It is recommended that the registered manager should ensure that a PRN Movicol protocol be developed. The Willow DS0000023058.V266786.R01.S.doc Version 5.0 Page 23 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.V266786.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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