Inspection on 20/11/06 for The Willows

This inspection was carried out on 20th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 21/09/09

The Willows 25/03/09

The Willows 24/07/08

The Willows 31/10/07

The Willows 11/05/07

The Willows 09/05/06

The Willows 19/01/06

The Willows 28/06/05

The Willows 11/11/04

The Willows 13/09/04

The Willows 03/03/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

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Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Willows, The 2 Tower Road Barbourne Worcester Worcestershire WR3 7AF Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 10:15 20 and 23rd November 2006 th 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 Willows, The DS0000018692.V318332.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. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows, The Address 2 Tower Road Barbourne Worcester Worcestershire WR3 7AF 01905 20658 * 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) Mr Tony Harborne Mrs Vivien Anita Harborne Mrs Lynda Jennings Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14), Physical disability over 65 years of age of places (14) Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Home may also accommodate a maximum of 4 people over the age of 65 with a dementia illness The Home may also accommodate one person over the age of 65 with a learning disability The home may also accommodate one named person who has needs which fall within the category MD, ie mental disorder, excluding learning disability or dementia. Date of last inspection Brief Description of the Service: The Willows is a large, detached, adapted property situated in a residential area near to Barbourne Park in Worcester. The home provides a residential care service for a total of 14 people over the age of 65 years who may also have a physical disability. The home may also accommodate a maximum of 4 people over the age of 65 years with a dementia illness and one person over the age of 65 years with a learning disability. Accommodation is located on two floors, with access to the first floor gained via a staircase and or a stair lift. Handrails are fitted throughout the home. Accommodation comprises of 14 single bedrooms. The home has one large lounge with a smaller room leading off it and a dining room. The registered providers are Mr and Mrs Harborne. The registered manager is Mrs Lyn Jennings. The fees at The Willows were at the time of the last key inspection earlier in the current financial year were confirmed to be £445.00 per week. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of any inspection carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at The Willows two visits to the home were undertaken. A key inspection regarding the service offered at this home was undertaken during May 2006 therefore making this the second key inspection during the current financial year. This inspection takes into account any information received by the CSCI since the previous key inspection as well as the visits to the home. Following the last key inspection a meeting was held at the local office of the commission, which was attended by one of the registered providers and the registered manager. The adult protection coordinator employed by Worcestershire Adult Services attended part of the meeting in order to discuss an issue which became evident as part of the earlier inspection. Part of this inspection was to assess the progress made in relation to the requirements from the last key inspection as well as from the assurances given during the meeting described above. As this was a key inspection the majority of the key standards were reassessed, any not assessed on this occasion will be assessed as part of a future inspection to the service. Prior to the last key inspection (May 2006) a pre inspection questionnaire was posted to the registered manager requesting certain information. This document was completed in part and handed to the inspector as part of the previous visit. In addition to the pre-inspection questionnaire a number of comments cards were also forwarded to the home, the findings of these comment cards are included within the last report and therefore this report should be read in conduction with the last report. A partial look around the home took place concentrating primarily on communal areas and facilities. The care documents of a number of residents were viewed including care plans, daily notes, risk assessments and accident records. Other documents seen included medication records, some service records and staffing records. In addition to the manager limited discussions took place with one of the owners and carers. Discussions also took place with a number of residents although some of these were brief. Due to a number of serious concerns a number of immediate requirements were made during this inspection. These concerns were followed up by means Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 6 of two separate letters to the registered persons detailing the action to be taken within 48 hours of issuing the original notice. In addition to these concerns were others, which also needed urgent attention but would require more than 48 hours to address; as a result a further letter given 28 days to comply was written to the registered persons. What the service does well: What has improved since the last inspection? What they could do better: The commission has a number of serious concerns regarding a range of matters at The Willows. As reported earlier due to the serious nature of some of these the home was issued with immediate requirement notices. Care plans and risk assessments remain insufficient and fail to identify care needs of residents. Care plans were not up to date to reflect changing care needs of residents and one care plan failed to evidence action regarding medical. Concerns were brought to the attention of the registered manager regarding the management and administration of medication. The trolley was left open and unattended and medication records were unsatisfactory completed. Some medication had run out therefore denying residents prescribed items. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 7 During the previous inspection the commission had concerns regarding the safe guarding of vulnerable adults. Although details were given at that time regarding suitable staff training none has taken place. A number of uncovered radiators and the delivery of very hot water in some bedrooms was of concern. Environmental risk assessments are either not in place or insufficient and must be addressed as previously reported. The continual lack of rotas and therefore evidence of suitable staffing levels is a concern and needs addressing as reported within the previous report. The recruitment of staff does not meet the required standard to ensure that residents are safe guarded. Mandatory training is required for a considerable number of staff. The lack of suitable training in areas such as fire awareness and moving and handling is of concern. Quality assurance systems are not in place. The registered persons do not have a development plan for the home. A number of health and safety requirements remaining within The Willows some of which give cause for serious concern. 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. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 8 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 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 9 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): Standard 4. Standard 6 is not applicable Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Training in dementia care needs to be provided for all carers, the improvement in the provision of dementia care training at the home assists to provide appropriate care. EVIDENCE: The Willows is registered to care for up to four (4) persons who have a diagnosis of dementia. The care of persons with a dementia type illness is specialised therefore making it necessary for staff to received suitable training in order that care needs can be met. Following the last inspection during which the training of staff was assessed as insufficient the registered persons were required to ensure that dementia care training was provided for all members of staff. It was pleasing to note that progress in this matter has Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 10 taken place. It was reported that 8 carers and the registered manager have enrolled on a level 2 Certificate in Dementia Care course at a local college. Progress with this training will be assessed as part of future inspections. As a result of other concerns regarding The Willows the remaining standards within this section were not assessed as part of this inspection. Documentation regarding the assessment of a newly admitted resident will form part of future inspections as will the information provided to potential residents such as the service users guide and the homes terms and conditions. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, and 9 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments continue to be insufficient and fail to demonstrate that staff have the knowledge to meet care needs as required and as assessed. The management of medication is of concerns and potentially places residents at risk. EVIDENCE: Over recent inspections improvement has taken place regarding standard of care plans. Despite the noted progress in care planning within the last report further improvement was required to take place. Improvement was also identified as necessary regarding the standard of the daily notes and elements of the risk assessment process in particular areas around fall prevention and moving and handling. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 12 A small number of care plans and other documents were viewed as part of this inspection. The care plan of one resident recently discharged from hospital was sought on the first day of this inspection however this was not available. A care plan in relation to the same resident was viewed during the second part of this inspection, however it was dated the day after the first visit. An earlier version of the care plan was in place however this was not reviewed and up dated following a recent discharge from hospital. The daily notes seen gave further cause for concern in that they detailed care needs which were not sufficiently included within the care plan. The care plan failed to evidence that suitable action was taken regarding health care needs. The risk assessments held on file were insufficient especially in relation to nutritional risk assessment. Other risk assessments viewed were either insufficient or non-existent and required urgent attention. Due to the above shortfalls the registered persons were required to take suitable action within 28 days to ensure that care plans and risk assessments were sufficient and up to date. The commission has over recent inspections had serious concerns regarding the administration and management of medication. Due to the previous serious concerns meetings have taken place at the local office of the commission involving the registered persons and representatives of the commission including on one occasion a pharmacist inspector. Improvements were noted during the last inspection however concerns remained in place, which required urgent action to address. As part of this inspection the administration and management of medication was re assessed. The visit coincided with a visit from the supplying pharmacist to audit the medication procedures within the home. As a result the inspector carried out a joint inspection of the medication with the pharmacist. The inspector discussed further concerns with the registered manager following the departure of the pharmacist; due to the seriousness of the concerns an immediate requirement notice was issued regarding the following matters: Security of medication – upon arriving at the home the inspector noted that the medication trolley was unattended. The doors of the trolley were open displaying the medication, while a rack of blister packs were stowed on top of the trolley. Examination of the Medication Administration Record (MAR) sheets evidenced that on occasions medication was not signed as given or a code entered to explain why the medication was omitted. Gaps were Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 13 evident for medication administered earlier on the morning of the inspection as well as other days. The MAR sheets evidenced that on a number of occasions medication had run out or was not available. The cycle regarding the need to reorder medication was not consistent therefore creating shortfalls and difficulties, which need to be better managed. Medication prescribed on a variable dosage did not always have recorded the actual dosage given Handwritten amendments / additions to the MAR sheets were not double signed Other areas included Although it was noted that in many cases medication remaining within there original containers were dated to show when open this was not always the case especially regarding some bottled medication. A tub of liquid paraffin within a residents bedroom had an expiry date of 2001 therefore 5 years out of date. The previous report made reference to a concern raised with the commission regarding a lack of awareness in relation to upholding privacy and dignity. No concerns were either raised or noted during this inspection. Willows, The DS0000018692.V318332.R01.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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There continues to be concern about both the level of activities and social stimulation for residents. Positive comments were received regarding the food provided. EVIDENCE: Open visiting is in place whereby no restrictions exist. Residents can choose to see their visitors in their bedroom, one of the lounges or in the dining room. During this inspection it was stated that carers lead activities during the afternoon shift. A list of events was on display by the lounge. One resident commented that ‘things can get a bit boring.’ A game of catch was taking place within the lounge during this inspection. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 15 Residents who commented upon the food provided at The Willows were satisfied with the quality and the quantity provided. The standard of meals at The Willows will form part of a future inspection at the home. Due to the serious concerns regarding care planning and staffing the standards in this section were not assessed in any greater detail. Other comments regarding daily life are included within the previous inspection report when some of the standards were assessed as met. Willows, The DS0000018692.V318332.R01.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): Standards 16 and 18 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The continual lack of training regarding the safe guarding of adults is of serious concern and has the potential of leaving residents at risk. EVIDENCE: The commission for social care inspection have received no complaints regarding the service offered at The Willows. The previous inspection report stated: Staff have received no training regarding adult protection, advise regarding suitable training as stipulated by the local protection coordinator was given.’ Despite the concerns identified at the last inspection and a meeting attended by two of the registered persons with the commission and the above coordinator no staff training has taken place. It was however noted that information supplied by Worcestershire Social Services regarding vulnerable adults was on display. Willows, The DS0000018692.V318332.R01.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): Standards 19, 20 and 26. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The homes continues to be comfortable clean and homely. Some improvements have taken place with the environment, however additional improvements are needed to ensure that residents have a safe place in which to reside. EVIDENCE: As mentioned within previous report the communal lounge and smaller lounge are well furnished. The dining room was suitable for purpose. Lighting provided in communal areas is domestic in character, however the use of low Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 18 energy bulbs made the dining room appear dim when the natural light was fading. Some additional seating is provided in the hallway, this continues to be a pleasant area and frequently occupied by a couple of residents. At the time of the last inspection the carpet in the hallway and leading into the dining room was noted to have a number of ridges in it. The carpet has been stretched since the last inspection and therefore removed a potential risk. This carpet is however in places starting to look worn. A stair lift is provided to enable access to the first floor of the building. A hoist is provided over the ground floor bath. The servicing of these items of equipment is highlighted elsewhere within this report. The stair lift restricts access to the stair and needs risk assessing. Radiators in the lounge and a bedroom were hot to the touch. These radiators are not covered and are a significant risk to the health and safety of residents. Records showed that hot water was very hot in some bedrooms. It was evident that this matter was brought to the attention of the registered provider however no action was recorded as having taken place. Liquid hand wash and paper towels were in place within all communal bathrooms and toilets viewed. Bathrooms were clean and tidy without any clutter. The washing machine does not have a sluice facility, which could be a potential infection control concern. The Willows was found to be clean and free from offensive odours. The use of plug in air fresheners should however be fully risk assessed. Willows, The DS0000018692.V318332.R01.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): Standards 27, 28, 29 and 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Records held indicate that staffing is insufficient to meet the care needs of the residents. Carers’ having to undertaken additional duties is of concern due to the potential that care needs are not attended to sufficiently. National Vocational Training progress is good however other areas of training remain a serious concern. The recruitment procedures within the home continue to be poor and of concern due to the potential risk to residents if staff are not suitable. EVIDENCE: The previous inspection report stated that: ‘ The Willows continues to demonstrate non – compliance with the requirement to provide a staff rota.’ The requirement to have a rota in place was therefore reissued within the report stating that action must take place ‘without further delay.’ The action Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 20 plan provided by the registered persons and discussed during a meeting held at the commission stated that this was ‘done’. Despite the above comments no rota was available for the week prior to this inspection. As a result it was necessary to use timesheets to undertake an audit regarding the staff on duty during that week. Using this method of auditing staff shortfalls were evident. On Sunday 12th November it appeared that staffing consisted of: Two carers on duty 8.00 – 2.00 One carer on duty 1.00 – 6.00 Two carers on duty 6.00 – 10.00 No cook or domestic on duty at all On Monday 13th November it appeared that: One carer was on duty during the morning other than another carer who was undertaking cooking duties and the registered manager. The undertaking of catering duties by a carer introduces possible cross infection risks. Care staff undertake laundry duties in addition to their caring responsibilities. Due to the above concerns and following an management review at the commission a letter was issued to the registered provider requiring that sufficient and suitable staff are on duty and that a staff rota must be in place to evidence staffing levels. The rotas must be available for future inspections and retained for a period of three years, Previous inspection reports have highlighted concerns regarding the recruitment procedures at The Willows. The previous reported stated that the procedures ‘ remain to be insufficient and therefore fail to safeguard residents.’ Despite this comment similar shortfalls were identified as part of this inspection. The files of two recently appointed members of staff were viewed and both were unsatisfactory. one file contained a PoVA first (Protection of Vulnerable Adults) clearance and a CRB (Criminal Records Bureau) disclosure dated prior to the start of employment as required. However shortfalls were as follows 1. application form was incomplete 2. references as detailed upon the form were not returned prior to commencement of employment. Another reference associated with employment over 6 years ago was on file. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 21 another file demonstrated serious concerns with the following shortfalls 1. application form incomplete including no disclosure regarding convictions 2. No PoVA obtained before the commencement of employment 3. No CRB on file 4. One reference was in place Contracts on employment were not held on either file. Due to the above concerns the registered provider was required to take immediate action to ensure that recruitment procedures within the home are robust and in line with the regulations with immediate effect. In relation to the shortfalls identified above the registered provider was required to ensure that all documentation was in place within 28 days of the visit. Fire training records were insufficient and failed to show in house events such as fire drills as part of training. The records regarding some staff showed that no fire training had taken place for over 2 years. An urgent audit of fire training needs must take place and remedial action must take place. The training undertaken by staff in moving and handling was an additional cause for concern. Some staff have received no training at all while others last received training during July 2004. Further shortfalls were evident regarding training in: Infection control Basis food hygiene Health and safety Safe guarding vulnerable adults It was reported that three members of staff have undertaken first aid training. Due to the lack of rotas or evidence of when all members of staff were on duty it was not possible to ascertain whether a first aider is always available. This matters needs to be reviewed by the registered persons and suitable action taken if needed. Urgent action to address the above shortfalls was necessary and the registered provider was required to prepare a full and detailed training programme. It was reported that a total of six carers now hold either a level 2 or level 3 National Vocational Qualification. This represents 54.50 of carers and therefore in excess of the 50 level expected to meet the National Minimum Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 22 Standard. As another four carers are reported to be booked to undertake this training this level will increase further; this level of carers once achieved will be commendable. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Systems to monitor the quality of care provided and improve outcomes for residents are weak and in need of improvement. Significant concerns remains regarding the management of health and safety within the home potentially placing residents and others at risk of harm. EVIDENCE: The registered manager has as previously reported got extensive experience of working within the care sector. Previous reports have highlighted positive Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 24 comments made by persons consulted regarding the manager especially her commitment to the home and the residents. The Willows has made no progress regarding the introduction of quality assurance and quality monitoring systems. No progress has been made regarding the questionnaire mentioned within the previous report. No annual development plan is in place to systematically plan improvements within the home. In addition no business or financial plan are in place. The registered providers contain to fail to provide Regulation 26 reports regarding the conduct of the manager and the home. This was a requirement within previous inspection reports The Willows does not hold any money in safe keeping for residents. It was evident that some progress has taken place regarding formal staff supervision. Progress regarding this standard will be monitored as part of future inspections at The Willows. As reported throughout this report a significant number of records held within the home are in need of urgent improvement to ensure that residents are safe and cared for in line with the required standards and regulations. The lack of fire training for some staff is highlighted above. The registered providers have nominated two carers to undertake the in house training and to carry out the in house checking of equipment; these persons have not however received any formal training. The fire log was viewed and found to be generally in satisfactory order. One break glass point was reported as in need of replacement due to the difficulty in testing it. The replacement of this point needs to take place as soon as possible. A list of break glass points, fire extinguishers, detectors, emergency lighting needs to be included within the logbook. A fire risk assessment is in place. Persons within the home were not aware of the recent Fire Safety Order; a copy of this needs to be obtained and used to review the current risk assessment and fire procedures within the home. Shortfalls in other areas of health and safety are reported earlier within this report. These shortfalls give cause for serious concern. Environmental risk assessments seen were insufficient and failed to account for all aspects of potential risk within the home. The use of the stair lift and the reduced space available to both descend and ascend the stairs was highlighted during this inspection and in need of an urgent assessment. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 25 The previous report highlighted some concern regarding some bedrooms windows without a suitable restrictor. The provider previously stated that restrictors are not needed due to the height of the window. It was previously stated by the commission that this matter should be discussed with a health and safety officer at Worcester City Council and risk assessed. No risk assessment was in place. Service records evidenced that hoist were tested during May 2006 and where therefore due for a 6 monthly service. Other service records viewed including portable appliances, gas and fire extinguishers were satisfactory. Records regarding the temperature of hot food on serving needed to be improved. Some crystals to discourage cats and dogs from fouling on lawns were noted within the home. Although these were out of reach of most people it was still a concern. Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 26 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 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 2 3 2 1 1 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 5 Requirement A service users guide, that includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service users. (This requirement was not assessed as part of this inspection. The previous timescale remains 30/09/06. The date given is the date of this inspection) Timescale for action 23/11/06 2. OP2 5 The service users contract (statement of terms and conditions) must be amended so that it includes all of the information detailed in Standard 2.2 of the National Minimum Standards. (This standard was not assessed as part of this inspection) 23/11/06 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 28 3. OP4 18 (1) (a) The registered persons must ensure that staff both individually and collectively have the skills to deliver the care, which the home offers to provide. Dementia training must therefore be provided for all members of staff. (The timescale of 31/08/06 part met. An extended timescale is given for full compliance) 30/06/07 4. OP7 15 Residents care plans must be recorded in a style accessible to the service user, agreed and signed by the service user wherever capable and/or representative (if any). (Previous timescale of 31/05/05 31/08/05 31/03/06 and 31/07/06 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan shortfalls) 27/12/06 5. OP7 15,16 (2) (n) Daily records must demonstrate how residents have spent their day including activities that they have taken part in. (Previous timescale of 31/08/05 31/03/06 and 31/07/06 not fully met - an improvement in activities is needed in order to meet this requirement. A extended timescale is given) 28/02/07 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 29 6. OP7 15 Risk assessments must be in place covering all areas of care, including falls and moving and handling. These must be reviewed on a regular basis. (Previous timescale of 16/05/06 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan and risk assessment shortfalls) 27/12/07 7. OP7 15 (1) The registered person must ensure that service user plans cover all aspects of care as set out in Standards 7 and 3. Care plans must be reviewed on at least a monthly basis or more frequently in line with changing care needs. (Previous timescale of 16/05/06 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan shortfalls) 27/12/06 8. OP8 15(2)(b) 17(1)(a) Schedule 3 (p) The registered manager must ensure that risk assessments in relation to pressure care prevention are carried out. (Previous timescale of immediate and on going at the time of previous inspections not met. Pressure care prevention risk assessments must be completedthis information must be included within the care plan. Timescale of 16/05/06 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan shortfalls) 27/12/06 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 30 9. OP8 13 (1) (b) The registered manager must ensure that residents chiropody care needs are assessment, met and fully recorded. (This requirement was not assessed. The timescale is however amended in line with care plan requirements above) 27/12/06 10. OP8 17 (1) (a) The registered manager must ensure that a photograph of each resident is held for means of identification. (This requirement was not assessed. The timescale is however amended in line with care plan requirements above) 27/12/06 11. OP8 17 (1) (a) 3 (o) The registered manager must ensure that Residents care plans contain information regarding nutritional care needs. (Previous timescale of immediate and on going set on 28/06/05 20/02/06 and 16/05/06 not met. A timescale of 28 days was given within a letter dated 29th November for addressing care plan and risk assessment shortfalls) 27/12/06 12. OP9 13 (2) The registered manager must ensure that carers administer medication as prescribed The reason for any nonadministration of prescribed medication to residents must be DS0000018692.V318332.R01.S.doc 20/11/06 Willows, The Version 5.2 Page 31 clearly entered onto the Medication Administration Record sheets. 13. OP9 13 (2) The registered manager must ensure that medication is secured at all times. (This requirement was not met during this inspection. An immediate requirement notice was issued) 20/11/06 14. OP12 16 (2) (n) The registered persons must consult residents regarding a programme of activities. Previous time scale of 31/03/06 and 31/08/06 part meet. An extended timescale is given in order to improve resident consultation. 28/02/07 15. OP15 16 (2) (i) The registered persons must review the current routines within the care home regarding breakfast time and the ready plating of meals. A review of the menu should also be carried out. (This requirement was not assessed or discussed with residents during this inspection. The date given is the date of this inspection) 23/11/06 16. OP19 13 (4) The registered manager must ensure that environmental risk assessments are carried out and available for future inspections. 27/12/06 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 32 (Previous timescale of 31/07/05 31/03/06 and 31/07/06 not fully met. This requirement must be met without further undue delay) 17. OP26 13,16 A risk assessment must be carried out regarding the handling of soiled linen, the disinfection of commode pans etc. and a sluicing facility provided, if necessary. (Previous timescale of 31/05/05 31/07/05, 31/03/06 and 16/05/06 not met. As previously stated this requirement must be met without further undue delay) 27/12/06 18. OP26 16 (2) (j) 31/03/07 Appropriate facilities must be provided throughout the home to manage infection control. (This requirement is in relation to washing machine facilities. An action plan must be submitted by 31/03/07 regarding this matter) 19. OP27 17 (2)4 (7) A duty roster of all the persons working at the home (including their names and designations), that is dated and a record of whether the roster was actually worked, must be maintained, in accordance Regulation 17 and Schedule 4. (Previous timescale of immediate and on going set on 28/06/05 20/02/06 and 16/05/06 not met. This requirement must be met without further delay.) 23/11/06 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 33 20. OP27 18 (1) The registered manager must 23/11/06 ensure that all times suitable and sufficient staff are on duty to ensure the heath and wellbeing of residents. (Previous timescale of immediate and on going set on 28/06/05 20/02/06 and 16/05/06 not met. This requirement must be met without further delay.) 21. OP29 19 Recruitment procedures must be 23/11/06 developed in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. (Previous timescale of immediate and on going set on 11/11/04 28/06/05, 20/02/06 and 16/05/06 not met. This requirement must be met without further delay) 22. OP30 18 All staff must have individual training and development assessments and profiles. (Part met, an extended timescale given) 31/03/07 23. OP33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31/08/05 31/03/07 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 34 part met, a short but extended timescale of 31/07/06 was given and not met) 24. OP33 26 The person carrying out the monthly visit on behalf of the registered provider must prepare a written report on the conduct of the care home and supply copies to the registered manager in accordance with the requirements of Regulation 26. (Previous timescales of 31/05/05 31/07/05, 31/03/06 and 30/06/06 not met. A new timescale is given by which the requirement must be met) 31/03/07 25. OP36 18 (2) Care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. (Previous timescales of 31/05/05 31/07/05, 31/03/06 and 31/07/06 not met. A new timescale is given by which the requirement must be met) 31/03/07 26. OP37 17 All the records required by regulation must be fully and accurately maintained within the home in accordance with Regulation 17 and Schedules 1, 2, 3 and 4 DS0000018692.V318332.R01.S.doc 31/03/07 Willows, The Version 5.2 Page 35 (Previous timescale of 30/06/05 31/03/06 and 31/07/06 not met, a short but extended timescale is given unless required earlier as in this report) 27. OP38 13,18 All staff must be provided with updated training on moving and handling, food hygiene, fire safety and infection control. (Previous timescale of 31/05/05 31/08/05, 30/04/06 and 31/07/06 not met. A training plan must be provided 27/11/06 28. OP38 13 Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3. (Previous timescale of 31/05/05 31/08/06, 31/03/06 and 31/07/06 not met) 27/11/06 29. OP38 13 Evidence must be provided to demonstrate the homes compliance with all of the relevant legislation referred to in Standard 38.4. (Previous timescale of 31/05/05 31/07/05 31/03/06 and 31/07/06 not met. 27/11/06 29. OP38 23 A The Fire Risk Assessment must be reviewed to take into account the Fire Safety Order 31/03/07 Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 36 30. OP38 13 The registered provider must 28/02/07 ensure that suitable risk assessments are in place regarding the no fitting of restraints to some bedrooms windows. Suitable action must be taken following the findings of the risk assessment to ensure the health and safety of all concerned. (Previous requirement with a timescale of 16/05/06 not met. A new date is given.) 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 OP13 Good Practice Recommendations Relatives, friends and representatives of service users should be given written information about the homes policy on maintaining relatives and friends involvement with service users at the time of an admission to the home. This information should be included in the service users guide (The service users guide was not assessed during the visit) 2. OP14 Information on the service users right of access to their personal records, in accordance with the Data Protection Act 1998, and how this is facilitated for them should be included in the service users guide. (The service users guide was not assessed during the visit) Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 37 3. OP18 The homes policies and practices regarding service users money and affairs should ensure service users access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and advice on personal insurance, and preclude staff involvement in assisting in the making of or benefiting from service users financial wills. (Not assessed) 4. OP26 A detailed cleaning schedule for all parts of the home, including the kitchen, should be provided. (Partly done) 5. OP31 The job description of the registered manager should be reviewed in order to ensure that it includes all of the duties and responsibilities that are commensurate with her position and status within the home. (Recommendation remains in place from previous inspection reports) 6. OP34 A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. (Recommendation remains in place from previous inspection reports - no business and financial plans exist) 7. OP37 A statement to the effect that the service users have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records, should be included in the service users guide. (The service users guide was not assessed during the visit) The service users guide was not assessed during the visit Willows, The DS0000018692.V318332.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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