Inspection on 16/06/05 for The Willows

This inspection was carried out on 16th June 2005.

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

The Willows 04/09/07

The Willows 06/06/06

The Willows 21/11/05

The Willows 03/12/04

The Willows 21/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Willows 74 Station Street Rippingdale Lincolnshire PE10 0SX Lead Inspector Sue Hayward Unannounced 16 June 2005 09:30 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 C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Willows Address 74 Station Street Rippingdale Lincolnshire PE10 0SX 01778 440773 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) Mrs Ellen Floyd Mrs Ellen Floyd Care Home 31 Category(ies) of DE (E) Dementia - over 65 years - Both 4 registration, with number OP Old age - Both 27 of places The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 03/12/04 Brief Description of the Service: The Willows is situated in the vilage of Rippingale, six miles north of the town of Bourne. The vilage has a pub, shop/post office, church, GP surgery and a vilage hall. It is within easy reach of Bourne, which has a wide range of shops and amenities. The home is registered for 31 older people including up to 4 with dementia. The original house has been extended and accomodation is provided on two floors. First floor bedrooms can be reached by a passenger lift or stairs. There are a variety of communal areas including three lounges, a reading room, a sun lounge and two dining areas, one of which has a bar. There are 19 single bedrooms, two of these having en-suite facilities and three twin bedrooms with en-suite facilities. The gardens are spacious and enclosed. The rear of the property is laid to flower beds and lawns, with a furnished patio area. There is a raised pond, a summerhouse and a barbeque area. The property also has a driveway and car parking area. There is an adjacent building containing offices, a laundry and a large room used as a training venue. The home has achieved and maintained the Investors in People award. The owner/managers live in a house within the grounds. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced starting at 9:15 a.m. and took place over seven hours. It was carried out by one inspector as the first of two inspections required by law for 2005/6. The main method of inspection used was “case tracking”. This involved selecting three residents and tracking the care they receive through their records, discussions with two of them as one chose not to speak with the inspector and discussion with three of the care staff on duty. It also included discussion with two resident’s relatives. In addition two further residents were spoken to and a sample of regulatory records, policies and procedures were inspected. The Commission received six completed questionnaires from residents and nine from relatives/visitors as well as one telephone call from a relative. What the service does well: The home provides a clean and comfortable environment for the residents living there, which is being well maintained. Residents all commented that they were well cared for and relatives/visitors to the home all made comments that they were satisfied with the care provided. One comment was “I have nothing but praise for Mrs Floyd and her staff, they provided my mother with a high standard of care”. There are a range of policies and procedures which staff were aware of. The staff team is well established and were observed to treat residents in a kind and courteous manner. Staff have regular training to ensure that they can care for residents appropriately. Visitors commented that there were always staff around to speak to and all felt able to raise any concerns should they have any with the owner/manager. Visitors are made very welcome at this home. The needs of residents are reviewed on a regular basis and include residents and relatives wherever possible. The home is being well managed. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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 C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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, 2 and 3. Standard 6 does not apply as the home does not offer an internediate care service. The systems in place for the introduction and assessment of resident’s to the home ensure care needs are identified and met. Written information about the home is made available to residents and their representatives. EVIDENCE: The home has a statement of purpose and service user guide, which accurately reflects the service. The statement of purpose was on display in the small lounge off the entrance hall. All residents are given their own copy of “The guide to the Willows” on admission and inspection of personal records demonstrated that residents have been issued with terms and conditions of residency or a form of agreement if social services has been involved in the admission. The “Guide to the Willows” includes information that past inspection reports are held in reception should anyone wish to read them, most questionnaires from relatives/visitors indicated that they had access to reports, two did not. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 9 Discussion with the staff on duty and the owner/manager indicated that there is a thorough assessment process operated at the home. The home has a written admission procedure it follows which includes the owner/manager visiting prospective residents prior to admission and confirming in writing to them that they can meet their needs. In addition relatives spoken to on the day indicated that they had been able to visit the home on their relatives behalf and had opportunities to ask questions about the home. Both relatives confirmed they thought they had been given written information about the home in the past. Information is given to staff about any new admissions at shift handover sessions. All questionnaires completed by residents indicated that they felt well cared for at the home. Eight questionnaires completed by relatives/visitors indicated that they felt that the home consulted them about their relative’s care one said they were “sometimes” consulted. Records showed that the home assesses resident’s physical and social needs. Risk assessments are done in relation to various matters such as manual handling needs and outcomes recorded. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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 Care plans include information about residents individual needs and preferences and the action to be taken to ensure that needs are met. They are completed with residents or their relative’s involvement and are regularly reviewed. Action is taken to ensure that residents are treated with respect and have privacy. EVIDENCE: Care plans were in place for all resident’s records checked on the day. They all contained information which demonstrated that they are reviewed on a monthly basis and some contained annual review information. All care plans had been signed either by residents if able or their relatives/representatives and both relatives spoken to on the day said that they had seen care plans. Residents’ records included information, which indicated that they have visits from or to other health professionals as needed for example ophthalmologist and district nurse visits. The district nurse visited the home during the inspection. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 11 Visiting relatives made comments, which indicated that they thought their relatives were well cared for at this home and questionnaires completed by relatives/visitors to the home indicated that all were satisfied with the overall care that the home provides. As stated previously most felt that they were kept informed and were consulted about important matters affecting their relatives. All resident’s comments indicated that they were well cared for. Staff were observed to treat residents in a kind, courteous and respectful manner The home has a statement about privacy and dignity, which is included in the statement of purpose. Staff gave examples of how these principles are implemented and were observed to knock on doors before entering bedrooms. A matter was raised where a resident felt their privacy was not being fully respected. It is acknowledged that the owners were taking measures on the day of the inspection to address this issue by providing a lock on the resident’s bedroom door (some bedroom doors have already been provided with locks). A full inspection of the medication systems in place was not done on this occasion (this had been done at the previous inspection of 03/12/04 where it was noted that staff are trained and assessed as competent prior to being able to administer medication and there are satisfactory policies and procedures in place) however the requirement and recommendation made at the last inspection was checked during this visit. This related to the home obtaining a controlled drugs book and storing medication returns in a lidded container. Satisfactory action had been taken to address both issues. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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) 13 and 15 Visitors are welcomed at this home. Residents are provided with nutritious meals, which cater for their individual needs and preferences. EVIDENCE: Comments from residents, staff and relatives all confirmed that visitors are welcomed at the home. It was noticed that on the day of the visit a relative of a resident had been invited to have lunch at the home, as it was her birthday. Another relative confirmed that she had been invited to stay for meals and that the food provided was very good. Drinks are offered to visitors when they arrive. Visitors said that they are able to see their relatives/friends in private if they wish and staff said that a lounge area is made available or residents own rooms can be used if wished. There is a booklet kept at each entrance for visitors to sign in and out. The home has links with the local community, for example the local Church visits to conduct services and the home recently took part in the village scarecrow event. A record is kept of some activities, entertainment and events that occur at the home. It was recorded that in May and June there had been three lots of The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 13 entertainment arranged. In addition there had been a Church service and a memory game organised. Birthday celebrations were also recorded. Comments from residents all indicated that they did not wish to be more involved in decision making within the home and most residents thought that the home provided suitable activities. Two residents made comments that they would like to have more varied social opportunities. The home has in the past had a social committee consisting of residents, staff and relatives. The owner/manager confirmed that this committee was to recommence and would be a good method of identifying any additional activities residents may wish to pursue. Residents and relatives comments indicated that the meals provided are satisfactory. Residents have a choice as to whether they eat their meals in the dining rooms or their bedrooms. There is a range of breakfast foods available including a cooked breakfast. The main meal is a set meal but individual preferences are catered for as are any special dietary needs and the cook was aware of these. Records are kept of the food provided and there are policies and procedures in relation to food safety and nutrition. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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 There are satisfactory arrangements in place for raising concerns and for the protection of residents. EVIDENCE: There is a satisfactory complaints procedure in place. Whilst the complaints policy in the procedure manual has been reviewed to reflect the change of the Commissions name from the National Care Standards Commission to the CSCI the one on display needs to be altered. Neither the home nor the CSCI have received any complaints since the last inspection. There is a satisfactory adult protection procedure in place, which links with Local Authority Adult Protection procedures and there is a range of supporting policies such as Whistle Blowing. Staff spoken to gave a satisfactory description of the action they would take should either event occur in the home and knew who to report such matters to. Two staff members said that they had attended a recent session about adult abuse. All 6 questionnaires completed by residents indicated that they felt safe at the home and 5 indicated that they were aware of whom to speak to if they wished to raise concerns. Seven of the questionnaires completed by relatives/visitors indicated that they were aware of the homes complaints procedure, 2 were not however it was noticed at the time of the inspection that it was pinned on the notice board in one of the dining rooms. 8 questionnaires completed by visitors/friends indicated that they had never had to make a complaint. One The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 15 relative spoken to said that on the one occasion when she had raised a concern it had been immediately dealt with by the owner/manager, who she had considerable praise for. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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, 24 and 26 Residents living in this home live in a clean, comfortable and homely environment. Staff are provided with equipment to protect residents from the risk of cross infection. EVIDENCE: Those areas of the home seen on the day of the inspection included four residents’ bedrooms, lounge, sitting and dining areas and toilets. The home was clean and comfortably furnished. Staff comments and observations made, indicated that any necessary maintenance matters are dealt with promptly. For example on the day of the inspection there was a problem with the door to the passenger lift and a contractor was called out immediately to rectify it. Toilets were clearly labelled, clean, lockable and contained equipment to assist residents. The flooring in one was showing some signs of wear and tear but there is a maintenance programme in place. Staff are provided with the necessary equipment such as gloves and aprons to reduce the risk of cross infection. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 17 Resident’s bedrooms contained personal items and residents commented that they found their rooms to be comfortable. Some are lockable, some not. A lock had been provided at a resident’s request however consideration must be given to ensure that it is suitable for the resident to operate and a written risk assessment must be completed about this. A relative said that the home is always kept clean and tidy. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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 Staffing levels in this home ensure that the needs of residents are being met. The recruitment system ensures as far as possible that residents are protected. EVIDENCE: Discussion with staff and records demonstrated that the home is being staffed at a level to meet the needs of current residents. Rotas demonstrated that there are generally six staff on the morning shift during the week and five at weekends, in the afternoon four staff members, and at night two wakeful staff are on duty. Relatives comments indicated that they felt their relatives were well cared for and there were always staff around to speak to if necessary. A comment made was staff are “brilliant and caring”, another “my mother often expressed her frustration with her condition, but not towards the staff who cared for her”. Comments from staff indicated that staffing levels enabled them to meet resident’s needs. Residents commented that the staff treated them well and they were well cared for. Records of the recruitment of two staff were checked. They demonstrated that references, proof of identity and Criminal Records Bureau checks are carried out. A staff members comments further confirmed that this was the process in operation. Staff comments and records demonstrated that the home provides many opportunities for training with regular updates on some subjects such as manual handling and fire training. The Willows is an accredited centre for National Vocational Qualification in Care (NVQ) awards. The pre-inspection The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 19 questionnaire completed by the owner/manager indicated that 60 of staff working at the home had achieved NVQ level II or above and all 25 staff employed held a current First Aid certificate. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 20 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, 33 & 38 The home is being well managed and led by owners who have daily input into it. It is recommended that the quality audit system includes obtaining views about resident’s satisfaction with the arrangements in place to meet their social needs and will further demonstrate the homes commitment to listening to the views of residents. A risk assessment must be done in relation to the provision of a lock to a bedroom door in order that it can be demonstrated that home is operating to ensure the residents safety and independence. EVIDENCE: The owner/manager has recently completed the Registered Managers award. Staff said they had plenty of training opportunities and there are staff meetings held on a regular basis. Thank you cards from relatives were displayed on the notice board. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 21 The owner/manager provided a questionnaire, which she is due to use with residents and relatives. This forms part of the homes quality assurance system in place, but it is now over a year since it has been done. It was recommended that it is expanded to include views about the social and leisure activities offered as opinions from residents and relatives differed about this. The manager also intends to re-start the social committee, which she said was a useful way of obtaining residents and relatives views. The sample of records seen that are required by law to be kept were available and up to date, for example records of the fire alarm system indicated weekly checks are made, monthly checks of the emergency lighting in the home and 9 staff had attended fire training on 09/02/05. There are policies and procedures in place to safeguard and protect residents. Risk assessments have been completed in relation to fire safety and health and safety issues relating to the home environment. They are also conducted in relation to risks to individuals. A risk assessment needs to be done for the resident who had a door lock fitted on the day of the inspection. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 3 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 3 3 x 3 x x x x 2 The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 23 NO 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 38 Regulation 13 (4) Requirement A risk assessment must be undertaken and documented in relation to the provision of a door lock which demonstrates that the lock is suited to the residents capabilities, is accessible to staff in emergencies and meets with the approval of the fire brigade. Timescale for action 31st July 2005 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 33 Good Practice Recommendations It is recommended that the quality assurance system be conducted on at least and annual basis. The Willows C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection CSCI, Unity House The Point, Weaver Road off Whisby Road Lincoln, LN6 3QN 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 C53 C04 S2467 The Willows V225329 160605 Stage 4.doc Version 1.30 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. 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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