Inspection on 11/05/07 for The Willows

This inspection was carried out on 11th May 2007.

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 Willows 21/09/09

The Willows 25/03/09

The Willows 24/07/08

The Willows 31/10/07

The Willows 20/11/06

The Willows 09/05/06

The Willows 19/01/06

The Willows 28/06/05

The Willows 11/11/04

The Willows 13/09/04

The Willows 03/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Willows, The 2 Tower Road Barbourne Worcester Worcestershire WR3 7AF Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 14:30 11th May 2007 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 Willows, The DS0000018692.V334841.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. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows, The Address 2 Tower Road Barbourne Worcester Worcestershire WR3 7AF 01905 20658 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) Mr Tony Harborne Mrs Vivien Anita Harborne Mrs Lynda Jennings Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14), Physical disability over 65 years of age of places (14) Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Home may also accommodate a maximum of 4 people over the age of 65 with a dementia illness The Home may also accommodate one person over the age of 65 with a learning disability The home may also accommodate one named person who has needs which fall within the category MD, ie mental disorder, excluding learning disability or dementia. 20th November 2006 Date of last inspection Brief Description of the Service: The Willows is a large, detached, adapted property situated in a residential area near to Barbourne Park in Worcester. The home provides a residential care service for a total of 14 people over the age of 65 years who may also have a physical disability. The home may also accommodate a maximum of 4 people over the age of 65 years with a dementia illness, one person over the age of 65 years with a learning disability and one named person who falls within the category MD (mental disorder), excluding a learning disability or dementia. Accommodation is located on two floors, with access to the first floor gained via a staircase and or a stair lift. Handrails are fitted throughout the home. Accommodation comprises of 14 single bedrooms, all of which have en-suite facilities. The home has one large lounge with a smaller room leading off it and a separate dining room. The registered providers are Mr and Mrs Harborne. The registered manager is Mrs Lyn Jennings. The fees were reported to be currently £480.00 per week. Additional charges are made for hairdressing, newspapers, clothing and toiletries. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. As part of the overall inspection of the service offered at The Willows a number of short visits to the home were undertaken over the period of one week. All the visits were unannounced. The last visit to the home was in November 2006 This inspection takes into account any information received by the CSCI since the previous inspection as well as the visits to the home. The registered provider was on holiday during this inspection. The registered manager was on duty for the first 30 minutes of the first day of this inspection and throughout other visits. In addition to the manager, discussions took place with a number of carers, a cook and residents. A period of time was spent sat within a lounge observing life as experienced by residents. At the time of this inspection the home had two vacancies, therefore accommodating 12 residents. Following the finalisation of the previous inspection report an improvement plan was issued for the registered persons to complete. Although completing and returning an improvement plan is a legal requirement this document was not returned to the commission within the given timeframe. As a result of the findings during the previous inspection a number of immediate requirements were issued as well as other requirements which appeared within the report; some of these requirements were unmet from earlier inspections. The purpose of this inspection was to assess compliance with requirements issued within earlier reports as well as to assess the standard of care provided to people living within the home. A partial look around the home took place which included a number of bedrooms as well as communal areas. The care documents of a number of residents were viewed including care plans, daily notes and risk assessments. Other documents seen included medication records, service records and staffing records. Willows, The DS0000018692.V334841.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: Due to the concerns during the previous inspection immediate requirements were issued which were followed up by means of a number of letters. These shortfalls were in relation to the management and administration of medication, recruitment procedures, care planning and risk assessments, environmental risk assessments, staff rotas and a staff training programme. The registered provider failed to respond to the immediate requirement letters. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 7 In addition to the above failure the registered provider also failed to respond to the requirement to complete an improvement plan. The lack of a response is a serious concern and questions the providers acknowledgment of their responsibilities under the Care Standards Act 2000 and The Care Homes Regulations 2001. It was of concern that residents are admitted into the care home without any needs assessment having taken place. Evidence was lacking of visits to the home by any potential residents. In addition confirmation that care needs can be met is not supplied to potential residents or family / representative. An admission assessment, which should evidence the recognition of care needs, was not in place for staff to refer to for a period of 8 weeks; this needs to be done prior to admission. Care plans continue to be insufficient in many areas of care need and failed to give either up to date information or worthwhile strategies. Risk assessments are in place but insufficient and no plan of care to reduce the risk was evident. Further improvements regarding the management of medication are necessary. Some out of date eye drops were in use which needed to be withdrawn immediately, however this left the resident without their prescribed medication. Residents consulted wanted more to do during the daytime. The activities within the home are limited. No budget is provided to the manager to meet residents social care needs. Despite a previous requirement and a previous concern no training regarding adult protection procedures has taken place. Local and specific procedures were not held within the relevant file. The registered provider has failed to take note and take the necessary action regarding a number of potentially serious health and safety matters. One matter was dealt with during the inspection however the requirement was originally set 12 months beforehand. Other matters remain unmet despite earlier requirements. Another health and safety matter was identified during the inspection and did not receive the anticipated response. Infection control practices are in need of improvement by having suitable facilities available to staff. Training shortfalls are of serious concern especially regarding mandatory training such as fire and moving and handling. Emergency procedures are not in place and staff had conflicting views regarding how to read the fire alarm panel. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 8 Quality assurance systems remain insufficient. The home lacks business and financial plans as well as a development plan. Environment risk assessments are insufficient and do not cover all areas of the home or one particular area identified as part of a previous inspection. 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. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 9 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 Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 10 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): Standards 2, 3 and 4. Standards 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of pre admission assessment means that potential residents cannot be confident that their care needs are going to be able to be fully met. Initial care plans are not written upon admission to supply carers with the information they need to provide the level of care needed. Information about the care home is available to prospective residents and their carers. EVIDENCE: A copy of both the service users guide and statement of purpose were obtained as part of this inspection. These documents have been briefly viewed. It is Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 11 evident that they were recently reviewed as they contained up to date information regarding fees and staffing. The files of two recently admitted residents were viewed. Both files evidenced a lack of pre-admission assessments. On one file a document entitled ‘Admission Assessment’ was seen however this was undated, unsigned, lacked detail and appeared to of been written after admission. Another ‘Admission Assessment’ was not initially available although later handed to the inspector this document was completed 8 weeks after the admission had taken place. As both residents were admitted without any input from social services the need for a full assessment of care needs is paramount, this had not happened. There was no evidence that the registered person had written to either the prospective resident or their family to confirm that care needs could be met. One recently admitted resident stated that they had not visited the home prior to admission but that a family member had done so. The service users guide states that residents are initially admitted on a fourweek trial basis. The homes contract (terms and conditions) was not available for one recently admitted resident; it was reported to be with the residents relative. Another contract was seen but it was incomplete in that it did not have information entered regarding fees charged for retaining the bedroom if in hospital. The Willows is registered to care for up to four (4) persons who have a diagnosis of dementia. The care of persons with a dementia type illness is specialised therefore making it necessary for staff to received suitable training in order that care needs can be met. A previous inspection assessed the training of staff as insufficient and the registered persons were required to ensure that dementia care training was provided for all members of staff. It is pleasing to note that 5 members of staff have completed a level 2 Certificate in Dementia Care. Another 4 members of staff are awaiting verification that they have also completed this training. The Willows does not offer intermediate care therefore standard 6 is not applicable. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 12 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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living within the home have a plan of care, access to medical services and are treated respectfully. The absence of up to date or accurate information within the care plans fails residents in ensuring care needs can be met. The management of medication especially eye drops needs improvement to ensure health care needs are met. EVIDENCE: Individual care plans are in place for each resident. A representative sample of care plans were viewed and assessed during the inspection. Although care plans have improved over recent inspections they are in need of further improvement in order to fully meet the regulations. One care plan gave good information which could have given the reader details of the assessed needs however some information was incorrect therefore reducing its Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 13 worth. Another care plan viewed gave cause for concern as although recently reviewed it failed to cover many significant care needs evident from reading the daily notes. The care documentation failed to guide staff in relation to strategies found to be beneficial and worthwhile. The final care plan briefly viewed was not up to date and had not received a recent review. One resident confirmed that he/she had seen their care plan. Risk assessments are in place however suitable care plans need to be drawn up in conduction with the identified risks. On one file the risk assessment regarding both pressure care and nutrition stated ‘at risk’ however no strategies were recorded to reduce the risk. Some but not all of the care plans seen were reviewed on a monthly basis. Care plans need to be reviewed on at least a monthly basis or more frequently to support individual residents needs therefore it is vital that important information is captured, this was not always taking place despite the monthly updates which were in place. Resident’s weights were recorded although no written instructions regarding actions to be taken in the event of weight loss/ gain were seen. Weights are taken using a pair of traditional domestic bathroom scales; the use of these scales needs to be risk assessed to ensure residents safety while they are used. It was evident that the home acts appropriately in seeking medical attention for residents when circumstances dictate. One resident became ill during the inspection and the required action was taken by telephoning a doctor and an ambulance. Over recent years inspection reports have highlighted a range of concerns and non-compliance regarding the management and administration of medication at The Willows. Due to breaches of legislation a number of immediate requirement notices have been issued. In addition to immediate requirement notices a number of meetings involving the registered persons have been held at the local office of the commission. Generally improvement was noted regarding the management and administration of medication when the system was assessed as part of this visit. The vast majority of Medication Administration Record (MAR) sheets were signed appropriately to indicate the administration of the medicine. Improvement was also noted in relation to the need to record any known allergies and having a second signature to verify handwritten amendments as these were in place on the majority of occasions, these matters were part of the shortfalls noted as part of the previous inspection. Medication was not always booked into the home as necessary. It was noted that the instructions on one resident’s Monitored Dosage System (MDS) cassette stated to ‘Take one at night when required’, this information Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 14 was not fully transcribed onto the MAR sheet. The MAR sheets evidenced that the medication was given every night. The date of opening was recorded on items not held within the blister pack making it possible to carry out a full drugs audit. It was of concern to find some eye drops with a date of opening record as 09/04/07. The box clearly stated ‘Discard 1 month after opening.’ As this inspection was undertaken on 11th May it was evident that these drops had passed their expiry date; no systems were in place to ensure that these circumstances did not occur. The MAR sheet was viewed again as part of the second visit when it was apparent that no new supply was obtained resulting in the resident not receiving any eye drops. It was noted within the daily records that a carer had applied an non prescribed over the counter anti inflammatory (pain killer) gel to a resident without authorization. Training records indicated that some carers have completed medication training while others are currently undertaking it. Residents seen looked suitably attired taking into account gender issues and weather conditions. Carers consulted were able to give a reasonably good verbal account of the care needs of two residents who were case tracked, despite the evident gaps within the care planning. The Willows has two male staff (including the provider) working along side primarily female staff. An informal relaxed atmosphere existed within the home; carers seen were respectful to residents. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There continues to be concern about both the level of recreational activities and social stimulation for residents. Positive comments were received regarding the food provided. EVIDENCE: Visitors are able to call at any reasonable time although none were seen during this inspection. Visitors are able to use communal areas such as the lounges or dining room as well as resident’s own rooms as they wish. A list of planned activities was displayed on a notice board outside the main lounge area. Activities listed included manicure, hairdressing, quiz and music and movement between Monday and Friday. A file within the office contained some information regarding 3 events to date during May and a total of 3 during April 2007. A sheet was held within each residents file entitled activities however these were blank in the files seen. The daily notes gave additional evidence of activities undertaken which did not match the other records Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 16 On the afternoon of the first visit to the home four residents were playing a game of cards. Activities were discussed as part of a recent resident meeting during which some suggestions for activities were discussed. Feedback from residents during this inspection suggested that residents would like more to do. The inspector spent some time in the lounge during which residents were given a cup of tea. After having their drink residents were disengaged and looked isolated from each other. The television was turned on but the sound was turned down. Staff were not present in the lounge during this time. One resident commented staff are busy during the morning cleaning and cooking therefore you have to ‘hang about’ until the afternoon. The manager has no specific budget for activities within the home. Representatives from a local church visit on a monthly basis. A hairdresser visits weekly. Staff are aware of residents dietary likes and dislikes. A menu is held within the kitchen but not displayed elsewhere. One resident comment that you ‘don’t know what’s for lunch until its served.’ Staff were heard discussing what one resident would have to have for tea therefore indicating that a choice is not given due to the staff’s perception of what an individual would want. Feed back from residents regarding the food served was good; one resident stated that the food is ‘excellent’. Willows, The DS0000018692.V334841.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): Standards 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place and included within the service users guide. It is not displayed to allow residents easy access to it. The continual lack of training regarding the safe guarding of adults is of serious concern and has the potential of leaving residents at risk. EVIDENCE: The commission for social care inspection have received no complaints regarding the service offered at The Willows since the last inspection. The registered manager stated that no formal complaints have been received at the home since the previous inspection. Residents consulted stated that they would report matters to the manager if they were worried or had a complaint. An incident noted within the daily records regarding clothing was not recorded as a complaint. Information regarding the homes complaints procedure is included within the homes service users guide and statement of purpose. Information upon how to complain is not displayed within the home or available in any other format. A previous inspection report stated: Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 18 Staff have received no training regarding adult protection, advice regarding suitable training as stipulated by the local protection coordinator was given.’ The last inspection report concluded that despite the previous concerns, as well as a meeting attended with the commission, which was attended by two of the registered persons, no staff training has taken place. It was reported at the start of this inspection that training had not taken place due to staff attending training in dementia care. It is of concern that this training has not taken place. It was noted that a poster supplied by Worcestershire Social Services regarding vulnerable adults was on display. A file contained information from the Department of Health regarding referrals to the PoVA (Protection of Vulnerable Adults) list, but did not contain additional information regarding policies and procedures within Worcestershire or policies specific to The Willows. One member of staff was able to give a reasonable response when asked about the action they would take and expect others to take in relation to the safeguarding of vulnerable persons if an allegation was made. Willows, The DS0000018692.V334841.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): Standards 19, 20, 21, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home continues to be comfortable clean and homely. However improvements previously identified remain unmet, these are a potential risk to the health and safety of residents. EVIDENCE: The Willows has two lounges one larger and one primarily used for receiving visitors or as a quite lounge, both are well furnished. The dining room is suitable for purpose and the tables were laid up for lunch in an attractive manner. Additional seating is provided in the entrance hall, this area continues to be pleasant and popular with residents. The décor in communal areas was in good order. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 20 The carpet in the hallway and ground floor communal areas is now free from ridges previously noted; it is however showing signs of wear in places. The carpet leading into one bedroom had come away from the carpet grip and posed a potential trip hazard. Low energy bulbs are used throughout the home. In places this made the lighting dim. Bedroom doors are lockable. Currently nobody holds a key to his or her own bedroom. All bedrooms are single and offer en-suite facilities. Residents consulted stated that they were satisfied with their bedrooms, it was evident that residents are able to personalise their rooms. The previous report stated: ‘ Radiators in the lounge and a bedroom were hot to the touch. These radiators are not covered and are a significant risk to the health and safety of residents. Records showed that hot water was very hot in some bedrooms. It was evident that this matter was brought to the attention of the registered provider however no action was recorded as having taken place.’ The registered manager stated that the heating was turned down to prevent the risk of scalding; this may not be a suitable alternative to providing safe systems. One resident commented that the radiator in his/ her bedroom got very hot at times. Some exposed pipes were seen, these need to be risk assessed. Should any of these pose a risk of scalding appropriate action needs to be taken to safeguard residents. An officer from Worcester City Council Environmental Health recently visited the home and made a number of comments which need to be fully actioned in particular the full implementation of the Safer food – better business document. A cleaning schedule within the kitchen has not been implemented. Temperature records regarding fridge / freezer temperatures and hot food are in place but need to be improved as they were not always completed. Both anti bacterial soap and paper towels were available within the toilet near to the lounge in line with good infection control procedures. Other communal facilities did not have both of these facilities for example a linen towel was held within the staff toilet. The laundry is located in the cellar; the washing machine does not have a sluice facility. Willows, The DS0000018692.V334841.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): Standards 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Lack of clarity and information on the rota makes it insufficient to demonstrate an ability to meet the care needs of the residents. Care staff having to undertaken additional duties is of concern due to the potential that care needs are not attended to sufficiently. National Vocational Training progress is good however other areas of training and the lack of compliance to requirements remains a serious concern. The recruitment procedures within the home have improved and assist to safeguard residents against potential abuse. EVIDENCE: Recent inspection reports have highlighted the need to have a staff rota in place. A list of staff planned to be on duty was available however it continued to be insufficient as it contained gaps regarding carers and failed to show other staff such as catering staff. The number of carers on duty during these visits was not always sufficient to ensure that care needs could be met. As a result the registered manager has Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 22 to frequently assist with care duties therefore detracting from the time available to undertake management responsibilities. In addition to care duties staff were having to take on other duties such as preparing tea. The preparation of tea at one time involved both carers on duty therefore taking them away from carrying out care duties. A cook is employed between 9.45 am – 12.45 pm each day with the exception of a Sunday when cooking is undertaken by the providers or their son who also works as a carer within the home. The night shift is covered by one wakeful carer and one person sleeping in. One resident described the staff as ‘very good, very kind and very patient’ The number of carers who have undertaken a National Vocational Qualification (NVQ) level 2 or 3 is good with 7 persons holding this award. The number of qualified staff equates to just over 50 of carers. An additional 4 carers are working towards an NVQ. Although it is acknowledged that staff have worked towards NVQ training as well as attended dementia care training other training remains lacking. No member of staff has attended moving and handling training since July 2004 and a significant number have not attended any such training while working at The Willows. Catering and domestic staff have not attended any training upon the moving of loads. Fire training remains insufficient. The previous inspection report stated: ‘ Fire training records were insufficient and failed to show in house events such as fire drills as part of training. The records regarding some staff showed that no fire training had taken place for over 2 years. An urgent audit of fire training needs must take place and remedial action must take place.’ Records of fire drills are in place and these are happening on a regular basis, however they do not show the names of staff involved. Over the last 12 months a total of 6 members of staff have attended fire awareness training, therefore indicating that other staff have not received training. The fire training which has taken place was carried out by persons who have not received any formal training for trainers. The requirement to audit training needs has not taken place. Other training such as health and safety, first aid, protection of vulnerable adults and infection control have similar shortfalls. Training is booked for staff to undertake basic food hygiene however one of the cooks is currently working without having had any training. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 23 The registered manager did not have any training plan for staff other than planned training in June / July for basic food hygiene. This was of concern given that the registered provider was given up until December 29th 2006 to prepare a full training programme for all members of staff detailing training needs and when and how training needs were to be met. Although some induction training has taken place in the past the registered manager was not aware of the Common Induction Standards which have been developed by Skills for Care. Guidance issued by the commission was left with the manager regarding these standards. The file of a recently appointed member of staff was viewed. The file contained the necessary documentation such as two written references and evidence that suitable checks were made in relation to the Protection of Vulnerable Adults (PoVA) list and the Criminal Records Bureau (CRB) for an enhanced disclosure. Willows, The DS0000018692.V334841.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): Standards 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The failure to respond as required to the commission demonstrates a disregard to met regulatory obligations. Effective quality assurance and monitoring systems are not fully in place to ensure positive outcomes for people living within the home. A lack of consistency in ensuring health and safety systems are in place has the potential to place people within the home at risk. EVIDENCE: Following the finalisation of the previous inspection report the commission required the completion of an improvement plan by the registered provider. It Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 25 is a legal requirement to return a completed plan within a timescale. The registered persons failed to return this document. Furthermore at the conclusion of the previous inspection a number of immediate requirements were issued. A letter to the registered provider confirmed the immediate requirements and the action needed. The registered person should of responded in writing to tell the commission what actions had taken place to meet the requirements issued. Although an extension to the time frame was given (due to Christmas and New Year) no response was received. The registered manager is currently undertaking the Registered Managers Aware which is a National Vocational Qualification (NVQ) level 4 in management. This training is in addition to the NVQ level 4 in care qualification previously undertaken. The managers CV (Curriculum Vitae) highlights other training undertaken such as dementia, mental health, depression, medication and moving and handling. Little progress has taken place in relation to having suitable quality assurance systems in place. Following a recent residents and relatives meeting for which minutes are available the registered manager, has issued questionnaires covering areas such as food, daily living and care. Two responses received to date were seen and contained positive comments. No annual development plan is in place to systematically plan improvements within the home. No business or financial plans exist. The registered provider continues despite repeated comments within inspection reports to not provide Regulation 26 reports regarding the conduct of the manager and the home. These reports should be available within the home for inspection purposes. The Willows does not hold any money in safe keeping on behalf of residents. A certificate showing details of the homes public liability insurance was displayed within the office. The homes certificate of registration was displayed in the hallway. The frequency and areas covered during staff formal supervision sessions needs to be developed further. As reported elsewhere within this report it continues to be evident that some records are not sufficiently up to date in order to ensure effective and efficient running of the home. The inspection report dated May 2006 highlighted concern regarding some bedroom windows without a suitable restrictor. The provider has previously stated that restrictors were not needed due to the height of the windows. Within the report of 12 months ago it was stated by the commission that this Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 26 matter should be discussed with a health and safety officer at Worcester City Council and risk assessed. No risk assessment was in place when the home was visited in November 2006. During the second visit work was undertaken to limit the window opening however the opening remains in excess of the guidance issued by the Health and Safety Executive. It was of some concern that an oxygen cylinder was located near to the manager’s office where the medication trolley is stowed. No warning of compressed gas was posted and the cylinder was not secured making the potential of accidental toppling a health and safety matter. Despite bringing the above concern to staff within the home the above cylinder was still in the same location 66 hours later. The previous inspection report highlighted a range of concerns regarding fire safety. Shortfalls regarding fire training are reported within an earlier section of this report. The fire log was viewed as part of this visit and highlighted some similar concerns to the previous inspection. Shortfalls were identified within the testing of break glass points, which although carried out on a weekly basis had missed one point on three occasions and was therefore last tested on 19/12/06. One break glass point was mentioned within the previous report as in need of attention, due to staff experiencing difficulty in testing it. The registered manager stated that the necessary work was undertaken however it was evidenced that the last time staff had tested the alarm from that point was 04/09/05 therefore over 18 months ago. Despite bringing to the attention of the registered persons within the previous report the home did not have a copy of the Fire Safety Order. The current fire risk assessment was dated November 2006 with a date for review three months afterwards, this had not happened. A fire extinguisher viewed showed that it was last inspected during July 2006 therefore within the last 12 months as necessary. Monthly visual checks of extinguishers are taking place, although clarification regarding the number of pieces of equipment needs to be sought and recorded. Staff consulted gave conflicting information when explaining the fire panel. Staff did know the whereabouts of the mains power and gas stop tap but did not know where the water stop tap was. The home had no emergency plans to cover events such as flooding. Service records regarding hoisting equipment including the stair lift were in order. The gas safety records were out of date and in need of urgent action. Records regarding the testing of portable electrical items (PAT test) could not be found on the first visit, a fan stored in the bathroom had no visible evidence of undergoing a PAT test. A label on an iron stated 25/04/06, which suggested that it was last tested over a year ago. Hoisting equipment was last serviced during January 2007. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 27 Due to inclement weather conditions it could be consider unlikely that residents would venture outside on to the patio. However it was a concern and an indication to the general disregarding for appreciating potential risk that containers of weed killer were on the patio. These were removed once brought to the attention of the registered manager, but demonstrated a general lack of insight within the care home to potential hazards. A small number of environmental risk assessments have been carried out however these did not include the use of the stair lift and the reduced space available to both descend and ascend the stairs. The need for an urgent risk assessment regarding the stair lift was highlighted as part of the previous inspection report and was included within a letter of serious concern requiring action within 28 days therefore before the 29th December 2006. Some previously issued requirements from the previous inspection were found to be met. The remaining unmet requirements have been revised and grouped into a more limited number in line with CSCI policy. Therefore the reduction in requirements does not therefore indicate improvement in standards. Willows, The DS0000018692.V334841.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 2 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 3 3 X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 2 3 2 1 1 Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 29 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 OP3 Regulation 14 (1) (a) Requirement A full assessment of individual care needs must be completed prior to the admission of a resident into the care home. Daily records must demonstrate how residents have spent their day including activities that they have taken part in. Previous timescale of 31/08/05 31/03/06 and 31/07/06 not fully met - an improvement in activities is needed in order to meet this requirement. An extended timescale was given up to 28/02/07. This requirement remains unmet 3. OP7 15 Risk assessments must be in place covering all areas of care, including falls, pressure care moving and handling. These must be reviewed on a regular basis. DS0000018692.V334841.R01.S.doc Timescale for action 01/06/07 2. OP7 15,16 (2) (n) 30/06/07 30/06/07 Willows, The Version 5.2 Page 30 Previous timescales some dating back to 28/06/05 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan and risk assessment shortfalls. This requirement is not met. 4. OP7 15 (1) The registered person must ensure that service user plans cover all aspects of care as set out in Standards 7 and 3. Care plans must be reviewed on at least a monthly basis or more frequently in line with changing care needs. Previous timescale of 16/05/06 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan shortfalls This requirement is not met. 30/06/07 5. OP8 17 (1) (a) 3 (o) The registered manager must ensure that Residents care plans contain information regarding nutritional care needs. Previous timescale of immediate and on going set on 28/06/05 20/02/06 and 16/05/06 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan and risk assessment shortfalls This requirement was not assessed. 30/06/07 Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 31 6. OP9 13 (2) Medication must be given as prescribed and recorded accurately to safeguard the welfare of residents. Systems to ensure that medication is ‘in date’ must be in place. 11/05/07 7. OP18 13 (6) Arrangements must be made through staff training and robust procedures to safeguard residents against potential abuse or neglect. The registered manager must ensure that environmental risk assessments are carried out and available for future inspections. Previous timescale of 31/07/05 31/03/06 and 31/07/06 not fully met. The previous report stated that ‘this requirement must be met without further undue delay’ – this requirement remains unmet. 31/07/07 8. OP19 13 (4) 30/06/07 9. OP26 16 (2) (j) Appropriate facilities must be 31/07/07 provided throughout the home to manage infection control. This requirement is in relation to washing machine facilities. The previous report stated that ‘An action plan must be submitted by 31/03/07 regarding this matter’ – this has not happened. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 32 The requirement remains unmet. 10. OP27 17 (2)4 (7) A duty roster of all the persons working at the home (including their names and designations), that is dated and a record of whether the roster was actually worked, must be maintained, in accordance Regulation 17 and Schedule 4. Previous timescales of immediate and on going set on 28/06/05 20/02/06 and 16/05/06 not met. The previous report stated that ‘this requirement must be met without further delay’ – this is partially taken place. 30/06/07 11. OP27 18 (1) The registered manager must 10/06/07 ensure that all times suitable and sufficient staff are on duty to ensure the heath and wellbeing of residents. Previous timescales of immediate and on going set on 28/06/05 20/02/06 and 16/05/06 not met. The previous report stated that ‘this requirement must be met without further delay’ – this is partially taken place. The requirement remains unmet. Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 33 12. OP30 18 All staff must have individual training and development assessments and profiles. Part met, an extended timescale given 30/06/07 13. OP33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. Previous timescale of 31/08/05 part met, a short but extended timescale of 31/07/06 was previously given and not met as was 31/03/07 31/07/07 14. OP33 26 The person carrying out the monthly visit on behalf of the registered provider must prepare a written report on the conduct of the care home and supply copies to the registered manager in accordance with the requirements of Regulation 26. Previous timescales of 31/05/05 31/07/05, 31/03/06 and 30/06/06 not met. A new timescale of 31/03/07 was given which is not met. 30/06/07 Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 34 15. OP37 17 All the records required by regulation must be fully and accurately maintained within the home in accordance with Regulation 17 and Schedules 1, 2, 3 and 4 Previous timescale of 30/06/05 31/03/06 and 31/07/06 not met, a short but extended timescale was given within the last report – this remains unmet. 30/06/07 16. OP38 13,18 All staff must be provided with updated training on moving and handling, food hygiene, fire safety and infection control. Previous timescale of 31/05/05 31/08/05, 30/04/06 and 31/07/06 not met. The previous report stated that ‘A training plan must be provided’ – this has not happened. 31/07/07 17. OP38 13 Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3. Previous timescale of 31/05/05 31/08/06, 31/03/06 and 31/07/06 and 27/11/06 not met 30/06/07 Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 35 18. OP38 13 Evidence must be provided to demonstrate the homes compliance with all of the relevant legislation referred to in Standard 38.4. Previous timescale of 31/05/05, 31/07/05, 31/03/06, 31/07/06 and 27/11/06 not met. 30/06/07 19. OP38 23 A The Fire Risk Assessment must be reviewed to take into account the Fire Safety Order Previous timescale of 31/03/07 not met. 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations A copy of the service users guide which needs to cover all necessary areas should be readily available within the home. Records should indicate when a copy of this document is supplied to residents and or their representatives. Not assessed Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 36 2 OP13 Relatives, friends and representatives of service users should be given written information about the homes policy on maintaining relatives and friends involvement with service users at the time of an admission to the home. This information should be included in the service users guide Not assessed 3 OP14 Information on the service users right of access to their personal records, in accordance with the Data Protection Act 1998, and how this is facilitated for them should be included in the service users guide. Not assessed 4 OP18 The homes policies and practices regarding service users money and affairs should ensure service users access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and advice on personal insurance, and preclude staff involvement in assisting in the making of or benefiting from service users financial wills. Not assessed 5 OP26 A detailed cleaning schedule for all parts of the home, including the kitchen, should be provided. Recommendation remains in place from previous inspection reports 6 OP31 The job description of the registered manager should be reviewed in order to ensure that it includes all of the duties and responsibilities that are commensurate with her position and status within the home. Recommendation remains in place from previous inspection reports Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 37 7 OP34 A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. Recommendation remains in place from previous inspection reports - no business and financial plans exist 8 OP37 A statement to the effect that the service users have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records, should be included in the service users guide. Not assessed Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Willows, The DS0000018692.V334841.R01.S.doc Version 5.2 Page 39 - 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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