Inspection on 15/05/07 for The Willows

This inspection was carried out on 15th May 2007.

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 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 07/05/08

The Willows 30/10/06

The Willows 09/11/05

The Willows 21/09/04

The Willows 26/04/04

The Willows 26/01/04

The Willows 12/05/03

The Willows 28/10/02

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

CARE HOMES FOR OLDER PEOPLE The Willows Dangerfield Lane Darlaston Walsall West Midlands WS10 7RT Lead Inspector Rosalind Dennis Key Unannounced Inspection 15th May 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 DS0000020785.V339681.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 DS0000020785.V339681.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address Dangerfield Lane Darlaston Walsall West Midlands WS10 7RT 0121 568 7611 0121 568 7989 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) Regal Care (Darlaston) Limited Mrs Tracey Maria Parkes Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 48 frail elderly people over the age of 60 years who require nursing care That the following staffing levels are adhered to as minimum numbers and subject to increase as dependency levels require: 8:00 am - 8:00pm - 2 trained nurses 8:00pm - 8:00am - 1 trained nurse 7:00am - 2:00pm - 9 carers 2:00pm - 9:00pm - 7 carers 9:00pm - 7:00am 4 carers Date of last inspection Brief Description of the Service: The Willows is a modern purpose built home first registered in May 1998. There are 48 large single bedrooms, all but one having en-suite and a number being linked, to accommodate couples. There are 3 good size lounges, 2 with dining area providing spacious communal areas on both floors. The rooms are spacious and colour co-ordinated, each has a good-sized double glazed window and on the ground floor, patio doors to the gardens. Rooms are light and airy with a view onto either the garden or onto Dangerfield Lane/Moxley Road. In addition to the en-suite provision there is a plentiful number of baths, showers and toilets distributed around the building. The enclosed gardens are large and accessible from downstairs, bedrooms and lounge area. The ancillary services of catering, laundry housekeeping and maintenance are provided in-house. The home provides plentiful off road parking. Fees for this home currently range between £327 and £520. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10.00 and was conducted by one inspector over a period of around 7 hours. All ‘key’ standards were assessed during the day- that is those areas of service delivery that are considered essential to the running of a care home. Time was spent observing staff working, looking at documentation, speaking with some of the people living at the home and observing a selection of bedrooms on the ground floor. Observations confirmed that people appeared well cared for and staff were seen to be attentive and responding competently to people’s needs. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls within this home are few. However this inspection identified that processes to ensure all medication is stored at the required temperature has not been achieved. The home must also follow good practice guidance when The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 6 administering PEG feeds and in the management of Sharps Disposal, to ensure that people are protected by the home’s infection control systems. During a tour of the home it was seen that a number of bed rails in use were compromising the safety of people living at the home as they were not fitted correctly, this resulted in the issuing of an immediate requirement notification for the home to take immediate action to assess those people with bed rails in use and to ensure all bed rails were fitted in accordance with MHRA/HSE guidance. It was found that one member of staff had been recruited without a CRB Disclosure and the home is required to ensure that all pre-employment checks are undertaken before an individual starts work. An audit of all staff files is advised to ensure that people already working at the home have the required information on their personnel files. 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 DS0000020785.V339681.R01.S.doc Version 5.2 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 DS0000020785.V339681.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. The home has a satisfactory admissions procedure and the assessment processes in use demonstrate that the home is able to meet the needs of people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of four care files shows that people are assessed prior to and on admission to the home. The people who were case tracked were unable to give their views of the admission process but documentation showed that staff had been pro-active in finding out about the person’s needs through discussion with the person, their significant others and healthcare professionals as appropriate. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 9 The statement of purpose and service user guide were not observed at this inspection, however discussion with the manager indicated that these documents will need amending and updating to include reference to the fees charged by the home. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. Care plans and risk assessments are generally well written and provide staff with information to meet people’s needs. Improvements in how people are assessed for the use of bed rails are needed to ensure that safety needs are fully met. The administration of medication is generally good, however the storage of medication is not satisfactory and this could impact on the effectiveness of the drugs and put service users at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who were able to communicate their needs spoke of how the staff are helpful and ‘very good’, this was also confirmed by three visitors to the home. People appeared well cared for, staff were attentive in attending promptly to The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 11 people’s needs and a good rapport was observed between staff, people living at the home and visitors. Observation of care documentation for four people shows that care plans and risk assessments are generally completed well, providing guidance for staff on how to meet people’s needs and evidence was available to show that staff regularly review care needs. Staff complete good assessments of people’s wounds, however some inconsistencies in documenting when dressings had been applied were seen in two peoples care records which could result in dressings not being applied to the required frequency. It was also noted that staff had not consistently signed or dated care documents with the specific date of entry in the records. Care plans made reference to the use of bed rails, however risk assessments were not in place or evidence to show that the use of the bed rails had been discussed with the person and/or their representative and permission for their use obtained. A review completed by a social worker had identified that a person did not have care plan in place to provide guidance to staff on the person’s specific cultural and spiritual needs and it was discussed with the manager at this inspection that it is disappointing that a care plan had still not been drawn up to provide this guidance for staff. Care records show that the home contacts appropriate healthcare professionals for advice as necessary and medical input is provided via local GP practices. Medication administration is restricted to qualified nursing staff and a new member of staff confirmed recent training on using a Monitored Dosage system. Medication administration record charts appear to have been completed accurately by staff to confirm that people had received their medication as prescribed. Insulin was stored correctly and in accordance with the manufacturer’s instructions. Observation of the drugs fridge temperature records showed that the temperature of the fridge was outside of the required range of 2°C to 8°C, for example staff had recorded fridge temperatures as low as –3°C and as high as 11°C, which suggests that staff recording the temperature are not aware of the required ‘safe’ temperature range. The home has not yet implemented a process to ensure that the temperature of the medication storage rooms within the home are monitored and maintained below 25°C-the treatment room on the ground floor was notably warm on the day of inspection. Syringes designed for single use were identified as being washed by staff and re-used for the administration of artificial feeds-staff were informed that this practice is not acceptable and must stop immediately. Boxes designed for the safe disposal of sharp instruments had not been signed and dated on opening. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 and 15 Quality in this outcome area is good. Daily routines are flexible with residents being offered a choice of varied activities and the home is currently exploring ways to further enhance the social well being of people living at the home. The home provides meals that offer variety and cater for different nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has attempted to recruit a staff member for the purpose of promoting activities within the home and the manager confirmed that a new person should be starting soon-this should enhance the social/recreational needs of people living at the home. At the moment care staff provide activities such as quiz games and bingo supplemented by visits from entertainers such as singers, people promoting ‘exercise to movement’ and notices were seen advertising a ‘jewellery party’ to be held at the home. The manager confirmed that visits outside of the home are also planned. Two people spoken with were satisfied with the current level of activities. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 13 Meals are served either in the dining areas or private rooms dependent on the wishes of each individual. A discussion with the cook and observation of menus shows that the home offers choice, respects individual preferences and provides meals, which are varied, balanced and nutritious. Regular drinks and snacks are offered between meals and staff were seen providing help to people who needed assistance with eating and drinking. Three people living at the home who were able to communicate their views commented that the meals provided by the home are good. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The home has a complaints procedure that ensures that people’s concerns are listened to and acted upon and staff are provided with training to equip them with the knowledge to protect people from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has its own complaints/concerns procedures, a copy of which is displayed at the entrance of the home. Visitors and people living at the home commented that they would raise any concerns with the manager and felt confident that their concern would be taken seriously. The manager demonstrated a sound knowledge of dealing with concerns, complaints and adult protection issues. CSCI has not received any complaints in respect of The Willows since the last inspection. Observation of the process used by the manager to record concerns or complaints demonstrates that the procedure to record, investigate and monitor complaints and their outcomes is good. Training records show that staff have received training in adult protection/abuse awareness. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. The home is well maintained and provides a comfortable environment for people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are in good condition and spacious corridors and bathroom provide people dependant on wheelchairs space for moving and transferring. Bedrooms that were seen were tastefully decorated, with good quality furnishings and fittings. People are able to bring in personal possessions to decorate their rooms to promote a more homely feel. The home has a well-equipped laundry with designated staff who provide a daily service. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 16 All parts of the home, which were observed, were very clean apart from one bedroom where the carpet was noted to be soiled in places. Staff were seen during the inspection using appropriate protective clothing for care activities and food handling. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is adequate. Training opportunities within the home ensure that staff are appropriately skilled and competent to carry out the duties for which they are employed. The recruitment process is not robust and does not fully protect people living at the home from the employment of inappropriate staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager and senior member of staff confirmed that staffing numbers are maintained at sufficient levels to meet the needs of people living at the home with either the home’s own staff or agency staff used to supplement staffing numbers during periods of sickness. People spoken with were satisfied that the care they receive meets their needs and described staff as ‘very good’ and ‘helpful’. One person commented that staff work extremely hard and did comment that very occasionally staff are not able to immediately provide help because they are busy caring for someone else. During the inspection staff were observed attending to call buzzers and to people’s needs promptly. Observation of training records shows that the home provides all mandatory training with updates in practice provided when necessary. The home supports The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 18 staff to achieve NVQ Level 2 in care and 56 of staff have currently achieved this level, two staff have achieved NVQ Level 3 with three staff awaiting confirmation of completing this award. The home provides a comprehensive induction programme, which incorporates a section on treating people with respect and information to promote cultural awareness. Files for three members of staff showed that the home had not obtained a CRB Disclosure for one member of staff appointed last year, although all other preemployment checks were present on this person’s file it is considered a serious oversight that this member of staff had been appointed without a POVA First check and CRB being obtained. CRB Disclosures were present on the two other staff files seen. The registered person must take prompt action to ensure that all pre-employment checks are consistently undertaken. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. The home monitors and reviews processes to ensure that residents receive a range of quality services. The home has systems in place to protect residents from harm however by not adhering to current guidance regarding the safe use of bed rails the health, safety and welfare of residents is not fully promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 20 The manager is a registered nurse with a good range of skills and experience. A discussion with the manager confirmed an enthusiasm to improve services within the home. Throughout the inspection staff were observed to be accessible, good communicators and interacted appropriately with the residents. The home operates a quality assurance system based on seeking the views of people where capable and/or their representatives, and examples of these questionnaires were seen at the last inspection. The home acts on results from feedback and an example of this is how the home altered menus to take account of people’s comments regarding meals. The company responsible individual continues to conduct monthly, unannounced visits of the home and a copy of this report is sent through to CSCI. Financial records were not seen at this inspection; the manager confirmed that the process remains the same as at the last inspection where it was assessed that the home has good accounting practices. The home conducts a range of assessments to manage risks presented by everyday practice. The manager has recently developed a risk assessment on the use of bed rails within the home although the elements contained within the risk assessment had not been implemented. People with bed rails in use did not have risk assessments in place or a record made to show that permission for use had been obtained from the person and/or their significant other. During a tour of the home it was seen that a number of bed rails in use were compromising the safety of people living at the home as they were not fitted correctly, this resulted in the issuing of an immediate requirement notification for the home to take immediate action to assess those people with bed rails in use and to ensure all bed rails were fitted in accordance with MHRA/HSE guidance. Observation of staff records show that staff are provided with formal staff supervision and annual performance reviews are undertaken. The Willows DS0000020785.V339681.R01.S.doc Version 5.2 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. 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement Medication must be stored in accordance with manufacturers’ instructions This is to ensure that medication is stored correctly to prevent people being placed at risk of harm and from receiving ineffective medication. (Previous timescale of 30/11/06 not achieved) Timescale for action 15/07/07 2 OP29 19, Schedule 2 3 OP38 13 (4)(c) Staff recruited by the home must 15/07/07 have all required preemployment checks undertaken. This is to protect people from the employment of inappropriate staff. Bed rails must be assessed, 15/05/07 fitted and maintained by a competent person in accordance with MHRA/HSE guidance. This is to protect the person from the risk of harm and promote their safety (15/05/07-Immediate requirement issued). The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 23 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 OP7 Good Practice Recommendations Staff are advised to sign and record the specific date of entry when writing in care records. This is to ensure accuracy and to provide information, if required, of the staff member deemed responsible for ensuring care needs are met. Care plans should take into account a person’s specific cultural and spiritual needs. This is to ensure that staff are provided with information to meet the person’s needs and preferences. The home must follow good practice guidance when administering PEG feeds and in the management of Sharps Disposal. This is to ensure that people are protected by the home’s infection control systems. The manager should increase the opportunities for service users to have stimulation through leisure and recreational activities (15/05/07-Assessed as in progress at this inspection). The floor of the shower should be adapted to prevent water overflow into the corridor (15/05/07-Not assessed at this inspection). It is recommended that staff files are audited. This is to ensure that all required pre-employment checks have been completed, to meet legislation and protect people living at the home. . 2 OP7 3 OP9 4. OP12 5. OP19 6 OP29 The Willows DS0000020785.V339681.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 DS0000020785.V339681.R01.S.doc Version 5.2 Page 25 - 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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