Inspection on 19/06/07 for The Willows

This inspection was carried out on 19th June 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 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 09/01/06

The Willows 21/07/05

The Willows 24/11/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOMES FOR OLDER PEOPLE The Willows 90 Uttoxeter Road Blythe Bridge Staffordshire ST11 9JG Lead Inspector Dawn Dillion Key Unannounced Inspection 19th June 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 DS0000060725.V344053.R02.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 DS0000060725.V344053.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 90 Uttoxeter Road Blythe Bridge Staffordshire ST11 9JG 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) 01782 399411 atol54@dsl.pipex.com Gary Leslie Day Stuart Kirk Gary Leslie Day Care Home 12 Category(ies) of Dementia - over 65 years of age (7), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5) The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: The Willows Care Home is located in Stoke On Trent, Staffordshire and provides a service for older people. The homes registration category enables them to offer a service to individuals suffering with dementia or a mental health problem. The home is situated in a residential area and is keeping with the local community; it is accessible via public transport and is in close proximity to local amenities. The Willows Care Home is a large Victorian house that has been extended and designed to accommodate twelve people. The property comprises of one shared bedroom and ten single occupancy bedrooms located on both the ground and first floor level. A number of bedrooms are equipped with en suite facility. Bathrooms and toilets are situated on the ground and first floor and are in close proximity to bedrooms and communal areas. There is a stair lift in place, to enable people to access all provisions within the home. Appropriate aids and adaptations were provided to meet the needs of people living in the home. A lounge area is provided on the ground floor, equipped with essential furnishings and fitments, where individuals are able to relax or socialise with other people using the service. The home also provides a lounge/dinning room, domestic style kitchen and a laundry. People using the service have access to a beautifully well-maintained garden at the rear of the property. Limited car parking is available at the front of the property. Staffing is provided on a 24-hour basis to ensure the total supervision and support of people living in the home. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 5 People who use the service have access to relevant healthcare services, if and when required. The fees chargeable for the service provided at The Willows Care Home is £348.00p – £420.00p per week. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Key Inspection of The Willows Care Home was undertaken within seven hours. The inspection methodologies that were used, to establish the quality of care provided and the effectiveness of the management of the home, to promote quality, diversity and best practices entailed the examination of the records, relating to the homes policies and procedures. People using the service and staff members were interviewed during the process of the inspection, to ascertain their views in relation to the service delivery. Comments were also obtained from a District Nurse. A tour of the property was undertaken, to ensure that the environment and systems in operation were safe and conducive in meeting the needs of the people using the service. The Registered Manager was present during the process of the inspection. The home provided a very high standard of care, with staff demonstrating a sound knowledge of the care needs of the individuals living in the home. What the service does well: The service provided at The Willows Care Home was of a high standard, providing a service that was flexible to meet the needs of people living in the home. Care plans and risk assessments provided comprehensive information relating to the support people required, to enable the individual to live a fulfilled lifestyle. The homes policies and procedures incorporated information relating to equality and diversity. Interviews with people living in the home, confirmed their contentment with the service and provisions provided. The Registered Manager was proactive in promoting a high standard of care and the rights of the individual. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 7 General observations during the process of the inspection identified that staff interacted with the people that use the service, in a positive and professional manner. One person living in the home informed the Inspector that she was “ happy living at the home as long as the staff are here, they are lovely.” What has improved since the last inspection? What they could do better: The Willows continues to provide a very high standard of care and no requirements have been identified within the contents of this report. Recommendations have been identified in relation to the homes medication system, to ensure that a protocol is in place for the use of PRN (when required) medication. The homes menu did not provide information of an alternative choice, to reflect the individual likes and dislikes. The Registered Manager did confirm that people were provided with an alternative choice on a daily basis. The fire risk assessment did not incorporate information relating to the homes evacuation procedure. The homes contract of residency did not identify the fees chargeable for the service provided. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 8 The Commission for Social Care Inspection have received confirmation, from the Registered Provider, that recommendations identified within the contents of this report, have now been addressed. 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 DS0000060725.V344053.R02.S.doc Version 5.2 Page 9 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 DS0000060725.V344053.R02.S.doc Version 5.2 Page 10 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): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of the homes Statement of Purpose, Care Management Assessment and the admission procedures. Prospective people who wish to access the service are given essential information, relating to the service and provisions provided within the home, to enable them to establish whether the service will meet their assessed needs. EVIDENCE: The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 11 The homes Statement of Purpose provided comprehensive information relating to the service and provisions available. Contracts were issued with reference to the terms and conditions of residency, the fees chargeable for the service was not identified on the contract. A Care Management Assessment (Pre admission assessment) was undertaken prior to admission, to ensure that the home is fully equipped to meet the needs of the individual before the offer of a placement. The assessment also identified the necessary intervention of other healthcare agencies, to maintain the individual’s health and welfare. The homes admission procedure incorporated a trial visit, to enable the individual to visit the home prior to admission, having the opportunity to view the premises, meet the other people living in the home and the staff team. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. The examinations of care plans, risk assessments and discussions with people living in the home and staff members. The health and personal care that people received was based on their individual needs. The principles of respect, dignity and privacy were put into practice. EVIDENCE: Information obtained from the Care Management Assessment (Pre admission assessment), provided the foundation for the development of a care plan and the risk assessment. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 13 Where possible the individual or there representative were actively involved in the development of the care plan, providing a background history of the individuals healthcare, social, cultural and religious needs. Two care plans were randomly selected for examination; both provided comprehensive information, relating to the care needs of the individual and the level of support and assistance required for the person to live a lifestyle of their choice. Care plans identified the intervention of relevant healthcare professionals and also information relating to the cultural and spiritual needs of the individual. Information obtained from a District Nurse confirmed that the home had a good rapport with the General Practitioner and the Nurses and were fully aware when specialist healthcare intervention was required. A nutritional and a moving and handling assessment were also in place. Care plans were reviewed on a regular basis to reflect the changing needs of the individual. The home operated the Boots monitored dosage system, records relating to the storage, administration and the recording of medicines were examined, of which were satisfactory. Discussions with the Registered Manager and the examination of the medication administration record identified that PRN (when required) medicines were in use. There were no protocols in place for the use of these medicines. Discussions with people using the service, staff and general observations, identified that the homes practices promoted the privacy and dignity of people living in the home. The Willows Care Homes does not provide nursing care, where people require the input of a nurse, the home had access to a District Nurse. Should continued nursing intervention be required, the home would not have the capacity to meet the individuals needs. Information contained within the care plan, identified details of the individuals wishes in the event of their death. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Discussions with people using the service, staff members and the Registered Manager. The examination of records and general observations. People using the service were able to make a choice relating to their lifestyle in respect of their cultural and religious needs. EVIDENCE: The general routine within the home was relaxed, with people having freedom of movement throughout the home. People living at The Willows had access to a variety of social activities within and outside the home. The individual was also able to maintain contact with their family and friends and had a positive presence within their local community. Social activities consisted of boat trips, visiting the local pub, The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 15 visiting the stables, shopping, dinning out, visits to Trentham Gardens, sing a longs, films, board games, painting and seasonal events. The home was conducted in a manner to maximise people’s capacity to exercise personal autonomy and choice. The homes policies and procedures promoted equality and diversity of which, was identified within the homes Statement of Purpose and within the care plans. People living in the home were able to continue to practice their religious/spiritual beliefs. People living at The Willows were able to participate in their political interests; a voting request plan was identified within the care plan. The home operated a four weekly menu, providing a well-balanced nutritional diet. There were no alternative choices identified on the menu. Discussions with the Registered Manager confirmed that an alternative choice was provided to reflect the individuals likes and dislikes. A number of people required a special diet of which, was catered for, a dietician was also involved in respect of one person. One person using the service informed the Inspector that, “the food is nice, you can’t fault it.” The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. The examination of the homes complaints policy and the recruitment procedure. People using the service were protected from abuse by the homes policies, procedures and general practices. EVIDENCE: People using the service had access to the homes Statement of Purpose that included the homes complaints policy. The Registered Manager informed the Inspector that safeguarding training for staff was booked for 12 September 2007. Files that were examined pertaining to staff working in the home, evidenced that the appropriate safety checks were undertaken prior to the commencement of employment. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A tour of the property and the examination of safety records. The design and layout of the home was suitable to meet the needs of people accessing the service. EVIDENCE: The Willows Care Home is located in Stoke On Trent, Staffordshire and is situated in a residential area. The large Victorian house had been extended and designed to accommodate twelve people. The property comprised of one shared bedroom and ten single occupancy bedrooms located on both the ground and first floor level. Eight bedrooms were equipped with en suite The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 18 facility and the remaining bedrooms were provided with a washbasin. The inspection of a number of bedrooms identified that the individual was able to decorate their rooms to reflect their interests. One person living in the home informed the Inspector that, “I am happy with my bedroom.” The home was decorated in manner to assist people to orientate themselves with their environment. Bedroom doors were painted in different colours to assist the individual to locate their rooms. Bathrooms and toilets were situated on the ground and first floor, the bathroom on the first floor had recently been refurbished, having a walk in bath equipped with a shower. An assisted bath was provided on the ground floor. There was a stair lift in place, to enable people to access all provisions within the home. Appropriate aids and adaptations were provided to meet the needs of people living in the home. A lounge area was provided on the ground floor, equipped with essential furnishings and fitments. The home also provided a lounge/dinning area; the kitchen had recently been refurbished. The laundry area was equipped with a washing machine that had a sluice programme. People using the service have access to a beautifully well-maintained garden at the rear of the property. Limited car parking was available at the front of the property. The cleanliness of the home was of a very high standard and appropriate systems were in place with reference to infection control. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 19 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, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of staff working rotas, training records and discussions with people living in the home and staff members. People using the service benefited from a mixed skill staff group, that were provided in sufficient numbers throughout the day and night. EVIDENCE: Discussions with the Registered Manager and the examination of staff rotas identified that sufficient skilled staff were provided to meet the needs the of people using the service. The examination of staff training records identified that the staff team had received appropriate training in relation to their respective roles and responsibilities. Records evidenced that staff had received training in moving and handling, fire awareness, first aid and health and safety. The homes recruitment procedure ensured that people living in the home were protected from abuse. The examination of staff files evidenced, that staff were The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 20 subject to the appropriate safety checks prior to the commencement of employment. Discussions with one staff member who had recently been recruited, confirmed that she had received a structured induction and training. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 21 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Discussions with staff members and general observations. The management and administration of the home was based on openness and respect, promoting the choice, rights and welfare of all people living in the home. EVIDENCE: The Registered Manager was experienced in social care and had obtained the necessary qualifications with regards to his roles and responsibilities. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 22 Discussions with the Registered Manager confirmed that there was positive commitment to the undertaking of periodical training, to keep abreast of issues relating in social and elderly care. Staff members that were interviewed confirmed that the management support was very good and that the Registered Manager was always at hand when you need him. The management style within the home created an open, positive and inclusive atmosphere. The Registered Manager demonstrated a sound knowledge of the needs of people in his care, promoting their welfare, choice and rights. Albeit there were no people in residence from the ethnic minority group, the homes policies and procedures incorporated information relating to equality and diversity, to ensure that individual would be able to live of lifestyle of their choice, maintaining their cultural and religious beliefs. A questionnaire relating to the quality of the service delivery was distributed to people living in the home. With reference to the financial affairs of people living in the home, the Registered Manager confirmed that the individual’s receptive family managed this. A small amount of cash was held in safekeeping. Three records and funds pertaining to people living in the home were examined of which were satisfactory; receipts were maintained for all expenditures. Discussions with a number of staff confirmed that they received regular supervision sessions and an annual appraisal. The examination of records relating to health and safety and the servicing of appliances, evidenced that appropriate checks were undertaken at regular intervals. The fire risk assessment provided insufficient information relating to the homes evacuation procedure. The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 23 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 4 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 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 4 3 3 3 3 3 3 4 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 4 4 3 X 3 3 X 3 The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. 1. Refer to Standard OP9 Good Practice Recommendations There were no protocols in place for the use of PRN (when required) medication. The necessary measures should be taken, to ensure that staff who are responsible for the administration of medicines, are aware of the appropriate methods of administration. The fire risk assessment did not incorporate an evacuation plan. The registered person should take the appropriate measures to ensure that this information is available to staff. The menus did not identify and alternative choice of meal. The registered person should ensure that people living in the home are provided with information, relating to an alternative option. The contract of residency did not incorporate information relating to the fees. The registered person should ensure that people accessing the service are fully aware of the fees chargeable for service provided. DS0000060725.V344053.R02.S.doc Version 5.2 Page 25 2. OP38 3 OP15 4 OP2 The Willows The Willows DS0000060725.V344053.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Local Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 OES 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 DS0000060725.V344053.R02.S.doc Version 5.2 Page 27 - 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!