CARE HOMES FOR OLDER PEOPLE
The Willows 197 Darkes Lane Potters Bar Hertfordshire EN6 1AA Lead Inspector
Neil Fernando Unannounced 13 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service The Willows Address 197 Darkes Lane, Potters Bar, Hertfordshire, EN6 1AA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01707 659205 01707 659202 Follett Care Limited Mrs E Hayward CRH PC 12 Category(ies) of OP - Old Age - 12 registration, with number of places The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: The home is registered as a Care Home providing personal care only to 12 service users under the category of Old Age. Date of last inspection 28 October 2004 Brief Description of the Service: The Willows is a detached Edwardian period, family house that has been converted into a residential care home for elderly people. The home is situated at the end of the main shopping parade in the town of Potters Bar. The accommodation is on two floors and consists of ten single occupancy rooms and one shared room. The home does not have a passenger or stair lift and service users admitted to the home must be assessed as having full mobility, if they are to be accommodated on the first floor. The home has a front yard with parking facilities for up to 4/5 cars and a very secluded garden at the rear of the property, which is set to lawn and benefits from a fish pond and mature trees. The home has easy access to the Motorways and the main line station. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first inspection for the year 2005/6 under the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The last inspection was carried out 28.10.04. The Willows is a residential care home, which is registered to accommodate up to a maximum of 12 older people. It is one of four care homes owned and managed by Follett Care Limited. There were 2 service users in residence at the time of the inspection. The inspection was carried out over half a day in mid-April 2005. All of the National Minimum Standards assessed bar four, have been met. Both service users and three staff members including the Manager were spoken to, in order to seek their views regarding the quality of life for residents at The Willows. What the service does well:
The arrangements to enable service users and their relatives the opportunity to visit and make an informed decision about the facilities offered at The Willows is being well managed. The assessment of needs carried out prior to any resident being offered a place is comprehensive. There is ample evidence to demonstrate that the health and personal care needs are being identified through a simple and clear planning process and monitored through a review system, involving the service user and significant others. Service users are treated courteously and their privacy is upheld. Social and recreational activities facilitated are tailored to suit the individuals. The complaint system is well advertised and service users felt able to raise any concern they may have regarding any aspect of the service. Effective monitoring takes place, in order to ensure that service users are protected from harm. Service users and staff members spoken to felt that the quality of services offered at this home is of a high standard. Overall, the standard of physical environment is adequate and comfortable for the current service users. Health and safety issues are being attended to and good care is taken to ensure that service users are not exposed to any hazard. The day and night staffing arrangements are satisfactory. Mandatory training including NVQ assessment for staff members is being dealt with, which staff members appear to appreciate. A robust recruitment process has been adopted, which protects residents from harm. The Manager is experienced and competent to manage this establishment. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5 The arrangements to enable prospective residents and their relatives to make an informed decision regarding the suitability of the home remain satisfactory. Service users and their relatives are being pro-actively encouraged to visit and meet with staff members and other residents. A comprehensive assessment of needs of the prospective resident is undertaken and this ensures that the home only admits service users whose identified needs are achievable. EVIDENCE: The case records for both service users were examined and these include comprehensive details of the completed pre-admission assessment undertaken by the Manager or a senior staff member. Records examined and information gained from one service user, the Manager and the visit from prospective resident’s friend on the day of the inspection, clearly indicate that the arrangements to enable service users and their relatives/friends the opportunity to visit and make an informed decision about the facilities offered at this establishment is satisfactory. They would spend time looking around, speaking to other service users and a meal is offered, as appropriate. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 9 Service users are admitted on a trial basis to give them ample opportunity to decide if they want to stay and also to give the home’s staff time to further assess the needs of the service users. A review meeting is held at the end of the trial period with the service user, relatives and placing authority, and only then the placement is made permanent. Good evidence is available to demonstrate that service users and their relatives are being empowered to participate in the decision making process, on issues that matter to them. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Service users’ needs and requirements, including health and personal care are being identified and addressed through a care planning process and monitored through a monthly review system. Residents and relatives participate in the care planning and review process. Nevertheless, some improvement to the monthly review notes is needed. Service users are positive regarding the manner their needs are being addressed. Feedback from the current residents and observation of care practice indicates that residents are treated with respect and the right to privacy, promoted. EVIDENCE: The care plans for both service users were examined and these were noted to be comprehensive. Information gathered from the current residents, two staff members, and care plans viewed indicate that the needs of residents are being identified and addressed on an ongoing basis and in a holistic manner. Service users/relatives are encouraged to sign the care plans where this is appropriate, in order to reflect their involvement and agreement with the content of the care plan. Monthly reviews of care plans are being carried out, but some improvement should be made, in order to reasonably reflect the changing needs and requirements for health and personal care for each service user. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 11 Records show that all residents are registered with a local GP of their choice who visits as and when required. Residents spoken with expressed a high level of satisfaction in the manner their health care needs are being addressed. The outcome of the Doctor’s visits is clearly recorded in the care plans. Service users see their visitors including the GP, in the privacy of their own room. There is a working pay telephone and residents are able to make and receive calls in private. One of the ways in which residents’ rights to privacy and dignity are promoted and respected is through staff members always knocking on bedroom doors before entering. Mail is delivered unopened and staff members would assist in reading if required. Both service users were dressed in fresh and appropriate clothes and staff members were seen to interact with them, in a manner conducive to good practice. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Service users’ interests, expectations and aspirations are being sought by staff and fulfilled as appropriate. Service users maintain good contact with their family and friends. The level and variety of social and recreational activities appear to be satisfactory, in order to maintain an adequate level of stimulation for the service users’ general wellbeing. EVIDENCE: Both service users clearly have their identified social, cultural, religious and recreational needs woven in their care plans. Information gathered from staff members, the residents and observation made clearly demonstrates that their identified needs are being addressed satisfactorily. There are currently only two service users accommodated, which in effect means that staff members have the time and opportunity to ensure an individual approach to their needs. Both residents are in the nineties and consequently, daily social and recreational activities are planned and facilitated to suit each person’s needs. Daily records of relevant occurrence evidence that a good level and variety of activities occur, in order to provide an adequate level of stimulation. However, there is no pressure to participate and residents are free to withdraw from any activity if they so wish. Evidence shows that visiting times are flexible and visitors are always welcome in the home. Both residents maintain good contact with their family and
The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 13 friends. Service users reported that they are able to entertain their visitors in private and also choose whom they see and do not see. Menus are discussed with the residents taking into account their taste and preference. Advice from a nutritionist is available as required. Both residents described the quality of food available to them as “Excellent”. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Information on how to make a complaint is available and service users felt able to make a complaint to staff members. Information gained suggests that complaints would be managed satisfactorily. There are various systems in operation, which should offer adequate protection to a resident from harm. Nevertheless, essential training on the Protection of Vulnerable Adults should be made accessible to staff members. EVIDENCE: Staff members interviewed demonstrated a good understanding of the complaints procedures. Information on how to make a complaint is also included in the home’s statement of purpose and service users’ guide. Residents felt able to make a complaint if they were dissatisfied with any aspect of the services they receive. The home maintains a complaints record book, which indicates that there have been no complaints made to the home since the last inspection on 28.10.04. The home has procedures on Adult Protection and “Whistle Blowing”, and a copy of the DOH guidance ‘No Secrets’ is available to the staff team. Staff members interviewed was able to demonstrate an understanding of the ‘Whistle Blowing’ procedures and said that they would report any allegation and incident of abuse to the Manager or a senior member of staff on duty. Staff and service users felt that The Willows is a safe home for resident to live in. Training on the protection of vulnerable adults is an integral part of the induction for all staff members. It is however recommended that essential training on the Protection of Vulnerable Adults should be made accessible to all
The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 15 staff members, to enable them to more effectively protect and promote the welfare of residents. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home appears to continue to provide good living conditions to the current service users. The accommodation is bright and comfortable. Redecoration of the communal area has significantly improved the physical environment for the service users. Upgrading and extending the accommodation no doubt, will further improve the physical environment and the quality of life for service users. The standard of cleanliness was high and furnishings are satisfactory. EVIDENCE: Bedrooms are decorated and furnished in a style that promotes a domestic atmosphere. The lounge/diner is being decorated to a very high standard. The carpet in the ground floor bathroom is worn out and needs a replacement. The home does not have a passenger lift to access the first floor and therefore, only service users who are physically fit and mobile could be accommodated in its upstairs eight bedrooms. There are strong indications to suggest that the occupancy has dropped to its current level (2), mainly due to the home not having a passenger lift. However, on a more positive note, the Responsible Individual has confirmed in writing to the Commission that arrangements are being made for the Organisation to submit an application for upgrading and extending the accommodation, including the fitting of a passenger lift to the
The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 17 appropriate Planning and Building Control Department. This is welcome by the Commission. With this in mind, it would be fair to view the shortfall with respect to the lift the context of the proposals and therefore, no recommendation is being made. A standard of cleanliness was evident throughout those areas viewed. There were no mal-odours present. There are infection control policies and procedures in place. Suitable arrangements are made for the storage and collection of domestic and clinical waste. Risk assessment of the physical environment is undertaken regularly. There were no health and safety hazards noted during this visit. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The day and night staffing arrangements are deemed to be satisfactory. The needs of the current service users are being well met. Staff recruitment process is robust, which means that residents are in safe hands. Staff members receive training to enable them to deliver a good quality service to residents. NVQ assessment for care staff is being progressed satisfactorily. EVIDENCE: Staff duty rotas for a period of 4 weeks and discussion with three staff members including the Manager shows that the day and night care staffing levels are adequate to meet the needs of the current service users. The staff members on duty also reconciled with the rotas for the day. The procedures for the recruitment of staff are comprehensive and the process is robust. Evidence is available to indicate that the Manager has made good effort, in order to ensure that all new recruits are subject to in depth checks, in line with the regulations and NMS. Both staff members interviewed reported that they have had their CRB checks completed. Information gathered from staff members and individual training profiles evidences that mandatory training has been provided to staff, as appropriate. Arrangements are in hand for all staff members to receive training in Health and Safety in May 2005. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34 and38 The management of this home remains satisfactory. The implementation of policies and procedures appears to promote consistency and continuity of care practice and service delivery. Equally, the health, safety and welfare of service users, and staff are safeguarded. The Willows is a safe home for service users to live in – a view shared by staff members and both residents. Records viewed are maintained in good order. EVIDENCE: The Manager has been a registered Manager for almost 18 years, the last 15 having been at The Willows. The Manager was able to demonstrate that she and her staff team have undertaken regular training so as to keep abreast of changes in best care practice for elderly people, which no doubt also ensure safe working practice. The lines of accountability within the home and external management remain consistently clear and well understood by staff members. The Manager is very capable of managing this establishment. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 20 Health and safety issues are attended to. Staff members are conversant with the Regulations on Control of Substances Hazardous to Health. Risk assessments are in place and updated regularly. Records show that the fire alarm system, hot water temperature and portable electrical appliances are checked as appropriate. A requirement has been made for break glass points to be checked on a weekly basis. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x x 3 x 2 The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 23 (4) Timescale for action The registered person shall make 15.05.05 adequate arrangements, in order to ensure that tests of break glass points are carried out weekly. Requirement 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. Refer to Standard OP7 OP18 OP19 Good Practice Recommendations Monthly review notes should be in greater details, in order to reasonably reflect the changing needs and requirements of each service user. Essential training on the protection of vulnerable adults should be made accessible to staff members. The carpet in the ground floor bathroom should be replaced. The Willows CS0000019592.V221097.R01.doc Version 1.20 Page 23 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Herts AL7 3BQ 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 CS0000019592.V221097.R01.doc Version 1.20 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
