Inspection on 21/09/09 for The Willows

This inspection was carried out on 21st September 2009.

CQC found this care home to be providing an Adequate service.

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 25/03/09

The Willows 24/07/08

The Willows 31/10/07

The Willows 11/05/07

The Willows 20/11/06

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

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Willows 2 Tower Road Barbourne Worcester Worcestershire WR3 7AF Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 21st September 2009 17:00 DS0000018692.V377750.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Willows DS0000018692.V377750.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Willows DS0000018692.V377750.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows 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) mrkharb@aol.com Mr Tony Harborne Mrs Vivien Anita Harborne Manager post vacant Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places The Willows DS0000018692.V377750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) 14 The maximum number of service users who can be accommodated is: 14 25th March 2009 Date of last inspection Brief Description of the Service: The Willows is a large, detached, adapted property situated in a residential area near to Barborne Park in Worcester. The home provides accommodation and personal care to a total of 14 people who have needs related primarily to old age. 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, all of which have en-suite facilities. The home has one large lounge with a smaller room leading off it and a separate dining room. The home has a well maintained garden to the rear of the property. People using the service are able to use a patio area which can be reached from either the main lounge or dining room. Limited car parking is available to the front of the property. Information about fees charged at The Willows was not requested on this occasion. The reader should therefore contact the service for details. The Willows DS0000018692.V377750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was the second key inspection at The Willows during 2009; the last one was during March. A key inspection is one when we look at what we consider to be the most important outcomes for people using the service. Since the key inspection in March we have carried out one random inspection at the home. That inspection was a shorter, more focused visit concentrating on a smaller number of previous requirements. This key inspection commenced in the early evening of one day and involved one inspector. The main part of this inspection was conducted the following day and involved two inspectors. In addition to the visit to the home, we also took into account other information we had received since our previous inspection. Prior to our visit we requested an Annual Quality Assurance Assessment (AQAA) from the registered persons. This is a document within which providers of care services are able to demonstrate to us where they believe they are providing a good service and where they believe they could improve in the future. The AQAA also provides us with certain data which we need to know. The AQAA was completed by the deputy manager and returned to us. We also posted out some surveys to residents, their representatives and staff. Some returned on behalf of residents were completed by senior members of staff working in the home. We have taken the comments received into account within this report. During this inspection we had a look at communal areas of the home as well as some bedrooms. We read care plans and risk assessments regarding some people living in the home. We also viewed other documents such as medication and staffing records. We spoke to a number of people in the home including one of the providers, some members of staff, residents and visitors. We observed care practices throughout our time in the home. At the time of this inspection 9 people were living at The Willows. The Willows DS0000018692.V377750.R01.S.doc Version 5.2 Page 6 What the service does well: We have previously reported that people living within the home are positive about the care they received. This was our finding during this inspection also. Staff are generally knowledgeable about the care needs of people they are supporting. Within a questionnaire one relative, when asked what the home does well, wrote ‘Marvellous in every possible way.’ The home is welcoming to visitors. We found the home to be clean and most areas were tidy. What has improved since the last inspection? What they could do better: Further improvements are needed to ensure that a quality service is maintained. Assessments and care plans need further improvement to ensure that all information is recorded and evaluated. The Willows DS0000018692.V377750.R01.S.doc Version 5.2 Page 7 Records regarding resident’s weights now need to be kept up to date and need to be accurate to ensure that people who are nutritionally at risk are carefully monitored and supervised. Recording of medication administered needs further improvement to ensure that people receive their prescribed medication correctly and at the right time. The availability of staff to lead activities and provide social stimulation within the home for residents is limited due to other duties they need to perform. We found no progress in the need to ensure that policies and procedures are up to date within the home. The previously identified need to ensure that local procedures on safeguarding are available within the home had not received the necessary action. The home had made arrangements to provide training in safeguarding (protection of vulnerable people) for staff. This training had, however, been cancelled by the training organisation and will need to be rescheduled. Policies and procedures within the home need to be review in order to ensure that staff have information available to them to assist certain duties and responsibilities. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 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 The Willows DS0000018692.V377750.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. People using the service experience adequate quality outcomes in this area. The care needs of people are being assessed prior to admission but these are not being evaluated to ensure that the home is able to fully meet them. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We have during previous visits to The Willows obtained copies of the home’s Statement of Purpose and Service User’s Guide. We did not ask for copies of these documents during this inspection. Once management arrangements in the home have been fully addressed these documents will need to be amended to reflect these changes. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 10 However, we did notice a copy of the Service User’s Guide in the bedroom of one resident. Another resident confirmed that she had received information about the home when she was first admitted but was unsure where it currently was. Since our last inspection nobody has moved into the home on a long stay basis. The Willows has however admitted a number of people for short stay (respite). We looked at the assessment of one person who was admitted for respite care. The information in this assessment was limited and, in relation to the person’s dementia illness, provided no information about specific care needs or the ability of the care home to meet them. We note that the current registration of The Willows does not permit the admission of people with a dementia illness. We were assured that the care needs of this person could be met and we saw no evidence to suggest otherwise during our visit. However, it was of some concern that documentation showed the primary care need to be outside of the home’s registration category. The provider told us that one of the vacant bedrooms was awaiting a person who presently lives in the community but has regular respite care at the home. This person is getting to know staff and what the home is like in readiness for when the person comes to live at the home on a permanent basis. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11. People using the service experience adequate quality outcomes in this area. Staff have an understanding of people’s care needs and have written care plans available to them. People’s health care needs are being met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: As part of this inspection we read a number of care plans and risk assessments regarding four residents. A care plan is a document designed to guide staff as to the care each individual requires to ensure that needs are met. A risk assessment helps ensure that care is carried out as safely as possible. We have recently noticed an improvement in the care planning at The Willows. We have previously noted that the deputy manager had a good understanding of the need to ensure that care plans give a strong foundation for care staff The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 12 and managers to be able to monitor the care provided. Overall we found that this desire to improve has continued, however further development is needed. One person’s care records made reference to pressure sores. We were told that staff were referring to some ‘reddening to the skin’ and that no sores either existed now or had existed in the past. In the same care plan we saw that staff had commenced different record sheets regarding aspects of care needs. An audit of these documents showed that care needs were overall met however a lack of consistent recording could of lead to misunderstandings or care needs going unrecognised. We saw some elements of person centred care plans whereby they concentrated on what people could do rather than what they could not. These records, along with others, did however contain numerous grammatical errors. Care plans were in the main signed and dated by staff and not by the individual resident or their representative to show their involvement. Daily records are maintained however the information upon the majority of these was scant and basic. We have previously found inconsistency in the records held about people’s weight. Within our previous key report we wrote that either ‘sit on scales or other ways of monitoring people’s body mass index’ were needed. When we last visited the home the deputy manager undertook to contact a local community nursing team for guidance on how to use the information they had obtained on body mass. As the deputy manager was not present during this inspection we were unable to fully establish the progress made regarding this contact. It was however pleasing to see that the registered providers have recently purchased some sit on scales. Records of people’s weight are in place for most people. These now need to be accurately kept as errors prior to having these scales were seen and we saw no indication of the use of body mass tools. We previously brought to the attention of the home the need to have a reliable system in place to ensure that medical appointments are followed up. We were assured that a system would be introduced following our random inspection during the summer of this year. During this inspection we read records showing that health professionals are consulted as necessary. We saw records showing that staff have called medical practitioners or emergency services outside of core hours when needed such as during bank holidays. We also saw records following visits from a chiropodist. A GP (doctor) who attends the home wrote on a questionnaire returned to us prior to this inspection ‘Always met and accompanied by member of staff who knows patient.’ A district nurse stated on a separate questionnaire that an individual ‘ loves The Willows and staff so much she has expressed a wish to stay – she told me (the nurse) for the first time in along time she felt wanted and cared about.’ The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 13 One relative wrote that ‘the genuine love, care and individual attention is outstanding.’ We saw risk assessments were held on file and reviewed on a regular basis. Some old and now out of date assessments remained on file, these should be removed and held elsewhere in order to prevent any confusion amongst staff members. As a result of concerns with medication management during our random inspection on the 30th June 2009 we issued an Immediate Requirement Notice. The notice stated that in order to comply with Regulation 13 (2) of The Care Homes Regulations 2001 the registered provider needed to ensure that sufficient stocks of medication are available. Furthermore the notice stated that accurate records need to be kept as we were unable to balance some tablets with the records held. Following the immediate requirement we received a written response from the deputy manager detailing the action taken. These actions included having weekly audits, staff checking after each medication round that all medication was taken and ‘at the end of the last medication round in the evening staff to count all boxed tablets and enter running balance daily in box on the MAR sheet.’ Due to the Immediate Requirement Notice we carried out some audits of medication against the records held. We viewed the current months MAR (Medication Administration Record) sheets as well as the stock held. We also checked the records and actual medication held against information recorded on the daily records. The majority of the MAR sheets were completed correctly and the medication held corresponded with the written records such as care plans and daily records. However we were concerned to discover that we were unable to balance some painkillers held against the records maintained on the current months MAR sheet. As a result we viewed the MAR sheets from the two previous months. The number of tablets recorded on these sheets also did not balance. The sheets indicated that for 3 dosages medication was not available. Written records did not indicate that the person expressed any concern about pain during this time. We were able to speak to the resident concerned who confirmed that she took painkillers and told us that they were always available to her. We checked the balance of some other painkillers prescribed to somebody else. We were not able to balance these either. The directions for these tablets were ‘one to two to be taken every 4 – 6 hours’. The MAR sheet did not always show the number of tablets administered. Clarification was sought however this information did not enable us to balance the medication remaining in stock. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 14 Our findings show that staff have not undertaken the actions detailed within the response sent to the commission as the above shortfalls had gone unnoticed until our visit. We noted that the time spans on MAR sheets did not match the written direction. The direction stated take two (number of tablets) every four hours when required, however only a three hour gap was given on the MAR sheet. The MAR sheets lacked instructions regarding ointments such as where the item prescribed was to be applied. The member of staff assisting us during this part of the inspection took our concerns seriously and gave every assistance to try and understand what had occurred. The same member of staff undertook to contact the pharmacy to get the MAR sheets changed regarding times of administration. We observed staff throughout the time we were in the home. We saw staff being kind and courteous to residents. We saw staff knocking on bedroom doors and we heard staff offering people choices. Some terminology used, such as ‘good girl’ and ‘drinkey’ could be seen as inappropriate however these appeared to be well intentioned. Residents were seen to be wearing suitable attire taking into account gender, culture and weather conditions. In one care record we saw a person’s last wishes as indicated by their family member with name of funeral directors. No members of staff have completed any ‘end of life’ care planning training. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. Limited activities are provided if people wish to join in with them. Nutritious meals are available for people to enjoy. The availability of fresh products is at times limited. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Within some of the questionnaires we received back we noted that people believe that the provision of activities within the home needs to be improved. One comment received stated ‘the social side of things could be improved. More outings and activities would be excellent.’ During our visit to the home we saw no activities led by staff taking place. Care plans lacked information regarding social stimulation. A list of planned activities was displayed near to the main lounge but care staff confirmed that this plan is not adhered to. We saw one resident engaged in The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 16 doing a jigsaw puzzle. We were told both prior to our inspection as well as while we were in the home of a recent BBQ that was held for residents, their relatives and members of staff. On the afternoon of our final day in the home a group of singers and a local vicar visited the home and led a sing song in the lounge. We met the vicar and one of the singers who told us that it was the first time that they had visited The Willows but they would be willing to return in the future. They were pleased with the reception they had received saying they were made welcome. We were told that they enjoyed having a cup of tea and some cake with residents. Lunch on the first full day of this inspection consisted of Lancashire hot pot or minced meat over a jacket potato followed by sponge pudding and custard or crème caramel. One person told us that she liked a small amount of gravy on her lunch and that staff took notice of this preference. In responses to our surveys we received some comments that portions are at times too small but we received no such comments during our visit to the home. We received a comment that breakfast has to be completed before 8.00 am otherwise people would not receive any at all. We saw breakfast trays made ready during the evening for the following morning. On arriving at the home at 7.30 a.m we were told that the carer on duty during the night had taken breakfasts to residents. We were assured by the registered provider that people can have breakfast later than 8.00 if they so choose. This was confirmed by a member of staff and a resident. Over recent visits we have received information about the lack of fresh milk within the home. At one time during this inspection we noted that no milk was in the ‘fridge. This was confirmed by care staff on duty at the time, therefore staff had to use powder milk in tea and coffee. Later that morning the registered providers returned to the home having done grocery shopping. The items purchased included milk and fresh produce. The Willows holds a ‘Good’ food hygiene rating awarded by Worcester City Council Environmental Health Services on 24th February 2009. We saw records regarding food temperatures, these were in good order. We were told that the provider has purchased a new food probe thermometer since the visit from Environmental Health. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People using the service experience adequate quality outcomes in this area. People are aware that they are able to tell the providers if they are not satisfied with the care provided. Staff have an awareness of how to recognise potential abuse. Record keeping and procedures are not sufficiently robust to ensure that any concerns are dealt with consistently. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: As part of the pre inspection activity we received a number of comments regarding a range of matters which we took into account as part of this inspection. Although we received some concerns about the service everybody told us that they are aware of how to make a complaint about the service provided. The majority of people stated that the service had responded appropriately if any concerns were raised. The AQAA submitted by the service showed that no complaints had been received by them during the previous 12 months. The home has a complaints procedure. A copy of this procedure is attached to the inside of every bedroom door. The size of the type on the procedure is, in the majority of cases, small and may therefore be difficult for some people to read. The procedure made no The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 18 reference to the Care Quality Commission and the fact that people are able to contact us at any time. Despite the assurance that no complaints had been received we asked to see the complaints log to ensure it could be easily obtained if needed. We were told that it was by the front door, this was not the case. The log could not be found during our time in the home. We looked at how the home safeguards people against actual or potential abuse. During our previous inspection we wrote within the report that the home had ‘not got an in house operational policy and procedure or a copy of the Worcestershire multi agency procedures.’ In our more recent random inspection report we wrote ‘Although a poster was on display the home still does not have the local procedures.’ We have previously noted that the name of the local safeguarding coordinator was not known. The registered provider was unable to name this person on this occasion. As part of this inspection we asked to see a copy of the local authority procedures. We were brought a number of documents and folders and asked whether they were what we wanted. None of these documents were what we needed to see. We saw a booklet on safeguarding issued by Worcestershire Adult Services in the office and mentioned this to the provider. The registered provider was not aware of this booklet or of its contents. It was evident that the local procedures were not available within the home, despite our previous reports. We informed people within the home that it was possible to obtain a full copy of the procedures via the local authorities’ web site. Action was taken to try and obtain these however due to some upgrading to the Worcestershire web site taking place this was not possible at the time. An assurance was given that the necessary document would be obtained. Once the document is available steps should be taken to ensure that procedures within the home work in conjunction with the local procedures. The provider informed us that the deputy manager was sorting training for herself in addition to the training due to be provided for carers. We were previously informed that training for staff was to be provided in the near future. We were informed that training was scheduled to take place however it was postponed. This training was due to be provided by the local authority. We later received confirmation that the training did not take place but that arrangements for training in the future would take place. A member of staff gave a reasonable response when we asked about what she would do if she suspected abuse taking place in the home. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 23, 24, 25 and 26. People using the service experience adequate quality outcomes in this area. People live in a comfortable home however they cannot be totally confident that it is maintained and managed in a way that fully safeguards people from preventable risks. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Willows offers comfortable ‘homely’ accommodation for people who live there. People are able to relax in a large communal lounge. A smaller lounge is available although it is somewhat cramped due to furniture and other items within it. This room can be used for people to meet their visitors in private. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 20 Limited seating is provided in the entrance hall where people can see the comings and goings within the home. A pay phone is available in the hall for people to use should they wish although it lacks privacy. The dining room, which is sufficient in size to accommodate everybody living in the home, is a pleasant area in which to eat the meals provided. Although the cutlery was not matching the tables were nevertheless attractively laid up with a linen tablecloth and linen napkins. Lighting in communal areas was sufficient. The lighting in corridors was generally not assessed however it was noted that it is activated by a sensor along part of a corridor. The décor within the home is satisfactory in most areas. Some paintwork is damaged due to wheelchairs getting knocked against it. Bedrooms are located on the ground and first floor. We saw the majority of bedrooms that are currently occupied. Everybody had personalised their bedroom with their own possessions such as photographs, pictures and ornaments. All bedrooms at The Willows are single occupancy and they all offer en-suite facilities. Some bedrooms have a small photograph of the current occupant on the door. The provider told us of plans to have one bedroom redecorated. Since our last visit a handrail has been fitted in one bedroom to assist a resident’s mobility. Some specialist equipment is available such as a pressure relieving mattress, a pressure pad and sit on scales. The Willows has three communal bathrooms. One of these rooms has a walk-in shower while the other two have a bath with a manual hoist fitted overhead. An emergency call system is in place. We heard the system activated on a small number of occasions during our visit. One resident told us that staff respond accordingly to the alarm system. We noted one bedroom where the alarm lead was behind a piece of furniture and therefore could not be used if needed. A stair lift is fitted to one of the main staircases. We noticed that at one point it was ‘parked’ at the bottom of the stairs but had not been folded away. This was pointed out to the provider as left open in this position it could cause a trip hazard. The home was generally clean and was tidier than during previous visits. We did not detect any malodours during our visit. Staff training in infection control has been taken by 4 members of staff. The cleaning of external windows was taking place while we were visiting. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 21 During recent inspection we have had concerns about infection control due to personal toiletries left within bathrooms. Within both the previous key inspection (March 2009) and the random inspection (June /July 2009) we highlighted the fact that paper towels were not provided in one bathroom. This continues to be the case in one bathroom. Other bathrooms were seen and found to be tidy and had both liquid soap and paper towels available. We observed a member of staff checking the water temperature of a bath. Temperatures are recorded on a sheet of paper in the bathrooms. We saw documentation regarding the monthly checking of hot water temperatures throughout the home. The back garden can be accessed via both the dining room and the lounge. A ramp is provided from both of these rooms onto a patio area. The slabs on the patio need attention as some are loose while others are uneven. We were told that work on the patio is due to commence and we saw materials to the front of the home to carry out this work. A ramp leads down to a lawn. Some garden furniture including some parasols are provided so that residents can enjoy warmer weather. We have previously pointed out some concerns about the carpets along the ground floor corridor and leading upstairs. We were informed that a deep clean has taken place and that the carpet was stretched to remove ridges however a few remain including some in the dining room. The carpet does however appears less stained but is nevertheless showing signs of wear and tear. We pointed out one part where the carpet had come away from the carpet strip and therefore could prove to be a trip hazard. The arm chairs in the lounge are also showing signs of wear and tear. We noticed a similar armchair in one bedroom where the arms were particular worn and dirty. The laundry is located in the cellar of the home. We saw laundry outside drying as well as washing ready to be returned to individuals. Clothing seemed to be well laundered. We saw a supply of disposable gloves available for staff to use in line with infection control procedures. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. Care staff have to undertake additional duties which may reduce their ability to ensure that people using the service receive the care they need. Staff training is not planned and provided in organised way. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Prior to this inspection we received a number of comments that gave us some worry about the number of staff on duty. We also received some information indicating that staff morale was not too good. This inspection commenced one evening and we found sufficient staff to be on duty at that time. When we returned during the day time we found in addition to care staff a cook and a domestic to be on duty. We were informed that a domestic is employed five hours per day Monday to Friday. Some people have voiced concern about staffing levels especially when staff have to perform other duties such as laundry and food preparation. Although we saw no negative outcomes, The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 23 other than a lack of activities, it is nevertheless important that staffing levels are in accordance with the care needs of people living in the care home. The Willows has a mixture of both male and female carers. We have in the past received assurances that a female carer is on duty at all times. This gives residents the choice of having a female member of staff provide care to them if they so wish. As part of this inspection we assessed the amount of training undertaken by the current staff team. We enquired whether a training matrix / planner is in place in order to oversee the training completed and highlight training needed in the future. We were told that a matrix will be drawn up in the future. Due to the lack of a matrix we sampled all staff files to establish what training has taken place. Training helps to ensure that staff have the appropriate knowledge and skills to meet the individual and collective needs of people who live at The Willows. We found some training certificates in staff files while some others were found in a separate file. Some certificates could not be located at all. We noted that some certificates had expired therefore people required refresher training. From the training records we concluded that only two members of staff had attended any recent fire safety training. Staff told us about dementia care training that some of them have done as part of a distance learning course. Two members of staff commenced employment at The Willows during November and December 2008. Since that time one person had attended two training sessions while the other had attended one. Information on a notice board showed scheduled forthcoming training in relation to moving and handling. We were given assurance that training shortfalls would be addressed and that staff files would be improved. Four members of staff currently hold an NVQ (National Vocational Qualification) level 3, this is 33 of the carers not including the two providers who also provide personal care. The associated National Minimum Standard states that 50 of staff should hold a level 2 qualification. Currently a further three members of staff are undertaking their level 3. A total of 5 carers are currently working towards a level 2. It is important that the current level of qualified staff is maintained and increased. We have previously had some on going concerns about recruitment practices. Our previous key report stated that no new staff had been recruited between The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 24 the inspection in January 2009 and that visit. During this visit we were informed that no new staff were working within the home but that some new employees were awaiting employment checks. It was therefore not possible to assess whether the home is continuing to full comply with employment requirements in order to safeguard people from having unsuitable staff appointed. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People using the service experience adequate quality outcomes in this area. People can have increased confidence in the management of the home as shortfalls are now more acknowledged by the providers. Systems in some areas remain weak and insufficient to ensure a quality service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Over the past 18 months a number of changes have taken place in the management of The Willows. The home currently does not have a registered manager. We have previously expressed our concerns about shortfalls in The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 26 management systems within the home. Although we have seen some improvements significant shortfalls remain which need to be addressed. We have previously discussed with the providers the fact that responsibilities between the manager, owners and others need to be clearly defined as these have proven to be difficult in the past. We received comments about low morale amongst staff as a result of difficulties between differing parties within the home. We have previously pointed out that people in management positions need to have additional training to other staff within the home in accordance with their role. During this inspection we were told of further plans regarding the position of manager at the service. It is becoming increasing vital, in order to provide staff with clear direction, that decisions are reached regarding who is to take the service forward and therefore who is taking responsibility for driving improvement. Prior to this inspection we asked for an Annual Quality Assurance Assessment (AQAA) to be completed and returned to us. The document was filled in and returned to us. The AQAA is a document within which providers are able to provide evidence of how they are meeting their regulatory obligations. It would be of benefit to the service if in future the document was more detailed. Systems to monitor the quality of the service provided remain insufficient. We asked for details of Quality Assurance systems. No system could be found although a policy on Quality Management dated 2006 and some other information dated 2007 signed by the former registered manager was pinned to a wall. The information stated ‘ internal audits should take place at least annually’ ‘ results of surveys should be published and made available’. We have however acknowledged in the past that the providers have tried to improve the service and continue to take advice from Worcestershire County Council. Short reports about the home are carried out by one of the providers which show discussions with the management. As the provider attends the home most day’s reports under Regulation 26 are not legally required however they are currently the only indication of any dialog with the deputy manager and how the service could develop. Policies and procedures are available for staff. We were shown two different files containing these documents. Within one file some headings were highlighted on a list of policies and procedures, the registered provider was unsure what this indicated. We briefly viewed some of the procedures and saw that they were all signed by the previous manager and dated 2006. Our previous report stated that the ‘registered provider and acting manager have engaged a consultancy firm to assist with developing health and safety practices, employment practices and policies and procedures.’ The registered provider was unable to answer when we asked what had happened about the reviewing of procedures. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 27 During our previous inspection the registered provider confirmed that he is appointee for one person using the service. This involved receipt of benefits and the management of finances. We continued to have concerns about the management of people’s money during our random inspection visit. We viewed the records now held. It was clear that improvement has taken place. The written records held were done retrospectively and were not always in chronological order. Now that these are up to date they should become an accurate and current record. One person now has a bank account into which money is paid. Some systems in relation to this person do however need further improvement to fully safeguard everybody involved. The certificate of registration mentioned earlier within this report was on display in the entrance hall of the home. During our previous key inspection we commented upon a health and safety inspection carried out by an independent consultant. A report written by the consultant made a number of recommendations which did not receive action within the time span suggested. During our random inspection were we unable to establish whether these recommendations had received suitable action. This matter was discussed with the provider in July 2009 during a meeting with CQC. During this inspection we were informed that the action had taken place in all areas such as fire safety, gas safety and asbestos. We were told that making the patio slabs even was due to happen. We did not see the report or any records detailing the actions taken during this visit. In the AQAA we asked for details of when some pieces of equipment were last serviced. This information was missing and therefore we sought the details of some equipment during our visit. A couple of different files are designated to keep these documents in however some were missing and the provider and a member of the care team had to spend a considerable amount of time searching for information. We have in the past brought to the attention of the provider guidance from the Health and Safety Executive (HSE) regarding the servicing of hoisting equipment. Records regarding equipment were found however they appeared to indicate that the frequency of service is insufficient and needs to be improved. We saw that it was expected that a service to the main stair lift was scheduled for October 2009 however the previous service had been October 2008. HSE guidance 2001 stated ‘The Lifting Operations and Lifting Equipment Regulations 1998 require that personal lifting equipment (hoists and lifts for people) are thoroughly examined every six months unless a separate thorough examination scheme is devised by a competent person.’ A chair lift has being recently fitted to a small number of stairs on the first floor. Although it is welcomed that this area of the home is now assessable the commissioning certificate for this piece of equipment could not be found. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 28 We saw a record regarding the gas safety check however this also took considerable time to be found Within the random inspection report June / July 2009 we stated that the ‘most up to date fire risk assessment on file was dated January 2008. The assessment stated that it should be reviewed in July 2008 but we saw no evidence that this was done. We noted that the assessment was incorrect regarding the action to be taken to open the front door as a key pad is now fitted.’ Despite us bring this matter to the attention of the registered provider the same risk assessment remained to be the most recent document. The fire safety policy was not dated or signed by a registered person. The policy contains the names of certain residents no longer residing within the home. A daily check list was in place and completed. The weekly fire alarm testing record needed attention as the testing was not in sequential order and one break glass was missing off the key. The records demonstrating the visual monthly checking of self closing doors and fire extinguishers were up to date. We asked to view records regarding water temperatures. These took some time to find however once found they showed that these checks as well as room temperature checks are done on a monthly basis. No records indicating the visual checking of window restrictors exist. Having a record regarding restrictors shows that the registered persons take the risk of people falling accidentally or identically from windows seriously. We are now more confident that we will receive a notification from the service in the event of certain incidents occurring in the home which have a direct or indirect result on people using the service. The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 29 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 2 The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 30 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 OP18 Regulation 13(6) Requirement You must make arrangements to provide managers and staff with the right information to use if they need to take action in the event that they suspect there has been abuse or neglect of a person living in the home. These must reflect the arrangements in place under local multi agency safeguarding procedures. This is so that the abuse or neglect would be identified and the right action taken to deal with it. Previous time scale of 30/04/09 and 30/06/09 not met. As it was confirmed that anticipated training was cancelled this requirement is repeated within this report and an extended timescale is, on this occasion, given. Timescale for action 30/11/09 The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 31 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 OP3 Good Practice Recommendations The pre assessment form needs further improvement to ensure it is person centred and demonstrates how the home is able to meet care needs. You need to continue the work on improving the care plans so they contain enough information to inform and guide staff in the right care to give each person. This recommendation remains from a previous report. 3. OP7 Off the shelf care record forms should be tailored to the needs of the home and the people living there. This recommendation remains from a previous report. 4. OP8 You need to avoid duplicating records about specific issues (eg healthcare visits, lists of current medication) so that it is clear where staff should write this information and to make sure the correct information is referred to. This recommendation remains from a previous report. 5. OP9 You need to review the recording of medication to ensure that audits balance and to ensure that sufficient time is given between dosages. You need to continue to find out what peoples social and leisure interests and preferences are and use this information to provide activities that people will enjoy. This information should form part of each individuals care plan. Information about activities, meals etc provided for people living in the home should be available in larger print and, if needed in other formats. DS0000018692.V377750.R01.S.doc Version 5.3 Page 32 2. OP7 6. OP12 7. OP12 The Willows This recommendation remains from a previous report. 8. OP27 You should consider how staff are deployed within the home to ensure that care staff have sufficient time to meet the identified care needs of residents. You should continue to develop the staff training and development programme and keep clear records of this to provide evidence of the training staff have done. This recommendation remains from a previous report. 10. OP33 You should set up an action and development plan for the service, which involves seeking the views of people using the service, and others such as relatives and professionals so. This will help you monitor the quality of the service you are providing and to act of the views of people receiving it. This recommendation remains from a previous report. 11. OP35 It is recommended that you continue to improve the systems in place to ensure that money held in safekeeping is accurately recorded. The review of policies and procedures should continue and staff should be aware of the contents of these documents. Staff involved in doing risk assessments need to be sufficiently experienced and trained for this role so they have the right knowledge and skills to do this work. This recommendation remains from a previous report. 9. OP30 12. 13. OP37 OP38 The Willows DS0000018692.V377750.R01.S.doc Version 5.3 Page 33 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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