Inspection on 24/06/09 for The Willows

This inspection was carried out on 24th June 2009.

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

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 21/10/08

The Willows 24/10/07

The Willows 07/02/07

The Willows 22/02/06

The Willows 17/10/05

The Willows 28/01/05

The Willows 11/08/04

The Willows 19/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Willows 1 Murray Street Salford Manchester M7 2DX Lead Inspector Adele Berriman Key Unannounced Inspection 10:00 24th June 2009 DS0000006730.V376395.R01.S.do c Version 5.2 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 DS0000006730.V376395.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 DS0000006730.V376395.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 1 Murray Street Salford Manchester M7 2DX 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) 0161 792 4809 0161 708 9481 msandher@aol.com Unity Homes Limited Mrs Mary Tennant Lunnie Smith Care Home 124 Category(ies) of Dementia (124), Old age, not falling within any registration, with number other category (124) of places The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home with Nursing - code N, to people of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP. Dementia - Code DE The maximum number of people who can be accommodated is: 124 Date of last inspection 21st October 2008 Brief Description of the Service: The Willows is a detached property providing accommodation for up to 124 older people. Unity Homes Limited owns the property. The responsible individual is the proprietor, Mr Sandher, and the registered manager is Mrs Mary Smith. The home is situated in a residential area of Broughton on the major bus routes and within ten minutes drive of Manchester City Centre and internally the buildings are accessible to all. Two car parks provide adequate parking for residents and visitors. The cost of the service is between £373.52 and £476.60 per week. The Willows DS0000006730.V376395.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 one star. This means the people who use this service experience adequate quality outcomes. This visit was undertaken by two inspectors as part of a key inspection, which includes an analysis of any information received by us (the Care Quality Commission) in relation to this home prior to our visit. We also looked at other information we had about the home. Before the visit the home manager was asked to complete an Annual Quality Assurance Assessment (AQAA) to provide up to date information. We sent our questionnaires out to people who live in the home, their families and staff in order to find out their views. We received 11 completed survey forms from staff. The visit was carried out by two inspectors and was unannounced and took place over the course of 8 hours on Wednesday 24th June 2009. During the course of our visit we spent time talking to residents, the manager and 5 members of staff to find out their views of the home. Time was spent examining maintenance records and the residents and staff files. A tour of the building was also carried out. There was evidence to show that the unit managers and staff continued to work hard to develop and improve the service. Health and Safety checks take place to make sure people are kept safe and good records are kept of these. What the service does well: Complaints received by the home are dealt with appropriately. Assessments of peoples needs are carried out before people move in to make sure the home can meet their needs. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 6 Recruitment is robust and makes sure that staff are safe to work with vulnerable residents. They have good working relationships with community nurses and GP’s. They speak to people to assess what they think of the care they receive. People who are unsure about moving in are given the option of a trial stay in the home to make sure it is the most appropriate place for them. They work closely with the principles of the end of life care pathway. What has improved since the last inspection? What they could do better: Care plans should be more detailed and where they have been reviewed any amendments should be added to the care plan. Daily records should be more detailed to reflect the care the staff are providing. Fire doors should be checked to make sure they close securely into the rebate. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 7 Windows should be restricted to minimise the risk of falls to people living at the home. Copies of documents given as proof of identity be signed and dated to show that the originals have been seen. It should be the responsibility of a clinically trained and qualified person to demonstrate clinical procedures to new staff and sign that they are competent. Personal information held by the home should be stored in line with the DATA Protection Act 1998. Where a care plan identifies areas of risk such as high/low sugar levels, detailed records must be kept to enable staff to monitor the person’s health. Staff must receive supervision at least six times a year and a record kept of the meeting. 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 DS0000006730.V376395.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given enough information, and have their needs assessed so they know that the home can meet their needs. EVIDENCE: We saw a sample of care plans. We saw they had a copy of the care manager’s assessment of need. They told us that the manager or a senior member of staff would also carry out a pre-admission assessment. This was carried out by the manager before admission to make sure that the home could meet people’s care needs. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 10 We saw a copy of the pre-admission assessment on care plans. The information gathered during the pre-admission assessment was used to write the person’s care plan. They told us that people were able to visit the home before making a decision to move in. Where this was not possible, relatives were invited to visit on their behalf. We spoke to people living at the home who told us “I had a look around and stayed for a bit”. The home did not provide intermediate care. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans and risk assessments did not fully address individual health, personal and social care needs. EVIDENCE: We saw a sample of care plans for six people. We saw that people had signed their own care plan. This means that people were involved in the planning of their own care. One person told us “yes I have seen something written down” and “they asked me what things I like”. We saw that some information in care plans was repetitive. An example of this was the mental health and cognition section contained the same information for each person with the name altered. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 12 We saw that daily records were being written in small notebooks then passed to the senior member of staff to write into care plans. These books held personal information about people’s care. This means that people would be unable to look at information about their care that was recorded in these books without also looking at other people’s details. This method of recording does not meet the requirements of the DATA Protection Act 1998. A requirement is made that records are kept in line with the DATA Protection Act 1998. The manager told us before we left that she would put a new system in place to make sure that the information was written directly into people’s care plans. We saw that people were registered with a local GP. We saw records of visits from other healthcare professionals in each person’s file. This showed that people had access to medical treatment when they needed it. We spoke to people living at the home. They told us “if I need the Dr they call him”. Another told us “they give me my tablets on time and if I am not feeling well they ask the Dr to come”. We saw that daily records were repetitive. They gave no information about what people did during the day. Entries in daily records included “care as plan” and did not reflect the care being given. A recommendation is made that daily records are detailed and reflect the care given. Daily records should also give details about how the person has spent their day. We saw one care plan where a risk relating to smoking had been identified. We did not see a risk assessment in the care plan. A recommendation is made that where a risk is identified a care plan should be in place that details what staff need to do to minimise the risk. We saw social care plans that identified the activities the person took part in. The activity organiser is on maternity leave and no organised activities are taking place. The care plan has not been altered to show the change in daily routines and the most recent review recorded ‘no change’. We saw that one person had diabetes. The Care plan stated that blood sugar levels should not fall below 4 or above 11 the care plan also indicated that the person’s blood sugar levels should be tested every Monday. We looked at the person’s records and found entries on three consecutive dates in June 2009, but there was no record of the blood testing taking place. We did see some blood monitoring records however the results of these records were not reflected in the care plan. In order to keep people safe staff must record the outcomes of blood glucose monitoring so that all staff have access to this information. We asked the nurse in charge for the blood sugar monitoring records for this person but they were The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 13 unable to provide a full record. This made it difficult for us to see how staff were monitoring this person’s blood sugar levels. A requirement is made that where a care plan identifies areas of risk such as high/low sugar levels, detailed records are kept of the risk levels and the action staff need to take. We saw one person’s fall prevention section of the care plan stated must use wheelchair at all times. The mobility section did not mention the wheelchair at all. This section stated mobilise with a zimmer frame for short distances. We spoke to this person at length and they told us they only use the walking frame around their bedroom. We saw a care plan for pressure ulcer prevention. This advised staff to monitor skin but did not give clear advice about what to look for or what action to take if skin was broken. We made a recommendation that in order to avoid risks to people care plans should give clear and detailed advice to staff. We saw one care plan gave conflicting information. Their care plan stated the person was continent. The review sheet in the care plan stated incontinent. This means that staff are not being given the correct advice on how to meet this person needs. The review did not state if the person had seen a specialist or if there was a continence assessment in place. A continence assessment identifies what type of pads or aids a person needs. We made a recommendation that where changes to an individual’s needs have been identified at review the care plan should be amended. We spoke to people living at the home. They told us that staff were “lovely they are really kind”. Another said “we have everything we need nothing is too much trouble”. We saw that staff treated people with respect and maintained people’s right to privacy and dignity. We saw that staff asked people what they wanted and encouraged them to be as independent as possible. Medication was stored and disposed of properly. We saw that records were kept detailing the receipt, administration, safekeeping, and disposal of controlled drugs. We saw that staff responsible for administering medication had been given medication training. We saw medication administration records. These showed that medication was being given as prescribed and that they could be tracked and accounted for. We saw that one person’s file had a letter from the GP agreeing to medication being administered covertly. This means that it is crushed and given without the person’s knowledge or agreement. Any decision like this has to be made in The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 14 the person’s best interest. We did not see any records that show that other healthcare professionals such as a pharmacist or the person’s advocate had been involved in making this decision. The senior nurse told us that the person’s GP gave authorisation over the telephone to use covert medication. The nurse also told us that she had insisted that she had this advice in writing. The manager later told us that a best interests meeting had taken place at the hospital, however this information was not disclosed to us during the visit. A recommendation is made that where decisions were made about covert treatments, appropriate multi-agency assessments should be carried out to show it was done in the best interests of the person involved and a copy of the best interests assessment be available to staff. This is in accordance with the Mental Capacity Act 2005 - Deprivation of Liberty Safeguards. It was also recommended that all nursing staff follow guidance issued by the Nursing and Midwifery Council regarding covert medication administration. We saw that moving and handling equipment was checked and maintained. This means that people had the aids and equipment they need. We spoke to the manager about end of life care. They told us that they have applied to the Primary Care Trust to take part in the Gold Standards Framework for end of life care. They are on the waiting list. They told us that they follow the end of life care pathway. This means that they talk to people and their representatives about the care they would like to receive. They told us that they can arrange for relatives to stay at the home. We saw that they had a mobile sensory unit. This is a system of lights, aromatherapy and music it is designed to create a calm atmosphere and help people to relax. They told us that they treat people as individuals and that the main aim is to keep people comfortable and free from pain. They also told us that people have access to a member of the clergy. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 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): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a good range of activities and a variety of home cooked food. EVIDENCE: We saw a sample of menus. They were varied and balanced and catered for people’s differing dietary needs. We spoke to the chef. They told us that if people wanted an alternative to the main meals they would prepare something. The meal on the day of our visit was steak and kidney pudding or sausages with chips and peas. The sweet was gateaux or cheese cake. They told us that they provide some pureed diets. We saw that these meals were presented well with each ingredient being pureed separately so that it looked appetising on the plate. People living in the home told us that “the meals are lovely”. Some told us “the food is alright, some is not very nice but on the whole it is good”. Another told us “I like my food and it is very nice”. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 16 We saw one person come to the dining room at 10:30 and the chef made them fresh tea and toast and cereals. This means that people were able to choose when to get up and what time to have breakfast. We spoke to the chef who told us “I make breakfast for whenever people want it” and “it is not a problem”. We spoke to people living at the home. They told us “the food is really nice” and “we are having steak and kidney pud today” another told us “yes it is my favourite”. Another person told us “they will make you something different if you want they are really good”. We saw staff helping people who needed support with their meals. We saw that staff were patient and helpful. We saw that mealtimes were not rushed and staff gave people time to eat at their own pace. We saw that there was a lot of banter between people living at the home and staff. They told us that the activity organiser was off on maternity leave. This means that regular planned activities were not taking place. We did see several people sat having their supper drinks. They told us that they had just finished playing bingo. This means that staff are trying to provide some recreational activities to occupy people. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 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): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to complain and are confident that their concerns will be listened to. EVIDENCE: People living at the home are given a statement of purpose and service user guide. This includes a copy of the complaint procedure. Relatives and staff at the home are made aware of the complaints procedure. We saw copies of the service user guide in people’s bedroom that explains how to make a complaint. This information is also displayed in reception for visitors’ attention. The complaint log gave details about the complaint, the investigation and the outcome. We saw that complaints were dealt with appropriately. They told us that concerns and complaints were used to improve the service. We spoke to people living at the home who told us that they would speak to the manager if they had a concern. One visitor told us ‘if we have any concerns we would speak to the manager or the deputy’. They told us that care staff received training that teaches them how to recognise abuse and report poor practice. There is an organisational procedure for staff to follow in the event of any allegations being made. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 18 There was a copy of the Salford All Agency Policy on the Protection of Vulnerable Adults available for staff to reference. We spoke to staff that were aware of the action to be taken in the event of an allegation of abuse being made. One member of staff told us “I would inform the manager as soon as it happened and if it was the manager I would contact social services”. There had been a number of safeguarding referrals made. These had been reported using the Salford safeguarding policies and procedures. They had been appropriately reported and investigated. This means that staff working at the home were aware of the procedures in place to safeguard vulnerable people. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 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): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in suitably adapted, clean, comfortable and very pleasant surroundings. EVIDENCE: We saw a sample of people’s bedrooms. We saw two bedrooms on the first floor where the window openings were not restricted. This means that the window opens wide and there is a potential risk to people. Windows should be restricted to minimise the risks of falls. A recommendation was made that windows be restricted to minimise the risk of falls to people living at the home. We saw that a number of bedroom doors did not fully close into the rebate. These are fire doors and should close fully to minimise the effects of smoke in the event of a fire. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 20 A recommendation was made that fire doors should be checked to make sure they close securely into the rebate. We saw that the home was generally well-maintained, bright and airy with views over the gardens. The dining rooms were spacious with a relaxed and comfortable atmosphere. People were seen reading, watching television, listening to the radio or relaxing in lounges. We saw that people had brought some of their belongings from home and they were able to come and go as they please. We saw that protective clothing such as latex gloves and plastic aprons were provided. We saw sanitising hand gel throughout the home. This means that they take care to reduce the risks of infection. We saw that aids and adaptations were provided to assist in moving people safely. These included manual hoists and adapted bathing facilities. We saw that staff were given manual handling training as part of the induction process. This means that they knew the correct way to operate equipment. We saw that there were large well-maintained gardens with a number of seating areas. People living at the home told us that they liked to sit in the garden in the nice weather. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 21 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): 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff was sufficient to meet the needs of the residents accommodated and staff have access to a wide range of training. EVIDENCE: We saw a sample of staff files. They had copies of application forms and two written references. We saw that Criminal Records Bureau Checks (CRB) had been carried out for all new staff. We saw that staff files contained photocopied documents, for example passports, utility bills and certificates. We saw that these documents had not been signed to show that the originals have been seen. It was recommended that copies of documents given as proof of identity be signed and dated to show that the originals have been seen. We saw that they had employed a training manager. We saw that they had started to develop a training matrix. The training manager told us that all staff had an induction period. We saw copies of the induction programme. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 22 We saw that staff have achieved NVQ at level 2. They told us that there were eight members of staff that have not been registered for NVQ2. This was because they had not been in the UK for three years. We saw that staff had received a variety of training. They showed us copies of induction records. Some of the people living at the home were unable to eat ordinary food and needed to be given a liquid feed through a tube in their stomach. We saw one member of staff had been shown how to clean the site of a tube feed. This training had been signed off by the training manager. We had concerns that this person was not qualified to assess competence in this area. This is a clinical procedure and requires a clinically trained member of staff to demonstrate the process. They told us that the training manager observed the clinical staff showing new staff the process. They told us that a group of night staff were shown how to carry out the procedure and were observed by the training manager. As the training manager has no clinical experience they should not be observing such intimate procedures. It should be the responsibility of clinically trained staff to demonstrate clinical procedures to new staff and sign that they are competent. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed so that it is run in the best interest of the people who live there. EVIDENCE: We saw that the manager had considerable knowledge and experience of running a care service for older people. They had a good understanding of the conditions and illnesses associated with old age. This means that people’s health care needs were identified and addressed quickly. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 24 We saw that the manager showed a good understanding of how the service could improve. They told us that they have an open door policy. This means that people living at the home, their relatives and staff can approach the manager at any time. We spoke to people living at the home and staff. They confirmed that they manager was approachable and always had time to answer any questions. The home’s certificate of registration and public liability insurance certificate were displayed in the hallway. This means that people living at the home and any visitors can see that the home is registered with the Care Quality Commission. We spoke to staff. They told us that regular supervision on a one to one basis was not taking place. We saw minutes of a recent staff meeting where supervision had been discussed. It was recorded that the manager did not have time to carry out supervision as often as it should be done. Informal on the job supervision was taking place. A recommendation is made that care staff should have supervision at least 6 times a year. We spoke to staff who told us “I had my induction but have not had a one to one supervision meeting yet”. Staff must receive supervision at least six times a year and a record kept of the meeting. The manager told us that she attended a three day training course on dementia care. She told us that this had been very enjoyable. The second part of the course is to be held in October 2009 and is for dementia Care Mapping. This means that the manager has specialist knowledge of the needs of people who have a dementia. They told us that they sought people’s views. This was done by asking people to complete a questionnaire. They told us that they had a social committee and that people living at the home gave comments about the service at committee meetings. We saw that policies and procedures were in place to support people in managing their own monies. This means that people’s money and personal effects are safeguarded. We saw that they had an incident and accident recording system in place. We saw that they monitored falls that people had experienced on a monthly basis. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 25 The manager continues to let us know about things that have happened since our last visit and have shown us that they manage issues well. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17(1) (b) Requirement A requirement is made that personal information held by the home be stored in line with the DATA Protection Act 1998 so that each person can access the information held about them. A requirement is made that where a care plan identifies areas of risk such as high/low sugar levels, detailed records are kept of the risk levels and the action staff need to take to minimise the risk. Timescale for action 24/08/09 2. OP8 12 (1)(a) 24/08/09 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 OP7 Good Practice Recommendations It was recommended that; In order to avoid risks to people a recommendation is made that care plans should give clear and detailed advice. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 28 Where changes to an individual’s needs have been identified at review the care plan should be amended. Daily records should be detailed and reflect the care given. Daily records should also give details about how the person has spent their day. Where a risk is identified a care plan should be in place that details what staff need to do to minimise the risk. A recommendation is made that where decisions are made about covert treatments, appropriate multi-agency assessments be carried out to show it was done in the best interests of the person involved. This is in accordance with the Mental Capacity Act 2005 - Deprivation of Liberty Safeguards. A recommendation is made that all nursing staff follow the guidance issued by the Nursing and Midwifery Council with regard to covert medication administration. A recommendation was made that fire doors should be checked to make sure they close securely into the rebate. A recommendation was made that windows be restricted to minimise the risk of falls to people living at the home. It was recommended that copies of documents given as proof of identity be signed and dated to show that the originals have been seen. It should be the responsibility of clinically trained staff to demonstrate clinical procedures to new staff and sign that they are competent. Staff should receive supervision at least six times a year and a record kept of the meeting. 2. OP9 3. 4. 5. OP9 OP19 OP19 6. OP29 7. 8. OP30 OP36 The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 29 Care Quality Commission North West 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. 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. The Willows DS0000006730.V376395.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!