Inspection on 17/08/06 for The Willows

This inspection was carried out on 17th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 01/12/08

The Willows 09/02/06

The Willows 22/08/05

The Willows 30/03/05

The Willows 29/04/04

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 The Willows Field Terrace Ripley Derbyshire DE5 3HF Lead Inspector Denise Bate Unannounced Inspection 17th August 2006 10:15 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 DS0000035584.V307934.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 DS0000035584.V307934.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address The Willows Field Terrace Ripley Derbyshire DE5 3HF 01773 728150 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) www.derbyshire.gov.uk Derbyshire County Council Jeanette Mary Gilmour Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: The Willows Care Home is situated within the community of Ripley, located near to the town centre and the local Community Hospital. The Home has places for 20 older people. Two rooms are used for respite care. All bedrooms are for single occupancy and are situated on the ground and first floor of the Home. There is a passenger lift to the first floor. There are no en suite facilities. The Home has a 3 lounge areas, one being used as a lounge/dining room. Fees are £364 per week for permanent service users, with a range of prices for short term care service users. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours. During the inspection six service users, one relative, and two staff members were spoken with. Two deputy managers were present during the inspection and provided assistance and information. Written information was provided by the manager prior to the day of inspection. A number of records were examined, including risk assessments and care plans, health and safety documentation, staff files, and medication records. Three service users were case tracked. A tour of the building took place. What the service does well: What has improved since the last inspection? Progress has been made on requirements made at the last inspection in February 2006. An extractor fan has been put in the medication room and the room was an appropriate temperature on the day of inspection. Staff are ensuring that all service users who keep their own medication, including short term care service users, keep their medication secure at all times. Staff have received adult protection training. The staff file seen had the appropriate The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 6 records included. Dementia awareness training has been provided. Mandatory training is undertaken on a rolling programme by all staff at work. 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 DS0000035584.V307934.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 DS0000035584.V307934.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home have a system for assessing service users’ needs to ensure that the care provided can meet service users’ needs appropriately. EVIDENCE: Assessments are carried out in the community by social workers and care managers and copies were seen on care planning documentation. Potential new residents are invited to spend a day at the home with their relatives, and this visit is used to verify assessment information, provide the service user with information and choice, and undertake any further assessments. The home does not provide intermediate care so standard 6 does not apply. The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plans relating to personal and social care needs of service users are completed in sufficient detail to direct and inform staff on how individual needs should be met. Service users are encouraged and supported to be independent and to exercise choice in all aspects of the home and are treated with dignity and respect. This contributes to the enhancement of service users’ everyday lives. EVIDENCE: All case tracked service users had personal development plans, daily logs, assessment forms for nutrition and tissue viability, risk assessments, monthly summaries, and monitoring forms e.g. heath professional visits, etc. The care plans, personal development plans, and risk assessments were clearly presented, very detailed, and reflected the individual needs and preferences of The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 10 service users together with comprehensive guidance to staff on how needs were to be met, e.g. daily routines, health problems and monitoring, communication issues. Service users had signed documentation indicating that care plans had been discussed with them. Information was recorded in detailed daily logs. One service user was discussed in relation to a risk assessment for bed rails. The administration of medication was inspected and records of case tracked service users found to be satisfactory. The inspector was informed that the pharmacist had visited recently and carried out a satisfactory inventory of the home’s medication storage and administration, and this report was made available. The home has a separate medication room with the medicines trolly, fridge and controlled medication cupboard. Derbyshire County Council have recently introduced a new medicines code for their residential homes and staff were in the process of studying this document to ensure that their practices complied. Arrangements for controlled drugs were satisfactory. Storage arrangements were appropriate, and the controlled drugs book was looked at and checked against the medicine held in the cabinet and found to be correct. There is a record kept of staff signatures. The home make a note when medication is opened, e.g. on eye drops, and these were seen to be within date. Staff were observed carrying out caring tasks sensitively and safely. They used every opportunity to communicate with service users. Service users spoke very positively about staff and said they were treated with dignity and respect. Service users commented that they were very happy at the home and had no complaints; ‘the home is well run’, ‘staff always have time to listen’. Confirmation was provided by service users that they are given choice and are able to follow their own routines, and several examples were given, e.g. choice of food, arrangements in the lounge. Some service users talked about their relationships with their key workers, which were clearly significant and helped improve their quality of life. Staff spoken to, as well as being committed and caring, gave examples of handling difficult situations sensitively and treating service users as individuals. The home have two short term care beds which are generally used by service users on a rotating basis. The inspector was informed that this system works very well. The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided that suit the expressed preferences of service users. Regular outside contacts are encouraged and supported. This assists in contributing to a pleasant atmosphere and the overall high level of satisfaction for service users. Dietary needs of service users are catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: Several of the staff at the home have a special interest in activities and have received training. The home have worked to improve activities since the quality assurance questionnaires feedback identified activities as an area for improvement. Regular activities include music and movement, quizzes, outings, in house entertainment, bingo and religious services. Details of forthcoming events and other information useful to service users and relatives/friends are displayed in the main entrance area and on notice boards The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 12 around the home. On the day of inspection activities were taking place in the afternoon, and some service users went on a trip last week. There were photographs of previous trips in the corridor. Festivities like Christmas and Easter are celebrated with enthusiasm and enjoyed by both service users and staff. Service users have a choice of lounge/dining areas. Several service users have formed significant friendships. The home have contacts with the local community groups. It was confirmed by service users that visitors to the home are welcomed. Most service users have regular contact with relatives and friends and some go out on a regular basis. The home have some volunteers who visit the home regularly, and are well established and have been through an appropriate vetting procedure. Most service users lived locally and reflect the cultural background of the local area. Service users and relatives spoken to were complimentary about the standard of catering, and the choice of menus that are available. One service user said that staff go out of their way to ensure that they get the food they like. Service users likes and dislikes are noted on care planning documentation. The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place which promote the Safeguarding Adults from abuse. A clear and accessible complaints procedure is in place ensuring service users can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a corporate complaints procedure in place, although most relatives and service users prefer to raise issues on a more informal basis. The manager and staff are viewed as approachable and responsive. There have been several informal complaints recorded which dealt with minor issues, but confirmed that service users felt they could raise issues with members of staff and be confident they would be dealt with. Derbyshire County Council has clear procedures for dealing with the safety of service users and safeguarding them from harm. Staff spoken to had had training in the protection of vulnerable adults and showed an awareness of adult protection issues and would pass any concerns on to their line manager. Training in adult protection has been provided for staff which meets the requirement made at the last inspection. The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 ,24 ,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment within the home is generally well maintained and provides service users with an attractive and homely place to live. EVIDENCE: The building provides service users with a comfortable and homely place to live with a variety of communal spaces offering a choice of seating arrangements for service users. The dining areas are pleasant and situated in the lounges. The building has continued to be maintained to a reasonable standard, apart from some redecorating as indicated below. There is a rolling programme for maintenance and redecoration. Some toilets and bathrooms were seen. The requirement made at the last inspection to replace the rotten wood covering pipes had been carried out, but The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 15 this toilet and some other toilets need redecoration and it is understood that this is planned. The two bathrooms have been decorated with murals that are interesting and unusual! In the downstairs bathroom there is a nautical theme, and the upstairs bathroom has a ‘tropical island’ theme. The upstairs bathroom has a new bath with an inbuilt hoist. The downstairs bathroom and hoist are older, and consideration may be given to replacing them in due course. Case tracked service users spoken to gave permission for the inspector to see their bedrooms, which were comfortable and had been personalised and arranged to individual preferences. However, lighting in some of the bedrooms was not very bright on the day of inspection, and the deputy manager has undertaken to explore the possibility of using light bulbs of a higher wattage in both some bedrooms and corridors. The lounges and dining areas provided a choice for service users and were comfortable and homely. There are plans to replace some of the chairs, and service users are to be consulted next week about fabrics, colours, etc. The inspector was informed that the lift is regularly serviced and there have been no operational problems with it. All areas of the home seen, including the kitchen and laundry, were clean and tidy. The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 ,29 ,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of service users currently accommodated within the home. EVIDENCE: Copies of the staff rotas had been made available prior to inspection. Discussion with staff, deputy managers, and service users indicates that there are sufficient staff to meet current service users’ needs, although some days are very busy. Managers help out with practical tasks at busy times, e.g. meal times. The deputy managers said that staff worked well as a team and were helpful, flexible and supportive. Staff spoken to were enthusiastic, responsible, committed and competent. There is a team approach to work. Staff said they feel supported by both their colleagues and their managers, and feel that they were offered good training opportunities. Derbyshire County Council has made a commitment to staff training and over 50 of staff are trained to NVQ2 or above. Staff have received training in safeguarding adults and there is an ongoing programme of mandatory training. In addition staff had undertaken The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 17 training in dementia, diabetes, and food safety legislation and further training is planned. A staff file seen had evidence of CRB checks, copies of contracts and references. Derbyshire County Council has a thorough and detailed recruitment and selection procedure. There is a very stable staff group, many of whom have worked at the home for many years. This is appreciated by service users as the current staff are able to provide very consistent care. The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of service users. EVIDENCE: The manager was not at the home on the day of unannounced inspection, but the two deputy managers were helpful and were able to provide all the information requested by the inspector. The manager is experienced and suitably qualified to run the home. Service users and staff spoke positively about the manager and the management team. There is an ‘open door’ policy The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 19 and several service users and relatives called into the office on the day of inspection. There is good communication between staff and effective handover arrangements. A relative said that they were always informed of any matters pertaining to a service users well being. The inspector was informed that the home is visited regularly by a representative of the registered person, but no copies of Regulation 26 visits had been received by the home since February 2006. There had been a quality assurance exercise which indicated that the majority of elements of the service provided at the Willows had been rated as good or excellent. The results of the survey had been made available to service users. Areas for improvement had been clearly identified and included activities, which the home have improved. Another area for improvement included providing information for service users prior to them moving into the home, although it is understood that the Statement of Purpose and Service User Guide are freely available for service users and their friend/relatives. At present residents finances are kept in the safe and manual records kept which appears to work satisfactorily. Staff confirmed that they have regular supervision and records were seen on an individual staff file. Information on maintenance and health and safety records was provided by the manager in the pre-inspection questionnaire and indicate that, apart from the electrical hard wiring certificate, matters pertaining to maintenance and health and safety are satisfactory. The electrical hard wiring certificate indicates that some electrical work needs to be carried out. The environmental health officer had recently visited and identified some minor improvements in the kitchen which had been completed or were due to be completed shortly e.g. probe replaced, filers cleaned). The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 20 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 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Willows DS0000035584.V307934.R01.S.doc Version 5.2 Page 21 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 OP37 Regulation 26(4) (c) Requirement The registered provider or person responsible for the home must prepare a written report on a monthly basis on the conduct of the care home. (previous timescale 30/03/06) Timescale for action 30/10/06 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 4 Refer to Standard OP20 OP21 OP21 OP38 Good Practice Recommendations Checks should be made to ensure all lighting in corridors and bedrooms is sufficiently bright to facilitate reading and other activities. The plan to replace replacement of some worn furniture in the living room should be carried out. The plan to redecorate the toilets and some bedrooms should be carried out. A satisfactory programme for carrying out work identified on the recently electrical hard wiring certificate should be drawn up. DS0000035584.V307934.R01.S.doc Version 5.2 Page 22 The Willows Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 DS0000035584.V307934.R01.S.doc Version 5.2 Page 23 - 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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