Inspection on 12/05/06 for The Willows

This inspection was carried out on 12th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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

CARE HOMES FOR OLDER PEOPLE The Willows 14 Wolverhampton Road Codsall Staffordshire WV8 1PP Lead Inspector Mrs Kathryn Marks Unannounced Inspection 12 May 2006 09:00 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 Willows DS0000066269.V293894.R01.S.doc Version 5.1 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 Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Willows Address 14 Wolverhampton Road Codsall Staffordshire WV8 1PP 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) 01902 842273 www.mimosahealthcare.com Mimosa Health Care Limited Helen Wilcox Care Home 28 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (6) The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: The Willows is a twenty-eight bedded care home for elderly people situated in Codsall, near to Wolverhampton. Resident’s accommodation is of a high standard and is located on the ground and first floor of the home. First floor bedrooms are accessed via a passenger shaft lift, a stair chair lift or staircase. The home offers both shared and single bedrooms, shared bedrooms have privacy screening, all bedrooms with the exception of one room have toilet en/suite facilities. The one bedroom without en/suite has a toilet next door. Bathrooms and remaining separate toilets are appropriately sited around the home and offer assisted facilities with appropriate aids and adaptations. Lounge and dining facilities are on the ground floor these areas are spacious, comfortably furnished and easy to move around in for residents. Externally the home has an enclosed side and rear garden where service users enjoy walking around and sitting in. There is the addition of a canvas pergola to provide extra shade for residents. The Willows aims to offer 24-hour high quality holistic care in a homely environment, where residents will have been allocated specific accommodation that they have chosen prior to admission. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was carried out on 12th May 2006 between 9.30 am to 3 pm. The home is owned by Mimosa Health Care having changed Proprietors on the 9th January 2006. The Care Manager provided information regarding staffing, staff training, menu and dietary provision that was observed by the Inspector to be in place at the home. On arrival at The Willows individuals were sitting in lounge areas of the home or in their bedrooms the majority having just completed breakfast. Individuals were deciding on their daily routines and plans for the day with a number of relatives visiting. The hairdresser was also present in the home. Resident’s accommodation is located on the ground and first floor observations of the Inspector were that the home was clean and maintained to a high standard. Resident’s bedrooms visited were individualised with favourite personal items they had brought into The Willows with them. The Willows has in place a statement of purpose and service users guide to inform residents of the services and facilities provided. All residents have a full assessment of their needs carried out prior to admission to the home. Arrangements are in place for meeting the health and personal care needs of residents and details are recorded in care records. Regular social opportunities are available for individuals who wish to be involved. No specific activities or social time was identified for residents with dementia this was discussed with the deputy and care manager and they are to look at this area. Residents are provided with a choice of well-balanced and nutritious food prepared by a qualified cook who consults with individuals on a daily basis. The home has a complaints procedure in place that residents were aware of and is given to them on admission to the home. The complaints procedure is also displayed in the home along with details of how to contact the Commission for Social Care Inspection. Staff, are experienced and competent to care for older people and were able to discuss diseases associated with old age. Appropriate recruitment procedures were in place and all staff prior to employment has Criminal Records Bureau and Pova checks carried out. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? 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 Willows DS0000066269.V293894.R01.S.doc Version 5.1 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 Willows DS0000066269.V293894.R01.S.doc Version 5.1 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): 1,3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service Users Guide provides prospective residents with details of the services the home has to offer enabling an informed decision about admission to be made. Resident’s relatives the inspector spoke to during an admission today confirmed this as did other relatives visiting the home. EVIDENCE: The statement of purpose and service users guide form part of the welcome pack in each resident’s bedroom. Resident’s names and room numbers need to be entered into packs. All packs have been updated to include Mimosa Health Care as the new proprietors. A full assessment of residents needs is carried out prior to admission to the home to ensure that the needs of residents can be suitably met. Procedure is in place to confirm in writing to residents the outcomes of assessments. Standard six is not applicable to the home. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health personal and social care needs of individuals are well met with evidence of good multi disciplinary working practices taking place. The systems for the administration of medication are good with clear detailed arrangements being in place ensuring residents medication needs are met. EVIDENCE: As at previous inspection all residents had an individual plan of care that is in modular form and reviewed on a very regular basis. Two residents were case tracked and all records relating to them were seen. Both residents were spoken with and said they were happy at the home individual bedrooms were also visited. Risk assessments are carried out where required reviewed on a regular basis and are included in care records. All contacts regarding health and personal care district nurse and doctors visits are recorded in care records. Medication is stored in a lockable facility with detailed records in place for the administration of medication. No resident is currently self-medicating. Inspector observed a new admission taking place the resident was made to feel at ease and relatives were made welcome into the home. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 10 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems for resident’s consultation in the home are good with a variety of evidence that indicates that resident’s views are sought and acted upon. There is a need to look at the diverse needs of small groups within the homes registration category. The cooks at The Willows are providing a choice of traditional food at the home with a mixture of frozen and fresh produce being used. EVIDENCE: Through discussions with residents the inspector identified that individuals were content with the lifestyle they experienced at The Willows. Comments from individuals include “ Look after you very well” “ I love my breakfasts” “ They do look after you here” “ absolutely wonderful” The activities organiser has left the home and staff are now working on activities with residents and decide daily with residents what the activity will be. The home within its registration category is registered for 7 residents with dementia. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 11 The Care Manager said that there is no specific activities or social events for residents with dementia and that they generally join in with the main activities. The home must review and plan for the diverse needs of this group of residents and evidence appropriate activities. Observations of staff interacting with residents were good with warm exchanges taking place. Positive comments were received on feedback cards from residents, relatives and health care professionals. A number of visitors coming in and out of the home some residents going out with visitors. Comments from visitors include “care is absolutely wonderful they cant do enough for you” “ They make me and my wife welcome whenever we visit” Community activities are accessed at the church hall, village hall, coffee mornings and the forget-me-knot club. There was a lively buzz about the home today music and movement taking place and the hairdresser was in. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 12 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place with evidence that resident’s views are listened to and acted upon EVIDENCE: The Willows has in place a satisfactory complaints procedure that has been discussed with residents and their relatives and is also contained in the service users guide in resident’s bedrooms. Individual residents and their relatives the inspector talked to say they were aware of the complaints procedure feedback cards also confirmed this. Residents said they would know who to talk to if they were unhappy about something. One complaint was made to the home in February 2006 regarding a chair collapsing in a residents bedroom this was dealt with by the home and a record maintained. Residents are protected from abuse by awareness of staff and staff training, the homes policies and procedures which staff are familiar with. The Care Manager and Deputy Manager have just completed training in challenging behaviour, dementia, and vulnerable adults. Staff members attended abuse awareness training in November 2005 those staff that did not attend this training will do so shortly. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 13 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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with an attractive and homely place to live. EVIDENCE: The home generally is well maintained and suitable for its stated purpose. Communal areas have recently been re-decorated. New soft furnishings have been provided in all old bedrooms curtains blinds bed throws and bedroom 12 has a new carpet. A new dishwasher has also been purchased. Consideration should be given to the provision of a hairdressing salon as the very small area where residents sit to dry their hair has no natural light and is a bit like a cupboard. Programmes of routine maintenance are in place work carried out being identified. Observations were that the home was clean tidy and odour free. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 14 Externally there is an attractive garden area with patio that is well used by residents and visitors gazebo and seating is provided. Bathrooms and toilets are appropriately sited around the home with a variety of assisted facilities. Specialist equipment is provided, as residents require. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 15 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffs throughout this visit were observed to be working as a team supporting each other and residents. EVIDENCE: Observations today were that staff on duty were as the rota and were sufficient in number to meet the needs of individuals in their care. Robust recruitment procedures are in place to employ staff Criminal Records Bureau checks are carried out along with POVA checks prior to permanent employment being offered. Staff training programme in place via Mimosa Health Care along with a training matrix and budget. All new staff completes Manual Handling and Fire Training before commencing duty with the homes residents. The Care Manager has completed NVQ Level 4 and is starting her registered managers award. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 16 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): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is well supported by Mimosa Health Care via line management in providing clear leadership throughout the home staff demonstrating an awareness of roles and responsibilities. Management operate an open door policy for staff, residents, and their relatives. EVIDENCE: The Care Manager has 20 years experience in the care of older people. She has NVQ Level 3 and 4 and also has D32/D33 assessors award. The Care Manager has also completed her Manual Handling Trainers Certificate. She attends regular training to update her knowledge. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 17 Staff at the home receive formal supervision on a regular basis however the Care Manager has yet to receive formal supervision from Mimosa Health Care. Quality assurance system in place that is reviewed on a regular basis to ensure standards are being met. Secure facilities are provided for the safe storage of valuables and monies. Resident’s finances sampled cash balanced with records maintained. The registered person ensures so far as is reasonably practicable the health safety and welfare of residents and staff. Health and Safety policies and procedures are in place to inform staff of practices in the home. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 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 3 The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16 2 (n) Requirement Timescale for action Consult service users about the programme of activities including 16/06/06 those service users with dementia and provide evidence that activity for this group of service users are being provided. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP11 OP31 Good Practice Recommendations Residents name and room number be identified in the service users guide. The Care Manager receives formal recorded supervision on a regular basis from Mimosa Health Care. The Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Willows DS0000066269.V293894.R01.S.doc Version 5.1 Page 21 - 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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