Inspection on 14/03/07 for The Willows

This inspection was carried out on 14th March 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 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

The Willows 06/12/07

The Willows 24/08/05

The Willows 13/04/05

The Willows 28/10/04

The Willows 29/07/04

The Willows 29/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Willows 197 Darkes Lane Potters Bar Hertfordshire EN6 1AA Lead Inspector Bijayraj Ramkhelawon Key Unannounced Inspection 14th March 2007 10:00 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 DS0000019592.V330426.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 197 Darkes Lane Potters Bar Hertfordshire EN6 1AA 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) 01707 659205 01707 659205 FP Follett Care Limited Mrs Elizabeth Hayward Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user who has a diagnosis of dementia for as long as the needs of that service user can continue to be met. 14th November 2006 Date of last inspection 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 railway station. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted the site visit that formed part of this inspection. On his arrival, he discovered tat the building was unoccupied. (There had only been two service users when the last visit took place). Later discussions with the providers revealed that they had not undertaken admissions to the home and that they were proposing to substantially upgrade the home now that it was empty. The registration has been ‘mothballed’ and the contents of the following report are therefore based on past knowledge of the service. 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 summary of this inspection report can be made available in other formats on request. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 6 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 DS0000019592.V330426.R01.S.doc Version 5.2 Page 7 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): 3. Standards 6 is not applicable, as the service does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission visits enables the prospective service user and their representatives to be involved in the decision making process, thus ensuring that their needs can be met on admission to the home. EVIDENCE: It was not possible to gain access to the premises on this occasion. However, past inspections have confirmed that the opportunity to visit the home and meet with staff members and other residents is seen as very crucial by service users and staff members. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 8 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): 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. Service users’ needs and requirements, including health and personal care have previously been identified and addressed through a care planning process and monitored through a monthly review system. EVIDENCE: Past inspection reports have confirmed the quality of care planning processes. Service users were reported as being comfortable and receiving care and attention in a timely and sensitive manner when the service was last operational. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 9 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): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Past visits to this service have revealed that the expectations of service users are not always met in full. However, service users relatives were encouraged to visit and the food was described positively EVIDENCE: In spite of the mental frailty of the current service users, it had been noted that they were encouraged to exercise choice and autonomy. The service users had described the quality of food available to them as “excellent”. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 10 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): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information on how to make a complaint was available in the past and service users should have been capable of making a complaint. The systems in operation should have offered adequate protection to a service user. EVIDENCE: At the last site visit, it was recorded that the home had a complaints procedure available and that service users felt able to make a complaint. There was also a whistle blowing policy available and accessible to the staff team. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 11 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): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises were in need of upgrading, but nevertheless appeared to provide good living conditions to the last residents. EVIDENCE: The providers maintained a good standard of internal decoration and cleanliness. The home does not have a passenger lift to access the first floor. The Responsible Individual has confirmed in writing to the Commission in a letter dated 26 August 2005 that good progress is being made to obtain planning consent, in order to upgrade and extend the accommodation, including the fitting of a passenger lift. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 12 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): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At the time that the last site visit was undertaken, there were sufficient numbers of appropriately trained staff. EVIDENCE: Past visits by inspectors have recorded that sufficient numbers of staff were deployed by day and by night to meet the needs of service users. All staff were provided with mandatory training and were regarded as being suitably skilled to provide the levels of care required. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 13 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): 31, 33, 35 & 37. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has always been managed appropriately and in the best interests of those who used the service. EVIDENCE: Past visits by inspectors have confirmed that the service was managed appropriately and that supporting the best interests of service users and staff was of paramount importance to the manager. The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 14 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 15 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 16 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 The Willows DS0000019592.V330426.R01.S.doc Version 5.2 Page 17 - 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!