Inspection on 06/12/07 for The Willows

This inspection was carried out on 6th December 2007.

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 14/03/07

The Willows 24/08/05

The Willows 13/04/05

The Willows 28/10/04

The Willows 29/07/04

The Willows 29/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Willows 197 Darkes Lane Potters Bar Hertfordshire EN6 1AA Lead Inspector Pat House Unannounced Inspection 6th December 2007 10:00 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 DS0000019592.V356188.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 DS0000019592.V356188.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 197 Darkes Lane Potters Bar Hertfordshire EN6 1AA 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) 01707 659205 01707 659205 FP Follett Care Limited Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user who has a diagnosis of dementia for as long as the needs of that service user can continue to be met. 14th March 2007 Date of last inspection 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 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. There is easy access to the Motorways and the main line railway station. Current fees for the home are £595.00 per week. The last CSCI inspection report is kept in the office and is available on request. Copies of the home’s Statement of Purpose and Service User’s Guide are also available from the office. The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Willows has recently reopened after a period of refurbishment, during which time there were no residents in the home. There is now a new manager in post. The home now provides accommodation for ten residents, instead of twelve, and all bedrooms are now single occupancy with toilets en-suite. A passenger lift is also being installed so that those with a mobility problem can access the first floor of the home. The current registration for The Willows, for 12 residents and with one “condition” no longer applies, and the manager is applying to vary the registration with the CSCI as the home now provides accommodation for only ten people. The inspection took place on one day, with one inspector. The manager was present and all parts of the home were visited briefly. Residents and staff were spoken with and a selection of records was examined. Another home in the group recently closed and so the residents from that home were given the opportunity to transfer to The Willows, and ten of those people chose to transfer, along with the staff group and manager from the ‘sister’ home. Residents and staff spoken with therefore all knew one another very well and said that they felt The Willows was like a family unit and was comfortable and ‘homely’. The manager had previously completed a Quality Assurance self-assessment document, (the AQAA) now sent out annually by the Commission. Details of current practices and plans for the future of the home were documented in this form, although The Willows had only reopened at the end of September 2007. Questionnaires were left at the end of the inspection so that any residents or staff could voice their views of the home to the Commission at any time in the future. Findings from returned questionnaires will be included in a future report. What the service does well: The Willows provides residents with a warm ‘family’ style home, where staff provide individual care to the people they know well. The views of residents are sought and used in all decision making about the running of the home. Staff are aware of all individual health needs and are able to ensure specialist treatment is sought for the residents and that treatment and progress is closely monitored. The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 6 Staff training is given a high priority and the staff team perform their roles in a professional manner, which is clearly appreciated by the residents. The food provided is of a high standard and is enjoyed by all the residents. Snacks and drinks are available at all times in the home. 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 summary of this inspection report can be made available in other formats on request. The Willows DS0000019592.V356188.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 DS0000019592.V356188.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): Standards 1 and 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Any future prospective service users can be assured that they will be given detailed information about the home and will have thorough assessments completed so that all parties can be sure that their needs can be met at The Willows. EVIDENCE: The home’s statement of Purpose and Service User’s Guide are currently being updated to incorporate the changes to the fabric of the home and the management arrangements. The manager said that all present and future residents would be provided with copies of the home’s Brochure/Service Users’ Guide, when completed. The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 9 All current residents of the home had been assessed initially at their previous, ‘sister’ home but the manager said that full assessments would be completed for any new residents, prior to a place being offered. The Willows DS0000019592.V356188.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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be confident that they will have a detailed care plan so that staff can be sure that individual needs are identified and met. They can be confident that the procedures followed in the home ensure that they will be treated with respect and the system followed for the administration of medication helps protect them from medication errors. EVIDENCE: Information provided by the manager in the Annual Quality Assurance Assessment (the AQAA), returned to the Commission, indicated that all residents had care plans, which were reviewed monthly and kept up to date. The plans of some of the residents spoken with were checked and all contained appropriate information and assessments. Risk assessments had been completed and updated and there was evidence of input from Health professionals, and, in one case, details were recorded of visits from a Community Psychiatric Nurse. The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 11 During the inspection a doctor visited one resident at the request of staff at the home and this person was being cared for in their room. The home has a medication trolley, which is kept secured and locked when not in use. The process for administering medication was checked and the system was generally thorough. Most medication is provided in blister packs, and the small amounts prescribed in individual packaging had dates of opening recorded. All staff receive training in the administration of medication and staff spoken with confirmed that another, accredited course had been booked for them in the New Year. At the moment the home has a written Medication Policy, provided by the owning company. This policy needs updating in line with current Health guidelines and must include the home’ s policy for nonprescribed drugs. The manager will be reviewing this policy in the near future. Residents spoken with confirmed that staff assisted them with personal care where appropriate and did so in a manner of their choosing. Residents also said that visitors were made welcome in the home at all times and that the staff always treated them with respect. The ladies spoken with in the lounge were all well dressed and said that they always received their own clothes back from the laundry and made their own choices about what to wear each day. The Willows DS0000019592.V356188.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can expect that they will be encouraged to make their own decisions about their daily lives and staff will support them to maintain family and community links so that they can remain as independent as possible. People who use the service are able to enjoy a well-balanced diet and staff provide stimulating activities and these daily events promote individual wellbeing. EVIDENCE: On the day of the inspection the home was full and all residents had moved together from their previous care home, along with the staff group. Residents spoken with during this inspection all said that this meant that they felt part of a ‘family’, knew everyone very well and were content with procedures and routines in the new home. The AQAA completed by the manager stated that, as soon as the move was completed in September, staff began ensuring that the home was being run The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 13 according to the wishes of the residents and a residents’ meeting was held in October. At the meeting, any current issues were discussed and plans for an activity programme were completed. During the inspection the ladies in the lounge took part in a knitting group, supervised by staff. Those spoken with confirmed that there were plans to introduce new activities in to the home, after the Christmas festivities had finished. All staff currently share the provision of activities and said they plan events as they go along. The manager said that this area would be developed in the New Year when more formal activity planning will be linked to the interests of individual residents. Residents’ participation in events provided are all recorded on care records. One resident has also brought their pet cat with them and he lives happily in the person’s bedroom. Most residents have relatives or advocates who help them handle their finances. Small amounts of personal allowances are also kept locked in the office for residents to use when they wish. The mid-day meal was cooked by a member of staff and served during the inspection. Menus are prepared with residents’ input and staff shop for ingredients locally. The residents spoken with said the food served was very good and plentiful and that drinks and snacks were available whenever they wished, as they would have been in their own homes. The meal seen was attractively presented and drinks were available on then tables and promoted by staff. The Willows DS0000019592.V356188.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are written policies covering Complaints and Adult protection and people who use the service are confident that any concerns they might have will be listened to and dealt with appropriately. EVIDENCE: The home has written policies on Making a Complaint, on Safeguarding Adults and on Whistle Blowing. The Complaints Policy is included in the Service User’s Guide. Residents spoken with during the inspection said they would feel confident telling staff if they had any concerns and were aware of the home’s Complaints Policy. There have been no referrals made under the Safeguarding Adults procedures but the manager was fully aware of the process. The Willows DS0000019592.V356188.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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with high standards of accommodation, which helps them enjoy their daily lives. The accommodation is kept clean and hygienic and this supports individual well-being. EVIDENCE: The Willows has been totally refurbished during the time it was closed. The original twelve bedrooms have been redesigned and the home now provides ten single occupancy bedrooms, all with en-suite toilets and with washbasins. All rooms have been decorated to a high standard and the residents spoken with said they were delighted with their accommodation. A passenger lift was being constructed during the inspection and will provide all residents with easy access to the first floor. The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 16 The kitchen was clean and well stocked during the visit, but the fridge/freezer was broken and leaking and must be repaired or replaced. The bathrooms and toilets provide appropriate assisted facilities but are still waiting for wall mounted liquid soap and paper towel holders to be fitted, to comply with current guidelines for the prevention of the spread of infection. The Willows DS0000019592.V356188.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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that they will be supported by adequate numbers of competent staff that have been appropriately recruited to ensure that they are safeguarded from abuse. EVIDENCE: On the day of the visit there were three care staff and the manager on duty and the rota seen showed that these were regular staffing numbers. Residents said that they felt that staffing numbers had been adequate so far in the home. As already stated, the present staff members and residents have all transferred from another home and staff are clearly aware of all individual needs and preferences and able to offer very individual care. There are no ancillary staff employed at present, so that care staff also provide cooking and cleaning duties and will provide a programme of activities when this has been finalised. Should the needs of current or future residents become more complex, the current staff numbers would have to be reviewed to ensure all aspects of daily care can continue to be properly provided. The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 18 The manager provided information in the AQAA that all staff members have either achieved, or are already working towards NVQ level 2 training. This means that over 50 of care staff are already trained to this standard. Staff spoken with said that training was given a high priority in the home and that updates of some core training courses have already been booked for the New Year. A certificated medication course had been booked and additional training has been arranged in Equality and Diversity for all staff. All staff had attended a training course in Dementia Care the previous week. The manager is currently completing an overview of all staff training. A selection of staff recruitment files was examined and evidence was seen of all appropriate employment checks and training certificates. The Willows DS0000019592.V356188.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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from living in a home, which is well run, and where their views are listened to and the procedures followed in the home ensure that the safety and welfare of residents and staff are promoted. EVIDENCE: The manager has extensive experience of running a care home and has achieved NVQ level 4 in Care Management. The manager will be applying for registration with the Commission and has been previously registered to manage a sister home. The deputy manager has completed NVQ 3 training and is a qualified NVQ assessor. The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 20 Staff and residents spoken with praised the manager and said the manager listened to all views about the day-to-day running of the home. The home has a policy for Quality Assurance and the manager said that questionnaires would be given or sent to all residents and stakeholders, early in 2008. The home has a written Health and Safety policy and the manager reviews and updates the general risk assessments for the home at regular intervals. Fire records were checked and details of all tests and drills were seen recorded. The Willows DS0000019592.V356188.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 x 3 x x 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 x x 3 The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Willows DS0000019592.V356188.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 DS0000019592.V356188.R01.S.doc Version 5.2 Page 24 - 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!