Inspection on 30/10/06 for The Willows

This inspection was carried out on 30th October 2006.

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

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

Other inspections for this house

The Willows 07/05/08

The Willows 15/05/07

The Willows 09/11/05

The Willows 21/09/04

The Willows 26/04/04

The Willows 26/01/04

The Willows 12/05/03

The Willows 28/10/02

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

CARE HOMES FOR OLDER PEOPLE The Willows Dangerfield Lane Darlaston Walsall West Midlands WS10 7RT Lead Inspector Mr Richard Eaves Key Unannounced Inspection 30th October 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address Dangerfield Lane Darlaston Walsall West Midlands WS10 7RT 0121 568 7611 0121 568 7989 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) Regal Care (Darlaston) Limited Mrs Tracey Maria Parkes Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 48 frail elderly people over the age of 60 years who require nursing care That the following staffing levels are adhered to as minimum numbers and subject to increase as dependency levels require: 8:00 am - 8:00pm - 2 trained nurses 8:00pm - 8:00am - 1 trained nurse 7:00am - 2:00pm - 9 carers 2:00pm - 9:00pm - 7 carers 9:00pm - 7:00am 4 carers 9th November 2005 Date of last inspection Brief Description of the Service: The Willows is a modern purpose built home first registered in May 1998. There are 48 large single bedrooms, all but one having en-suite and a number being linked, to accommodate couples. There are 3 good size lounges, 2 with dining area providing spacious communal areas on both floors. The rooms are spacious and colour co-ordinated, each has a good-sized double glazed window and on the ground floor, patio doors to the gardens. Rooms are light and airy with a view onto either the garden or onto Dangerfield Lane/Moxley Road. In addition to the en-suite provision there is a plentiful number of baths, showers and toilets distributed around the building. The enclosed gardens are large and accessible from downstairs, bedrooms and lounge area. The ancillary services of catering, laundry housekeeping and maintenance are provided in-house. The home provides plentiful off road parking. Fees for this home currently range between £327 and £520. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was undertaken by a single Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the unannounced inspection during October 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire and records held at the home. The inspection involved a full tour of the home including, bedrooms, communal rooms, service areas and provided an opportunity to speak with many service users, visitors and staff. What the service does well: What has improved since the last inspection? The home has made the information provided to current and prospective service users more accessible by separating the statement of purpose and service user guide. A small number of service users have very specific wishes in respect of meals, the home has sought to accommodate these by seeking their views and developing menus in response. Service user views of the service have been collected in a structured way. Staff supervision sessions have been improved by concentrating on aspects of delivering care. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Willows DS0000020785.V317151.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Standards 1 – 5 were inspected. Service users, prospective clients and their supporters are provide with good sources of information about the home and are invited to spend time at the home prior to admission to enable them to make an informed decision about entering the home. The staff group are stable well established and collectively have the knowledge and skills to assess needs and meet the needs of the current service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users guide were reviewed and extensively updated during December 2005 and include details of the current manager and provide current and prospective service users with a good sources of information from which to make informed decisions about the suitability of the home and the services they offer. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 9 Senior staff of the nursing home undertake assessments for prospective service users these include activities of daily living and a range of clinical risk assessments such as pressure areas, nutrition and falls, these are kept under regular review, the assessment evidences the involvement of the service user and their relatives as appropriate. In all cases the home confirms that the identified agreed needs can be met by the home in writing and a contract is issued at admission and terms and conditions kept on file, these require to include the room occupied which currently is only documented on the case file front sheet. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them but it is acknowledged that most service users are admitted from hospital. The home does not currently provide intermediate care. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Standards 7 – 11 were looked at. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Health care needs of service users are fully met. Medication practices are good ensuring service users medication needs will be safely met. Service users are treated with respect and their privacy upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of six case files were selected at random on each floor to be inspected and case tracked. The care plans were drawn from the assessed needs process and were relevant and maintained to a good standard. The care plans reflect actual care requirements and the service users preferences of how it is to be given. Contingency plans were seen for conditions such as diabetes and epilepsy providing good guidance for staff in dealing with emergencies. The case files clearly evidence family involvement at all parts of the process of assessing needs and planning care. The review of care plans were undertaken The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 11 at least monthly and are informative of the continuing needs of the service users. The Home has a good supply of pressure relieving equipment including pro-pad overlay foam mattresses, alternating airwave and complete high-risk systems, with provision for hire should there be a need for more systems. Continence assessment is included in the admission procedures with involvement of continence advisor as appropriate. A number of local General Practitioners provide medical care at the Home and other allied medical and therapeutic services are made available to service users. The Home uses the Boots Monitored Dosage system for the administration of medicines and the local Pharmacist undertakes frequent checks that the system is implemented correctly. The storage and administration of medicines are undertaken separately on each floor with full administration undertaken by staff on each floor. A recommendation is given that in addition to monitoring fridge temperature the room should also be monitored. The induction programme includes a section on treating service users with respect, this is also addressed in the customer care training. Privacy is upheld with locks fitted to bedroom doors, in addition staff were observed to knock before entering and interact in a friendly and open way using the service users choice of name. A number of service users have their own telephones and the service user guide provides details of availability for others. A notice offering access for such needs as ordering a taxi should address the lack of a public phone available to visitors. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 12 – 15 were looked at. The home provides limited but varied social and recreational activities that provide interest and pleasure for the residents. Visitors are welcome and help to keep service users informed about the wider community. Many aspects of care evidences that service users exercise choice and control over their lives. The meals at The Willows care home are good, offering both choice and variety and catering well for special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Social activities continue to be very limited due to the absence of an activities co-ordinator although this post has now been appointed to and starting shortly. Care staff make considerable effort to provide suitable activities in addition to their care duties. Currently able individuals are accessing social outlets in the community two attend a day centre regularly, others attend College, some go to local facilities during the day and evenings. In house events have been regular bingo sessions, a Halloween party is planned, table games are popular with some, the weekly exercise to music is very popular and weekly visits by the hairdresser is sufficient to meet personal wishes. The mobile library attends the home regularly. Entertainers continue to visit The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 13 fortnightly. The church is very active at the home and a combined church service is held on alternate Sundays. The home has an open visiting policy, which was observed in action with visitors arriving and leaving during the inspection. Local advocacy services are promoted. The inspection of a sample of case files show these to include a section that identifies personal likes and wishes. In conversation with service users they feel that these wishes are fully taken into account by care staff in the assistance they provide. Meals are provided using a 4 week rolling menu that includes choice which some service users continue to described as predictable and boring. A recent in-house survey found that overall service users are very positive about the meals and some offered suggestion for inclusion in the menus, which are being reviewed. The lunch observed to be served was noted to use both choices on the menu and further alternative to meet personal preferences, staff were observed to offer assistance. The evening supper served each evening requires to be included in the menu to demonstrate that the standard of no more than 12 hours interval between meals is complied with. This information is in the service user guide as a time of service. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 16 – 18 were looked at. The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse This judgement has been made using available evidence including a visit to this service EVIDENCE: The home has a detailed complaints procedure which is well promoted by way of notices and the service users guide. A number of concerns have been raised locally in recent times and resolved to the satisfaction of those involved, record keeping including outcomes is good. The manager confirmed that the electoral roll has been completed for the forthcoming year. All staff have attended adult protection training and receive annual updates, the topic is also included in NVQ training which all staff have either completed or are currently undertaking. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 19 & 26 were looked at. The environment of the home is maintained to a good standard, clean and hygienic providing the service users and staff with a comfortable and safe place in which to live and work. The communal areas provide comfortable attractive facility with suitably placed toilet facilities for the service users convenience. Each of the bedrooms are personalised with possessions and are furnished to individual needs, have a washing facility and toilets and bathrooms are close by providing for the comfort and convenience of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Purpose built, the premises are maintained in good condition and decorative order, a programme of decoration and re-carpeting of the corridor areas has recently been completed, the kitchen and first floor kitchenette have also been decorated. The external areas of gardens, parking and footpaths provide a The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 16 pleasant facility and outlook for service users and a supply of good quality garden furniture. A tour of the building confirms that the premises are maintained and cleaned to hygienic standards. The en-suite bedrooms are spacious and personalised and including some own furnishings, one service user had a refrigerator and said that the room was comfortable. Monitoring of hot water at service user outlets shows that the standard is being met consistently. It is recommended that an anti-scald test be undertaken annually and a record maintained. Other monitoring and maintenance requiring to be recorded includes wheelchair checks and window restrictors. The first floor shower adjacent to bathroom 3 requires attention to the flooring to prevent flooding out to the corridor. The laundry is modern and well equipped to meet all aspects of bed linen and personal clothing care. The home uses disposable bottles and bedpans for most situations and each sluice is fitted with a macerator to dispose of these. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 27 – 30 were looked at. The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An inspection of the current staff rotas show that sufficient care and nursing staff with the necessary experience are allocated to cover the full 24-hour day with appropriate support of ancillary staff. Each of the units, ground and first floor, are staffed separately, each having a Nurse and 4 care staff during the day and one nurse with 3 carers overnight, these numbers are assessed by the manager as adequate to meet service users needs for the current dependency levels. At the time of this inspection the numbers of staff holding an NVQ was identified as 65 of carers. The training matrix identifies good progress in achieving mandatory targets for moving and handling, fire safety food hygiene, adult protection and health and safety. Housekeeping staff have also had the opportunity to undertake NVQ training. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 18 A sample of staff files were inspected including recent starters and were seen to comply with good employment practices and includes all necessary checks such as CRB, POVA and nursing registration. Staff files also show that two references are obtained and a record kept of the interview. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 31, 33, 35, 36 and 38 were looked at. Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance which includes consultation and seeking the views of service users and their families and evidenced that it is acted upon. The arrangements for safekeeping of service users money safeguards their interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. The safety and welfare of service users is protected. This judgement has been made using available evidence including a visit to this service. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager is a registered nurse with extensive experience in care home management and holds the NVQ level 4 award in care management. Many staff gave the view that morale at the home is high and that the senior staff are very approachable and work closely with staff. Regular staff meetings also support this with good communication. A full satisfaction survey of service users and relatives is currently underway with 50 responses received, covering meals, activities, care and laundry the results have not yet been analysed but an overview shows a very positive view of the home and services. The company responsible individual visits weekly and undertakes monthly, unannounced visits in line with regulation 26 requirements. The home manager also undertakes a range of audits of the home including clinical and general services. The home does not act as appointee for service users but have in place good accounting practice to assist service users in keeping their personal allowance safe. Supervision is established at the home and is currently on target to achieve six supervisions for the year. Health and Safety is given appropriate priority with an extensive range of monitoring and maintenance in place. The home ensures safe working practices through good staff training and monitoring of activities of work and the environment and services. The range of risk assessments for the environment is good and include fire safety, security, catering, rooms and furnishings. The risk assessments identify monitoring requirements and these were seen to be thoroughly completed and up to date. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 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 3 X 3 The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 23 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person must ensure that medications are stored correctly. Rooms used for storage of medicines must have the temperature monitored and recorded. Opened insulin to be stored as instructed. Timescale for action 30/11/06 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. 2. 3 4. 5. Refer to Standard OP10 OP12 OP15 OP19 OP38 Good Practice Recommendations The manager should provide visitors with information in regard to the availability of telephone facility. The manager should increase the opportunities for service users to have stimulation through leisure and recreational activities. The manager should include the provision of evening supper on the menu. The floor of the shower should be adapted to prevent water overflow into the corridor. The manager should ensure a record is maintained of monitoring and maintenance of wheelchairs and window restrictors. The Willows DS0000020785.V317151.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000020785.V317151.R01.S.doc Version 5.2 Page 25 - 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!