CARE HOMES FOR OLDER PEOPLE
The Willows 197 Darkes Lane Potters Bar Hertfordshire EN6 1AA Lead Inspector
Neil Fernando Unannounced 24 August 2005 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 I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service The Willows Address 197 Darkes Lane, Potters Bar, Hertfordshire EN6 1AA 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) 01707 659205 01707 659205 Follett Care Limited Mrs Elizabeth Hayward CRH PC 12 Category(ies) of OP - Old Age - 12 places registration, with number of places The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: The home is registered as a Care Home providing personal care only to 12 service users under the category Old Age. Date of last inspection 13 April 2005 Brief Description of the Service: The Willows is a detached Edwardian period, family house that has been converted into a residential care home for elderly people. The home is situated at the end of the main shopping parade in the town of Potters Bar. The accommodation is on two floors and consists of ten single occupancy rooms and one shared room. The home does not have a passenger or stair lift and service users admitted to the home must be assessed as having full mobility, if they are to be accommodated on the first floor. The home has a front yard with parking facilities for up to 4/5 cars and a very secluded garden at the rear of the property, which is set to lawn and benefits from a fish pond and mature trees. The home has easy access to the Motorways and the main line railway station. The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second inspection for the year 2005/6 under the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The last inspection (Unannounced) was carried out 13.04.05. The Willows is a residential care home, which is registered to accommodate up to a maximum of 12 older people. It is one of four care homes owned and managed by Follett Care Limited. There were 2 service users in residence at the time of the inspection. The inspection was carried out over half a day towards the end of August 2005. All of the National Minimum Standards assessed on this occasion with the exception of three, have been met. Both service users and two members of staff including the senior staff in charge of the home were spoken to, in order to seek their views regarding the quality of life for residents at The Willows. What the service does well:
There is good evidence to demonstrate that the health and personal care needs are being identified through a simple and clear planning process and monitored internally through a monthly review system, involving the service user and their family where possible. Both service users appeared to be comfortable and received care and attention in a timely and sensitive manner. Residents’ interests, expectations and aspirations are being sought by staff members and fulfilled as appropriate. In spite of the mental frailty of the current service users, it is positive to note that they are being proactively encouraged to exercise choice and autonomy. The catering facilities appeared to be managed efficiently and both service users described the quality of food available to them as “Excellent”. In the main, they expressed a great deal of satisfaction regarding the services they receive. The complaints system appears to be managed satisfactorily. There are a number of monitoring systems in place and these should offer adequate protection to a service user. Staff members spoken to are keen and committed to their work. Some of the staff members have been working at this home for a significant period of time and this appears to promote consistency and continuity in the quality of service delivery for the residents. The staffing arrangements remain satisfactory. Overall, good evidence is available to suggest that the quality of care has been consistently maintained to a good standard.
The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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 I52-I02 s19592 The Willows v246042 24 08 05 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 I52-I02 s19592 The Willows v246042 24 08 05 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) 2 and 5. Standard 6 is not applicable. The opportunity to visit the home and meet with staff members and other residents is seen as very crucial by service users and staff members. This process enables the prospective service user and their representatives to be involved in the decision making process, thus ensuring that their needs can be met on admission to the home. EVIDENCE: Case files for the two service users in residence were examined and these include terms and conditions agreed and signed by the service user/relatives and or Care Manager from the placing authority. Information gained from case files and interview with two staff members including the senior care staff indicates that the prospective service user, relatives/friends and the Care Manager where appropriate, would be visiting the home before the prospective resident is admitted. They would spend time looking around, speaking to other service users and a meal is offered if required. Records also evidence that there have been similar visits to the home during the recent weeks. The service user is admitted on a trial basis to give them ample opportunity to decide if they wish to stay and also to give the
The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 9 home’s staff time to further assess the needs of the new resident. A review meeting is held at the end of the trial period with the service user and significant others, and only then the placement is made permanent. The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 10 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 and 9. Service users’ needs and requirements, including health and personal care are being identified and addressed through a care planning process and monitored through a monthly review system. Service users appeared to be comfortable and received care and attention in a timely and sensitive manner. EVIDENCE: Good evidence is available from the care plans, both service users and staff members to indicate that the needs of residents are being identified and addressed satisfactorily. A record of the care given, progress made and interactions with service users is maintained. Staff members reported that residents are always encouraged to sign their care plans where this is appropriate. Service users provided some good examples of how staff members assist them to address their needs on a day today basis. Records show that care plans are being reviewed on a monthly basis to reflect the changing needs and objectives for health and personal care. Monthly review notes are maintained and these are noted to be comprehensive. However, one service user has not had a formal review from their placing authority for the last two years. The registered person must ensure that this is carried out. The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 11 Records show that the residents are registered with a local GP of their choice who visits as and when required. Both service users expressed a high level of satisfaction in the manner their health care needs are being addressed. The outcome of the Doctor’s visits is clearly recorded. The procedures on administration and control of medication are available and accessible to staff members. All staff members including the Deputy Manager have enrolled on a six weeks course at a local college and it is envisaged that they would complete this training by November 2005. The current service users are mentally frail and they are therefore not able to administer their own medication. Staff members are however clear that residents would be encouraged to self-medicate where appropriate but a risk assessment would always be carried out first. Medicines are stored in a locked cabinet. Medication charts viewed are noted to be in order. The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 12 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) 14 and 15. In spite of the mental frailty of the current service users, it is positive to note that they are being proactively encouraged to exercise choice and autonomy. Both service users described the quality of food available to them as “Excellent”. EVIDENCE: Residents are encouraged to express their opinions regarding how their expectations and preferences are being met and there is good evidence to demonstrate that remedial actions are taken to remedy dissatisfaction, if any. The menu seen provided for a nutritious and varied diet. The lounge/diner is spacious, comfortably laid out and pleasantly lit by large windows. Provision is made for service users to take their meal in their own room if they so wish. The current service users prefer to eat together in the lounge/diner, as they have been friends for many years. Staff stated that although there are set times for meals individual arrangements are made when the need arises, i.e. if a service user is going and returning late or for some other reason, if this is made known. Alternative meals are provided if a service user decides they do not want the meal they have chosen. Advice from a nutritionist is available as required. Information gathered evidence that service users are fully satisfied with the variety and quality of food offered to them.
The Willows I52-I02 s19592 The Willows v246042 24 08 05 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 and 18. Information on how to make a complaint is available and service users should be capable of making a complaint. There are a number of systems in operation and these should offer adequate protection to a service user. EVIDENCE: The home’s procedures on complaints are available and accessible to all staff members. Staff members interviewed demonstrated a good understanding of the procedures and their responsibilities towards ensuring that any complaint is dealt with quickly and satisfactorily. Information regarding how to make a complaint is included in the statement of purpose and service users’ guide. Both service users spoken with reported that they are regularly encouraged to raise any concern or complaint they may have about the services they receive. Overall, service users felt able to make a complaint. The home maintains a record of complaints but there have been no complaints received by the home or the Commission about any aspect of care, since the last inspection in April 2005. The whistle blowing policy is available and accessible to the staff team. The home also has procedures on the protection of vulnerable adults from harm. Discussion regarding the procedures is part of the induction for all new staff members and as part of NVQ assessment. All staff members including the Manager have received formal training on the protection of vulnerable adults in July 2005 - a certificated course provided by “Guardian Training Partnership Ltd.”. Staff members spoken to are clear that any allegation or incident of abuse would be reported to a senior member of staff and followed up immediately.
The Willows I52-I02 s19592 The Willows v246042 24 08 05 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 and 26. The home appears to continue to provide good living conditions to the current service users. The accommodation is bright and comfortable. Redecoration of the communal area has significantly improved the physical environment for the service users. Upgrading and extending the accommodation no doubt, will further improve the physical environment and the quality of life for service users. EVIDENCE: Bedrooms are decorated and furnished in a style that promotes a domestic atmosphere. The lounge/diner has been decorated to a very high standard. The carpet in the ground floor bathroom has been replaced. The home does not have a passenger lift to access the first floor and therefore, only service users who are physically fit and mobile could be accommodated in its upstairs eight bedrooms. There are strong indications to suggest that the occupancy has dropped to its current level (2), mainly due to the home not having a passenger lift. However, on a more positive note, the Responsible Individual has confirmed in writing to the Commission in a letter dated 26.08.05 that good progress is being made to obtain planning consent, in order to upgrade and extend the accommodation, including the fitting of a passenger lift. This is
The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 15 very welcome by the Commission. With this in mind, it would be fair to view the shortfall with respect to the lift in the context of the proposals and therefore, consistent with the last inspection report dated 13.04.05 no recommendation is being made. A high standard of cleanliness was evident throughout those areas viewed. There were no mal-odours present. There are infection control policies and procedures in place. Suitable arrangements are made for the storage and collection of domestic and clinical waste. Risk assessment of the physical environment is undertaken regularly. There were no health and safety hazards noted during this visit. The Willows I52-I02 s19592 The Willows v246042 24 08 05 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 and 30. The establishment continues to provide the staffing levels required by day and night, and service users’ needs are being well addressed. The training needs of the staff team are being given a high profile and no doubt, this ensures an improved level of service delivery for residents. EVIDENCE: Staff duty rotas for a period of 4 weeks and discussion with two staff members including the senior person in charge of the home indicates that the day and night care staffing levels are adequate to meet the needs of the current service users. The staff members on duty also reconciled with the rotas for the day. Training and development profiles are maintained for each staff member. Staff members interviewed, expressed a great deal of satisfaction with respect to training they have received in the last twelve months. Information available indicates that staff members have received all mandatory training to assist them to do their work competently. The Deputy Manager has an NVQ 4 in Management and Care and the remaining members of staff have completed their NVQ Level 2 assessment giving a ratio of 100 . This is quite significant and the Organisation and staff members are to be commended for their achievement and hard work in this area. Training for staff appears to be given a high profile. Overall, good evidence is available to indicate that staff members are experienced and competent to undertake their tasks. The Willows I52-I02 s19592 The Willows v246042 24 08 05 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) 36 and 38. Care and staff management systems including health and safety matters are being implemented to good effect. The Willows continues to be a safe home for service users to live in. Records viewed are maintained in good order. EVIDENCE: There is good evidence to indicate that staff members have on going informal supervision from the Deputy Manager and Registered Manager, whilst carrying out their daily task. A formal supervision system is in operation and staff members interviewed confirmed that they receive formal one to one supervision every two months and that they are very satisfied with management support they receive. The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 18 The home has good procedures to ensure the health and safety and welfare of service users and staff. The staff team have received training that ensures safe working practice. Fire drills and weekly test of break glass points have been carried out and a record maintained. Hot water temperature is monitored regularly, in order to ensure a safe limit of 43 degrees centigrade at the point of outlet. Windows have been fitted with restrictors for the safety of service users and security of the building. Portable electrical appliances are checked, tagged and a record maintained. There are however two shortfalls identified, which require remedial action: a) Fire drills must be carried out once every three months, at minimum; b) Whilst all staff members have completed training in basic food hygiene, some members need a “refresher” course. The Willows I52-I02 s19592 The Willows v246042 24 08 05 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 x 3 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3
COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 x 2 The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 20 NO 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. Standard OP7 Regulation 14 (2) & 15 (2) (b) 23 (4) (e) Requirement The registered person must ensure that a formal placement review for one service user is carried out. Increase the frequency of fire drills to once every three months, at minimum. Timescale for action 24.11.05 2. OP38 24.10.05 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 OP38 Good Practice Recommendations Some members require a “refresher” course in basic food hygiene. The Willows I52-I02 s19592 The Willows v246042 24 08 05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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