Inspection on 21/11/05 for The Willows

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Willows 04/09/07

The Willows 06/06/06

The Willows 16/06/05

The Willows 03/12/04

The Willows 21/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Willows 74 Station Street Rippingale Lincs PE10 0SX Lead Inspector Sue Hayward Unannounced Inspection 21st November 2005 10:45 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 DS0000002467.V267147.R01.S.doc Version 5.0 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 DS0000002467.V267147.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Willows Address 74 Station Street Rippingale Lincs PE10 0SX 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) 01778 440773 willripp2@aol.com Mrs Ellen Floyd Mr Anthony Paul Floyd Mrs Ellen Floyd Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (27) of places The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: The Willows is situated in the village of Rippingale, six miles north of the town of Bourne. The village has a pub, shop/post office, church, GP surgery and a village hall. It is within easy reach of Bourne, which has a wide range of shops and amenities. The home is registered for 31 older people including up to 4 with dementia. The original house has been extended and accommodation is provided on two floors. Stairs or a passenger lift can reach bedrooms on the first floor. There are a variety of communal areas including three lounges, a reading room, a sun lounge and two dining areas, one of which has a bar. There are 19 single bedrooms, two of these having en-suite facilities and three twin bedrooms with en-suite facilities. The gardens are spacious and enclosed. The rear of the property is laid to flower beds and lawns, with a furnished patio area. There is a raised pond, a summerhouse and a barbeque area. The property also has a driveway and car parking area. There is an adjacent building containing offices, a laundry and a large room used as a training venue. The home has achieved and maintained the Investors in People award. The owner/managers live in a house within the grounds. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection required by law for April 2005 to March 2006. It was unannounced and took place over 5 ½ hours. The main method of inspection used was “case tracking”. This involved selecting three residents and tracking the care they receive through their records, discussions with two of them as one was unwell and with three care staff on duty. It also included discussion with two resident’s relatives and three other residents at the home. In addition a sample of records were inspected. What the service does well: What has improved since the last inspection? The one requirement of the last inspection has been addressed. A staff member has been appointed to co-ordinate activities for residents for two afternoons per week and the social committee has resumed since the last inspection. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 6 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 DS0000002467.V267147.R01.S.doc Version 5.0 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 DS0000002467.V267147.R01.S.doc Version 5.0 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): The core standards were not inspected on this occasion. They were inspected at the previous inspection and were being met. Standard 6 does not apply, as the home does not provide an intermediate care service. EVIDENCE: A resident was spoken to who had been in the home for 6 days. She commented positively about the care and accommodation and said she would recommend the home to anyone. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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 and 9 The care planning system in place ensures staff have information available in order to meet residents needs. The medication administration system in place does not fully ensure residents safety. EVIDENCE: Care plans were in place on all residents records checked on this occasion. Plans were detailed and there was information available to demonstrate that they are reviewed on a monthly basis or more frequently if needed. They had been signed by residents or their relatives to denote their involvement and agreement. Risk assessments had also been completed relating to individuals such as manual handling risk assessments. Relatives made comments that indicated staff kept them well informed about their relatives. Staff spoken to had a good knowledge of residents’ needs and how they are met. A “key worker” system is in operation; this gives staff specific responsibilities for specific residents such as personal shopping. There are policies and procedures in place in relation to the administration of medication. Those staff that administer medication have had training to do so. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 10 However, during discussions with staff and inspection of medicines two matters were highlighted that is not considered to be safe practice. The first involves an element of secondary dispensing of medication and the second the use of a particular medication as a stock medication. The manager confirmed that the home is currently reviewing medication policies and procedures. The storage arrangements and record keeping systems for medication are satisfactory. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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 and 14 There are opportunities for residents to participate in social and recreational activities. Residents have choices and are able to make decisions about how they lead their life at the home. EVIDENCE: All residents commented positively about the care and accommodation provided at the home. Comments were made which indicated that residents are enabled as much as possible to make decisions as to their preferred routines and how they lead their lives in the home. Records included information about residents’ personal preferences such as food, how they liked to be addressed and times of rising and retiring. Relatives said they were able to visit whenever they wished and were made to feel welcome. One commented that she had been encouraged to bring in personal effects from home to make her relatives bedroom more homely. There is a system in place which records any activities or social events that occur such as attendance of residents at the “remembrance day” service held in the home, dominoes and other such games, walks around the garden and letter reading. A relative said that the home had held a “family day” at which she had been invited to attend. Staff said that entertainers visit the home and The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 12 the home has links with the local community. Staff said that spending time with residents is seen as part of their role and that there was sufficient time to do so. Whilst residents commented positively about the care provided a couple of comments were made that they would like staff to have more time to spend chatting with them and another that they would like to have the opportunity to go out for more walks. Discussion with the manager indicated that as from 28/11/05 a staff member was being employed to co-ordinate activities two afternoons a week and that the social committee had resumed since the last inspection. This consists of the manager and staff, residents are able to attend as well but choose not to. (See also comments made at standard 39) The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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 and 18 There are satisfactory procedures in place to ensure residents are protected. EVIDENCE: There are satisfactory procedures in place relating to complaints and adult protection matters. The complaints procedure, which is on display on the notice board, has been updated since the last inspection. Comments from residents and relatives indicated that they knew who is in charge and would feel comfortable to raise any issues with the manager or staff. Staff members had a satisfactory knowledge of both procedures, who to report them to and the differing forms that abuse can take. Adult protection is included as part of staffs training programme. There have been no complaints or adult protection issues raised with the home or the CSCI since the last inspection. There is a satisfactory recruitment process in operation. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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 Residents live in a clean, tidy and comfortable home that is well maintained. EVIDENCE: Those areas of the home seen on this occasion were clean and comfortably furnished. Bedrooms seen indicated that residents are able to furnish them with their own personal effects should they wish to. Residents made comments indicating that they found their rooms to be comfortable and they felt safe at the home. A comment from a relative was that the home was always clean and tidy and staff said that any maintenance issues are dealt with promptly. There were no obvious safety issues noted of the areas seen on this occasion, which included a sample of three bedrooms, two lounge areas and a dining room, a downstairs toilet and a bathroom. Risk assessments were in place in relation to bedrooms such as the provision of locks. Radiators are guarded and there is a call bell system in place. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 15 The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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, 29 and 30 The home is being well staffed to meet the needs of residents. Staff are well trained and the recruitment procedure followed ensures as far as possible that residents are protected. EVIDENCE: Inspection of records and comments from staff indicated that the home is being staffed to meet the needs of residents. The home is currently fully occupied. Staffing rotas demonstrated that there are generally 6 staff on duty in the morning and three in the afternoon, with an additional staff member being rostered for specific hours. At night there are two wakeful staff on duty. Comments from staff members were that staffing levels were sufficient to meet the needs of current residents. Residents and relatives were complimentary about the standard of care provided and staff were noted to be attentive to and kind and courteous when carrying out their duties with residents. Residents described staff as “friendly and very nice” and both residents and staff felt comfortable to raise any problems they may have with them. Relatives also said that staff were always available if you needed to speak to them. Records and discussion with staff indicated that there is a training programme in place to ensure that staff have the necessary skills to meet residents needs, this includes for example, induction, first aid, basic food hygiene, fire training and adult protection and regular updates in relation to some matters. Most The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 17 staff have or are in the process of achieving a National Vocational Qualification award. The manager confirmed that there are currently only three staff that have not registered for the award. A recently employed staff members records of recruitment were checked. This demonstrated that a satisfactory process was in operation, which was also confirmed by a staff members comments. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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): 33, 35, 36 and 38 Residents’ health and safety is promoted and there are satisfactory processes in place to ensure that residents’ financial interests are safeguarded. A further quality audit should be undertaken to demonstrate the homes commitment to listening to the views of residents and obtaining feedback about the service provided. EVIDENCE: There has not been a formal quality audit for over a year although there are plans in place to do so and this task has been delegated to a senior staff member. As residents made varying comments about the social and leisure activities that the home provide it is recommended that any quality audit include obtaining residents views about their level of satisfaction regarding this. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 19 It was clear from comments that residents and relatives made, that they felt able to raise any issues with the staff or the manager and comments were positive about the care and accommodation provided. Staff felt valued and supported in their work. There is a supervision and appraisal system in place and staff meetings are regularly held. Records seen also confirmed this. A staff member commented that she had had a thorough induction into the work and had not been expected to undertake any tasks until she felt comfortable or competent to do so. One staff member commented, “I look forward to coming into work”. Staff participate in a TOPPS induction, which takes place over 6 weeks. The home has been successful in retaining its Investor in People Award, which is a quality award. The home has a range of policies and procedures to protect residents and ensure their safety, for example there are policies relating to any money or valuables held in safe keeping and satisfactory records are kept and systems in place to do so. There was one requirement from the last inspection relating to a health and safety issue. This has been addressed. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X 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 X X 3 X 3 3 X 3 The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 21 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. 1. Standard OP9 Regulation 13(2) Requirement The procedure for administering medication must be reviewed to ensure there is no secondary dispensing. The use of stock bottles of medication must also be reviewed. Timescale for action 31/12/05 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 OP33 Good Practice Recommendations It is recommended that the quality assurance system be conducted on at least and annual basis. The Willows DS0000002467.V267147.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows DS0000002467.V267147.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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