Inspection on 07/05/08 for The Willows

This inspection was carried out on 7th May 2008.

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

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

Other inspections for this house

The Willows 15/05/07

The Willows 30/10/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Willows Dangerfield Lane Darlaston Walsall West Midlands WS10 7RT Lead Inspector Mandy Beck Key Unannounced Inspection 7th May 2008 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.V363926.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.V363926.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 **Post vacant** Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places The Willows DS0000020785.V363926.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 15th May 2007 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 are not available in the Service user guide. Readers of this report are asked to contact the home directly for more information about the fees they will be charged. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • We also spent time talking to the people who use the service and to the staff who support them. • We looked at the care of three people who use this service in depth. This is part of our case tracking process and helps us makes judgements about the home’s abilities to meet people’s needs. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. What the service does well: What has improved since the last inspection? Since our last visit the home has taken steps to meet all but one of the requirements we made. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 6 Staff have received some training in safeguarding adults. The manager also told us that more is planned so all staff will complete this training. This means the people living here will be cared for by staff that understand what safeguarding adults is and how to protect the people they care for. The home has improved some of its medication practices, staff are no longer re using single use syringes to push medication through peoples tube feed. Medication is stored appropriately and safely, this gives people peace of mind be able to know their medication is safe and available for them when they need it. We had serious concerns about the lack of risk assessments in place when staff use bed rails for people’s safety. Bed rails were not always fitted in accordance with manufacturers guidance and placed people at risk. It was pleasing to see that bed rails have now been fitted correctly and the manager told us they are checked regularly by the homes maintenance worker. There is still work to be done with risk assessments for individual people’s care plans. The home has taken steps to recruit an activity coordinator since our last visit. The manage told us this will help to reduce some of the possible social isolation people can experience when they are in their bedrooms for most of the day. It is also hoped that the new worker will continue to plan and deliver activities for those people who are able to get out and about within the home. A new manager has been recruited to run the home in the best interests of the people living here. The manager has told us that she is aware of most of the shortfalls we have identified in this report and is taking steps to address them. Staff also told us “since she has been here I think things are better, residents meeting are taking place, we are getting more training its good”. 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.V363926.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.V363926.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): 1, 3, 6 Quality in this outcome area is adequate. People who may wish to use this service will have the information they need to make a choice about living there. The home must improve its record keeping so that it can demonstrate people’s needs have been assessed and the home is able to meet those needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and a Service User Guide. Both of these documents give people the information they need to make choices about the service the home provides. We have recommended the home include the range of fees it charges people to live there. Before people move into this home they will have the opportunity to discuss their needs and the manager will complete an assessment of needs. Once the home is confident it can meet the needs of the each person they will write to them and confirm this. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 9 We looked at the care files of four people who live at this home as part of our case tracking process. We found that there were significant shortfalls in some people’s needs assessments; one person did not have enough information for staff to be able to plan effective care. Another person’s assessment was however very detailed and gave a good picture of this person’s needs. The manager explained that new record keeping systems are being introduced and staff will be trained so that all required assessment information would be completed in future. This will mean that no information about people is lost and will enable staff to plan effective care with them. This home does not provide intermediate care services. The Willows DS0000020785.V363926.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): 7, 8, 9, 10. Quality in this outcome area is adequate. People who live in this home cannot feel confident their needs will be met. The home has poor record keeping systems in place that may mean people’s care needs are over looked and not met as a result. Medication practices have improved and people can feel assured their medication will be given to them as it is prescribed. Generally people are treated with respect and dignity but staff could make improvements to this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care plans for four people who use this service. We found that significant improvements must be made to the record keeping practices within this home. We identified shortfalls in all of the care plans we looked at. In some cases people did not have care plans at all, staff told us “we haven’t got around to doing them yet, sorry”. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 11 We were particularly concerned about this because one person had been admitted to the home with a grade 3 pressure sore and no care plan to demonstrate how they intended to meet this person needs in relation to their pressure sore care. We were able to evidence that although the care documentation was lacking, this person did have pressure relieving equipment and nursing staff were applying dressings in an attempt to treat the pressure damage. Care plans would give the nurses clear guidance on how to do this and give them a tool to evaluate the care they are giving and must be in place. The home does have risk assessments in place that look at people’s risk of falls, pressure sore development and moving and handling. It must however make sure that these risk assessments are reviewed regularly and kept up to date in order to meet the needs of the people living in the home. For instance we found that one persons Waterlow chart (pressure sore development) had not been updated since March 2008 yet the daily records showed that in May this person had developed a sacral break in their skin. The care plan did not reflect this change in the person’s condition either. Staff do not record people’s weight on admission, we found that in all the files we looked at there were shortfalls in this area. The home must record this information upon admission and regularly thereafter, they must do this so that changes in people’s weight can be identified and appropriate action taken promptly to prevent deterioration in their condition. The manager did tell us they have recently obtained a nutritional screening tool and this will be completed for each person. This will also help to identify those people at risk of malnutrition in future. Continence assessments are completed for each person but again the review of this assessment and people’s individual needs are not always recorded in their care plans. There is evidence to show that people are referred promptly to their doctors should they fall ill and other health care disciplines are involved with people’s care. We saw evidence of visits by the district nursing service, the memory clinic and community mental health nurses all of who help support the people living at the home. Medication systems have improved since our last visit. There are still improvements to be made but generally trained nurses administer medication safely. We have recommended the home review its homely remedy policy. We have asked for this to happen because we found that people are being given pain relief on a regular basis using this policy rather than asking the doctor to review the person’s need for their own prescribed pain relief. In another case we found that someone had been given Gaviscon to ease heartburn but this medication is not included in the homely remedy policy and should not have been administered. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 12 Staff are recording the temperature of the fridge in the treatment room. This is to make sure that all medication that requires cold storage is kept at recommended temperatures. Controlled drugs storage was good and the home keeps appropriate records of administration. We checked the balances of some of the controlled drugs and found them to be correct. This is good practice and safeguards the people who live there. Medication audits need to be completed on a regular basis. This will highlight any shortfalls in practice that need to be addressed. The manager told us that Boots do audit the home regularly as part of their contractual agreement. It is recommended the home supplement this with audits of their own. We found some discrepancies with administration and amount of medication when we conducted a mini audit during this inspection. We saw that a queue of people in wheelchairs was building up in front of the toilet. We hoped that this was not usual practice as it doesn’t promote people’s dignity or give assurance that daily routines are based on individual needs and preferences. The nurse in charge told us “it is because you (CSCI) have been talking to the staff, they are behind now, this doesn’t normally happen”. We observed staff assisting people to the toilet and chatting to them whilst they did this. We saw staff disengage from people once the task had been completed. Staff sat away from the service users choosing to sit at a dining table and chat amongst themselves until they were needed. This is not good practice as it could give impression of segregation and does not promote a person centred approach to care. People told us they are treated with respect and they felt the care staff met their needs as they wanted them to. They said “the staff are wonderful and very caring, they get me up when I want to get up”. We asked if staff were polite and if they gave them enough privacy, they said “oh yes dear”, “they never rush me”. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14, 15 Quality in this outcome area is adequate. People who use this service do have opportunity to take part in activity. The home has an open visiting policy and does try to support people in making choices. Meals are generally of good quality and meet people’s dietary needs. Staff need a better understanding of the principles of the Mental capacity Act 2005 if they are to support people living in this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since our last visit to the home there have been improvements in the activity provision. A new activity coordinator has very recently been recruited. This person will work 3 hours a day, 5 days a week in planning and delivering activities to those people who want to take part. The manager told us “I would like to see the role developed and in particular for those people who cannot come out of their rooms in the day. We hope to be increasing the social contact for them”. The home is taking steps to records individual likes and dislikes for each person. The manger told us that new paperwork is slowly being introduced The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 14 that will address this. We looked at people’s files and found that they were more individualised in some cases. Staff are recording people’s choices in relation to what time they want to get up and when they prefer to go to bed. One person chooses to get up at 5am, he told us “at first I think they thought I should stay bed but now its fine I get up when I want to”. Staff confirmed this when we spoke to them. Another good example of this was “likes to get up at 7am but does like a cup of tea at 1am with three sugars”. Staff must make sure that when people request services this happens. One persons daily notes clearly recorded “has asked for the vicar” but there was not further entry to show that this visit had been arranged or even had taken place for this person. The home must be able to demonstrate that this is capable of meeting the religious observance of the people who live there. People are encouraged to see their visitors at any time. They have the choice of where to meet with them, either in the privacy of their own rooms or in the communal areas with other residents. Throughout the inspection we observed a steady stream of visitors. We discussed the principles of the Mental Capacity Act 2005, the manager and staff both confirmed that no training in this area had taken place. The home will also need to obtain copy of the Code of Practice. This should happen in order for staff to understand their roles and responsibilities in supporting people who cannot make decisions about their care and treatment. Meals in this home are generally good. People told us “they are tasty, but sometimes I’d like more choice”. “the food is lovely”. The manager told us the home can cater for all dietary needs. The meals are prepared from a four weekly planned menu and changed seasonally. If people do not like what is on offer they can choose an alternative. Meal times were observed to be unhurried and people were assisted as they needed to be. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 15 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): 16, 18 Quality in this outcome area is adequate. People who use this service can feel confident that their concerns will be listened to and acted upon by the home. The home needs to review it safeguarding systems so that all staff are aware of their role and responsibilities in protecting vulnerable people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy that is available to all the people who use this service. The manager told us the review of the Statement of Purpose and Service User Guide is complete, both documents contain information about how to make a complaint and who to make it to. Since our last visit the home has received 7 complaints. There were records to show how the home has addressed these complaints and the investigations it undertook to resolve them. We asked staff what they would do if people expressed their concerns to them, they told us “I would try to deal with it straight away and document it, then tell the manager” another person said “I wouldn’t deal with a complaint I’d take the details and refer them to the manager”. The manager may wish to discuss these differing responses with the staff team to ensure that all staff approach complaint handling in the same way. In addition to recording the concerns and complaints the home has received, there is ample evidence to show that people are satisfied with the care they The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 16 have received. Thank you cards and letters of gratitude are displayed throughout the home, thanking staff for their hard work and care. There have been three safeguarding investigations since our last visit. We found one of these investigations was not dealt with, as we would have expected. This was acknowledged as an error by the home and appropriate action was taken once this error was pointed out. Another investigation is still ongoing and the home is working proactively with the multi agency team to reach a conclusion. The manager told us that this has been a positive experience “because it makes you more aware and things are changing all the time”. We spoke to staff about their knowledge of safeguarding adults. We asked what safeguarding meant to them, they told us “keeping people safe, to protect the vulnerable who can’t do it for themselves”. When we asked what they would do if a safeguarding alert was disclosed them, they said “Come and tell the nurse or report it straight to the manager”, “find out more from the resident and talk to the person who has been pointed at and report it to the manager”. Most of the staff we spoke to said they had recently undertaken training in safeguarding adults. The manager also told us that further training has been arranged so that all the staff will be included. It is recommended that the manager makes sure that all staff are aware of the home’s safeguarding policy and the whistleblowing policy so they understand their role and responsibility in reporting bad practice and acting upon disclosures. We have recommended this because not all of the staff we spoke to knew where the home’s policy was or what was in it. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 17 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): 19, 26 Quality in this outcome area is good. The home is well maintained and provides a pleasant place for people who use this service to live. The home has systems in place to prevent the spread of infection but improvements in staff training would benefit the people who live here. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and pleasant. We did not view the whole home on this occasion. We did visit some of those people whose care we looked at as part of the case tracking process. We did this to make sure that where their care plans indicated equipment should be used it was in place and being used correctly. We found that those people who needed pressure relieving equipment had this in place. They told us “I’m not a fan of the mattress but I know why I have to have it”. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 18 We also looked at bed rails for some people, again we found that they had been fitted appropriately and the staff had completed some risk assessments. They must however take care in keeping these risk assessments up to date and regularly reviewed for each person. This will prevent bed rails being used unnecessarily for people. We were concerned that despite the serous concerns expressed at the last inspection we also found bed rails in use for two people who did not have risk assessments at all. The manager must take action to address this. The home has not met the immediate requirement from the last inspection in full and it will remain as an not met. People’s bedrooms were personalised with their belongings. We asked if the rooms and furniture were comfortable. They said “oh yes its lovely, I’d like bigger rooms but who wouldn’t we always want more don’t we”. There are plenty of communal spaces throughout the home for people to enjoy each other’s company if they choose to do so. The home has an ongoing redecoration and refurbishment programme. Mr Takhar told us “we want to do the best we can for the residents here, it is their home”. There are systems in place to prevent the spread of infection. Staff have access to gloves and aprons, there is also liquid soap and paper towels for hand washing purposes in all toilets and bathrooms. Infection control training for staff would also build upon these areas of good practice. We have recommended that staff training be sought for all staff so that they are aware of current best practice in infection control and can put this into practice. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29, 30 Quality in this outcome area is adequate. The home has an acceptable use of agency staff but must keep staffing levels under review to meet people’s needs. Staff are recruited safely so that unsuitable people are identified and prevented from working with vulnerable people. The home needs to make improvements to the induction process for new workers to make sure they are equipped with skills to complete their work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is staffed with registered nurse 24 hours a day. The nurses are supported by care staff in sufficient numbers to meet the needs of the people living in the home. Agency workers supplement the staff team at times to cover absence or sickness. The manager told us that the home does use a lot of agency workers but they tend to be regular workers so that this does not impact too much on the continuity of care for the people living there. Staff we spoke to said “we work hard, if we had more staff I suppose we could take them out more or do more with them”. The care team also work alongside ancillary workers such as housekeeping, maintenance and kitchen staff. All of who help keep the home running smoothly. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 20 The home employs 28 care staff, 23 of them have achieved their National Vocational Qualification (NVQ) level 2 in Health and Social Care. This is very good and means that staff will have gained the knowledge they need to build on their skills and provide care to the people living in the home. We looked at the recruitment files for 3 staff employed at the home. We found that the required safety checks had been completed such as the Protection of Vulnerable Adults (PoVA) and criminal records bureau disclosure (CRB). However we also found that files were disjointed and did not contain all of the information they should. The manager confirmed that she was aware of this and had begun a process of auditing each person’s file to put this right. This will put further safeguards in place for the people who use this service. In addition to the recruitment files we also looked at the induction records for new workers. We could not find any records that showed us new workers are going through a structured induction. The home did tell us in the AQAA that this was happening they said “all staff are put on induction training when they start employment here”. We spoke to staff who were able to confirm that an induction had taken place, they said “I started and I had 12 weeks of induction doing training and supported by senior”. The manager said that induction records may be kept elsewhere but she hadn’t found them whilst doing her audit of staff files and training. We have recommended that records of induction are kept with staff files so that the home has evidence to show that staff are being trained and supported when they begin employment with the home. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 21 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): 31, 33, 35, 38 Quality in this outcome area is adequate. The home has a new manager who is aware of this services shortfalls and is taking steps to address them. This will help make sure that the home is run in the best interests of the people who live there. The health and safety of the people who use this service is promoted but improvements could be made to further protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since our last visit to the home there has been a change of manager. The new manager has many years of experience in care homes and has a wealth of knowledge to bring to this position. The manager has already identified many The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 22 areas for improvement in the home that would benefit the people who live there. Areas that have been identified for improvement are the care planning systems currently in place. She told us “some of the care plans are pre printed they are not person centred and to me don’t reflect people’s needs. We are beginning to make changes in this area”. We saw that these changes were happening when we looked at people’s care plans, they were more person centred and did reflect more of an individual picture of the person and their needs. The manager also told us that she intends to address the use of agency staff. She said “there is a lot of agency use at the moment I want to reduce this and use our own staff so that people will know who is going to be looking after them”. This will give people who live in the home continuity of care. We expressed our concerns about staff training. It was particularly disappointing to see that staff in this home had not had any fire safety training or fire drills for over 12 months. We provided the home with an urgent action letter asking them to tell us how they were going to address this. It was pleasing to note that within 24 hours the manager had arranged training for all of the staff over a period of three sessions. This training should make sure that staff knowledge has been updated and that they are prepared and will know what to do in the event of a fire. The manager also told us that following an audit of staff training files other shortfalls had been identified and she was in the process of arranging this so that staff knowledge was up to date and people’s health and safety was going to be promoted. The quality assurance system has not been updated for over 12 months. This means that people have not been consulted about the quality of their care for some time. The last recorded consultation with the people in this home was in 2006. The manager will need to take action to correct this. It was pleasing to see that the responsible individual Mr Takhar regularly visits the home and completes an unannounced visit on a monthly basis (regulation 26). This means that he is in a position to identify shortfalls in the home’s practice and take action when needed. The home currently only keeps money safe for two people who live there. We looked at the systems the home has in place to do this and have made recommendations for improvement. We found that people’s money is kept together not separately as outlined in the National Minimum Standards. The home has limited information on the transactions for each person. The manager explained that receipts and invoices are sent to the persons family for their information. The home must still be able to demonstrate what they have done on behalf of the person living in the home. Arrangements for access to The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 23 money also need to be reviewed. At present people can only access their money when the manager is on duty. This means that people will need to forward plan should they choose to go out at weekends and need their money. The manager also told us of alternate storage arrangements for money that is bought in at weekends. These arrangements are not ideal and will also need to be reviewed to ensure that monies are kept safe for those people choosing to hand over their money for safe keeping. Health and safety practices in the home are beginning to improve. The manager has told us that shortfalls in staff training are being addressed. She also told us that the previous immediate requirement for bed rails had been met. We also evidenced this by looking at people’s risk assessments and the fitting of some of the bed rails in the home. the home has shown in their AQAA that it is well maintained and safety certificates for electricity, gas and fire safety are all up to date. Hoists and lifts are serviced regularly. All of which contribute to the health and safety of the people who use this service. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 24 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 X X 2 The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 25 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 15 Requirement Every person must have a care plan that clearly details their heath care needs and how they will be met at the point of admission to the home. Each person who has a pressure sore must have an individual care plan that demonstrates the care they will need to promote its healing. The home must make sure that each person’s weight is recorded at the point of admission and regularly thereafter. Regular monitoring of people’s weights will enable to home to take action when unexpected weight loss/gain occurs. People who are being given pain relief regularly using the homely remedy policy must have their need for regular pain relief assessed by their own doctor and prescribed for them when necessary Staff must clearly record on the MAR sheet the amount of medication that has been received for each person. This DS0000020785.V363926.R01.S.doc Timescale for action 09/05/08 2 OP8 13(4) 09/05/08 3 OP8 13(4) 01/07/08 4 OP9 13(2) 01/06/08 5 OP9 13(2) 01/06/08 The Willows Version 5.2 Page 26 6 OP38 23(4) will assist in audits of medication administration and enable them to determine if people are taking their medication as required. All staff must participate in fire training and regular fire drills. This will help staff understand what to do in the event of a fire and protect the people living in the home. Urgent Action Letter sent 08/05/08 08/05/08 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 Refer to Standard OP1 OP2 OP7 Good Practice Recommendations It is recommended the manager include the current fee range in the service user guide so that people have this information readily available. Individual assessments should be more person centred in their approach. This will support an assessment based upon each person’s individual wishes and needs. Staff are advised to sign and record the specific date of entry when writing in care records. This is to ensure accuracy and to provide information, if required, of the staff member deemed responsible for ensuring care needs are met. Care plans should take into account a person’s specific cultural and spiritual needs. This is to ensure that staff are provided with information to meet the person’s needs and preferences. The homely remedy policy needs to be reviewed and agreed by people’s own Doctor’s. Staff should have access to a Code of Practice for the Mental Capacity Act 2005. They should also have training about this Act so that they are aware of their roles and responsibilities when supporting people who cannot make choices for themselves. Greater numbers of staff should have further safeguarding training. This will give them better knowledge of abuse DS0000020785.V363926.R01.S.doc Version 5.2 Page 27 4 OP7 5 6 OP9 OP14 7 OP18 The Willows 8 OP29 9 OP29 10 OP30 11 OP33 12 OP35 and how to take action if a safeguarding incident is reported to them It is recommended that staff files are audited. This is to ensure that all required pre-employment checks have been completed, to meet legislation and protect people living at the home. The manager should be in receipt of information about agency workers that shows they have been trained for they job they have been employed to do and that they are suitable to work with vulnerable adults. New workers must have an induction that meets with the skills for care common induction standards. This will ensure that staff are given the introduction to working in social care they require. The quality assurance systems within the home need to be put into practice. This will help the home understand if it is providing a service that is based upon people’s needs and is in their best interests. The home must review the way it looks after people’s money to safeguard those people who use this facility. The Willows DS0000020785.V363926.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V363926.R01.S.doc Version 5.2 Page 29 - 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. 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