Inspection on 22/08/05 for The Willows

This inspection was carried out on 22nd August 2005.

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

The Willows 17/08/06

The Willows 09/02/06

The Willows 30/03/05

The Willows 29/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Willows Field Terrace Ripley Derbyshire DE5 3HF Lead Inspector Jill Wells Unannounced 22 August 2005, 9.30am nd 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 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 C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Willows Address Field Terrace Ripley Derbyshire DE5 3HF 01629 580000 01773 728152 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Derbyshire County Council Jeanette Gilmour Care Home 20 Category(ies) of 20 - Older People registration, with number of places The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30th March 2005 Brief Description of the Service: The Willows Care Home is situated within the community of Ripley, located near to the town centre and the local Community Hospital.The Home has places for 20 older people. Two rooms are used for respite care. All bedrroms are for single occupancy and are situated on the ground and first floor of the Home. There are no en suite facilities. The Home has a lounge and a lounge/dining room for use by Service Users. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a four hour period. Four service users were spoken to on a one-to-one basis as well as one care assistant, the deputy manager and the manager. Information was used from the Pre-inspection questionnaire provided by the manager. Three service users files were checked as part of the case tracking methods used. Other records were also inspected. What the service does well: What has improved since the last inspection? The previous inspection highlighted that there was not clear record of choice is provided at mealtimes. This was now recorded. The kitchen has had a complete refurbishment to a high standard. Decorating has taken place in several areas of the home since the last inspection in order to keep the home to a high standard. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 standard(s) 1,2,3 Full and detailed information was provided to prospective service users, and their needs were fully assessed before a decision was taken as to whether the home could meet their needs. EVIDENCE: There was clear information for service users and their families to make an informed choice about whether they wish to live at the home. This included a statement of purpose and service user guide. Service users were given a copy of these documents. The service user guide included the terms and conditions of residency, and a copy of the complaints procedure. Three service user files were seen as part of the case tracking methods used. Each file had a full needs assessment in place. The assessment had been undertaken by a care manager/community care worker from Social Services. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 Service users health and personal care needs were met, however some practices concerning medication were not adequate. EVIDENCE: Each service user file had a service user plan in place. There was sufficient information within the plans to provide care staff with the detail of the support that each service user required. There was also a monthly review completed that reflected any changes. The plan was drawn up with the involvement of the service user and signed by the service user where possible. Daily records were in place for each service user. Although records were generally in good order some documents did not have full dates or signatures of the person completing the document. There was evidence in files that GPs and other health professionals were involved where necessary. The risk of pressure sores were assessed and action was taken including providing equipment when required. Nutritional screening was undertaken and service users weight was monitored. Service users have access to hearing and sight tests. Staff spoken to had knowledge of issues around sensory loss. Service users spoken to said that they could request the GP visit at any time. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 10 There was a written policy and procedure concerning medication. Each file had a declaration from the service user concerning whether they wished to self medicate or have staff assist with the administration of their medication. There was a medication room. At the time of the inspection the temperature of the room was 27°C. This was not a hot day, and it was of concern that the temperature of the room would likely to increase on warmer days. Medication administration records were in order. There was a lockable fridge that had a max-min temperature recorded. Medication stored in the fridge that needed to be discarded after four weeks did not have the date of opening placed on them. There was a medication signatures list to indicate all staff that were able to administer medication. The recording and storage of controlled drugs was in good order. Although there was a photograph of each service user within the medication records, there was no photograph of short-term care residents. The British National formulary(BNF) was dated 1997 which would make some of the information out of date. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 Service users lifestyle experienced in the home matched their expectations, and a wholesome diet was provided in pleasant surroundings. EVIDENCE: Service users had the opportunity to take part in activities organised by staff. These included movement to music, bingo, dominos and quizzes, listening to an organist and outside singers, as well as a monthly outing. Service users spoken to gave mixed messages concerning social activities. One service users said that they, dont want to join in the activities, I am quite content to sit and read and watch TV. Another service user said that although there were activities these were not everyday. Staff spoken to said that they had great difficulty motivating service users to take part in any activities. Although there was a recording system in place to evidence daily activities, this was often not completed, it was therefore not clear how regular activities were offered. The home had the income and expenditure of the amenity fund displayed. This showed evidence of paying for outings, volunteer expenses and garden parties. Service users spoken to said that they could have visitors whenever they wished, and their visitors were welcomed by the staff. There were two religious services per month at the home one organised by the Salvation Army and the second by the local Church of England. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 12 Mealtimes were set at 9 a.m., 12:30 p.m. 5 p.m. and 8:30 p.m. The menu showed that there was a choice at each meal time and special diets were catered for. The cook would talk with each service user to ascertain whether they were happy with the main meal and if not, discuss an alternative. All service users spoken to were generally satisfied with the quality of the food and confirmed that they could have a choice at each meal time. However several service users told the inspector on the day of the inspection that the chicken at lunch time was very dry. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 standard(s) 16 Complaints were taken seriously and acted upon. EVIDENCE: There was a clear written complaints procedure displayed in the entrance hall and within each service user guide. This gave details of the address and contact number of CSCI. There were records kept of complaints made by service users. There had been two complaints made since the last inspection. Records evidenced that they had been appropriately dealt with. Service users spoken to said that they would not hesitate to complain to staff or the manager if they were not happy with any aspect of the service. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 24 The environment was of a good standard and met the needs of service users living at the home. EVIDENCE: There were 20 single bedrooms at the home. No bedrooms have en suite facilities. Bedrooms seen had all of the required furniture, including a lockable drawer, and were well decorated. The several service users had chosen to personalise their rooms and bring in their own furniture and other possessions. There were three lounge areas, two on the ground floor and one on the first floor. Two of the three lounge areas were also used as dining rooms. There were 6 toilet facilities on the ground and first floor. There were also two bathrooms and one shower facility. These were not inspected on this occasion. Since the last inspection the kitchen has been completely refurbished to a high standard. Various areas within the home had been decorated including the stairs, hallways, corridors, and large lounge. All communal areas were clean, comfortable and well decorated, with goodquality furnishing provided. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 15 There was a call system in every room to allow service users to ring for assistance. Service users spoken to said that staff were generally quick to respond when they rang. The entrance hall displayed various information for visitors and service users. There was also a payphone in the entrance hall. There was an attractive garden area which was accessible for service users. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 There had been times at the home when staff numbers had been reduced which was likely to affect the care provided. The home was committed to ensuring that staff have the opportunity to undertake NVQ 2 Care EVIDENCE: There were usually two care staff on duty at all times as well as a manager or deputy manager available in the day. However there had been some occasions where there had only been one care staff and a manager on duty due to staff shortages. Staff explained that on these occasions the manager on duty would assist at tea time and support service users at bed time. It was stated that during these times service users were not able to have a bath. As there was no cook at tea time, this would cause pressures for staff on duty and take all staff away from service users. The manager stated that they were due to appoint a new worker to the vacancy which would help the situation. Staff spoken to have undertaken all the mandatory training including updates and some specialist training. Training records were not specifically inspected on this occasion. Information provided by the manager was that 75 of care staff had obtained NVQ 2 Care which was above the minimum standards and should be commended. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 38 The home was well run and managed by a competent management team. EVIDENCE: The registered manager had worked at the home for a number of years. She had obtained NVQ 4 Care and Management qualification. The manager undertakes periodic training to update her knowledge, skills and competence. She also attends regular managers meetings with other managers from homes within Amber valley. This gives the manager an opportunity to share ideas, receive support and look at how the service could be further developed. The manager is supported by three deputy managers working at the home. Together they make a competent team providing good leadership and an open management approach. Service users and staff spoken to said that they felt able to go to the manager at any time and know that they would be listened to. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 18 The service manager who had overall responsibility for the home visited at least on a monthly basis to support the manager and undertake the required reports. Safe working practices were observed, including moving and handling techniques, safe storage and disposal of hazardous substances and use of protective clothing. The main dining area had facilities for service users and their visitors to make drinks and snacks. The area had a kettle and microwave. A risk assessment had not been undertaken concerning this area. Although it was stated that this was very rarely in used, it was accessible. Information provided by the manager was that the Fire Officer had visited in April 2005 and made no recommendations. The fire equipment was checked as required and regular fire drills and training were taking place. All systems had been serviced including the heating system, portable electrical appliances, emergency call systems and emergency lighting. The lift was serviced in May 2005. The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 x x 3 x x STAFFING Standard No Score 27 2 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x x x x 2 The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? 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. 2. Standard 7 9 Regulation 17 13(2) Requirement All documents within service users files must be signed and dated. The temperature of the medication room must be monitored. If the temperature is regularly above 25 C, action must be taken to reduce this temperature. When instructions state on medication that it is to be discarded within four weeks, the date of opening must be recorded. The registered manager must ensure that there is a photograph in place of all service users including short-term care service users in order to identify them for medication administration purposes. Information available for staff concerning medication eg British National formulary must be upto-date. There must be adequate records to evidence that social activities are taking place. It is advised that staff record where activities have been offered and refused. There must be adequate staff on Timescale for action 15th September 2005 15 September 2005 3. 9 13(2) 4. 9 13(2) Immediate informed that the time of the inspection 15 September 2005 5. 9 13(2) 30 September 2005 30 September 2005 15 Page 21 6. 12 16(2) (m) 7. 27 18 The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 8. 38 13(4)(a) duty at all times in order to meet the needs of service users. There must be a written risk assessments concerning the accessibility of the kettle and the microwave in the dining area September 2005 15 September 2005 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 Good Practice Recommendations The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection South Point, Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows C02 C52 S35584 The Willows V245688 220805 Stage 4.doc Version 1.40 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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