Inspection on 09/02/06 for The Willows

This inspection was carried out on 9th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Willows 01/12/08

The Willows 17/08/06

The Willows 22/08/05

The Willows 30/03/05

The Willows 29/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Willows The Willows Field Terrace Ripley Derbyshire DE5 3HF Lead Inspector Jill Wells Unannounced Inspection 9th February 2006 09:45 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 DS0000035584.V281688.R01.S.doc Version 5.1 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 DS0000035584.V281688.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Willows Address The Willows Field Terrace Ripley Derbyshire DE5 3HF 01629 580000 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) Derbyshire County Council Jeanette Mary Gilmour Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: The Willows Care Home is situated within the community of Ripley, located near to the town centre and the local Community Hospital. The Home has places for 20 older people. Two rooms are used for respite care. All bedrooms are for single occupancy and are situated on the ground and first floor of the Home. There is a passenger lift to the first floor. There are no en suite facilities. The Home has a 3 lounge areas, one being used as a lounge/dining room. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a four hour period. This period included lunchtime. During this time residents were spoken with in private and residents records were inspected as part of the case tracking methods used. Staff and the deputy manager on duty were also spoken with. The environment was inspected. Staff were observed interacting with residents. What the service does well: What has improved since the last inspection? There were several requirements made at the previous inspection concerning medication administration and recording. This had now improved. There was some improvement in the activities provided, including the recording of activities although more was needed and this was likely to further improve when the 10 hour care assistant/activities coordinator post had been appointed to. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 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 Willows DS0000035584.V281688.R01.S.doc Version 5.1 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 DS0000035584.V281688.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Full and detailed information was provided to prospective service users, and their needs were fully assessed before a decision was taken as to whether the home could meet their needs. EVIDENCE: There was a ‘service user reference guide’ file in the entrance hall. This had the homes statement of purpose, complaints procedure and information concerning residents’ rights. There was also a copy of the most recent inspection report and a copy of the National Minimum Standards. Residents and visitors could view this file. Three residents’ files were seen as part of the case tracking methods used. Each file had a full assessment undertaken by a social worker/care manager from Social Services. A resident confirmed that detailed information was taken from them before they moved into the home. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Residents’ health and personal care needs were met, and medication administration followed good practice. EVIDENCE: There was a personal service plan within each residents file that was seen. These have been drawn up with each resident and detailed the action which needs to be taken by care staff to ensure that all aspects of residents health, personal and social care needs were met. Care staff reviewed the plans of care on a monthly basis. Residents health was promoted and access to health care services were provided. There were records of contact with relevant health professionals within each residents file. Nutritional screening was undertaken on admission and a record was maintained of weight gain or loss, and any appropriate action that was required. Medication was inspected. At the previous inspection it had been highlighted that the medication room became very hot and was likely to at times be above the required 25°C. The registered provider was in the process of looking at ways of rectifying this. There was a one resident that self-administered The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 10 medication. Although they had signed that they were aware that they must keep medication locked, they were not doing so. Staff had not monitored this. A record was kept of medication administered and was in good order. Controlled drugs were stored in a metal cupboard, which complies with the Misuse of Drugs Regulations. There was a controlled drugs register that was checked and found to be in good order. There was a lockable fridge for the purpose of storing medication that required refrigeration. Staff were now recording the date of opening when medication had a ‘use by’ date. Residents had a photograph in place on their medication records, which was good practice. The home had recently purchased an up-to-date British National formulary to assist with drug information/ identification. Staff were observed interacting with residents. They were seen treating residents with respect and being sensitive, particularly around personal care giving. Staff were aware of residents preferred term of address. Resident spoken to said that staff were very kind and respected their privacy. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15. Residents have opportunities to take part in appropriate activities. The meals provided were of a good standard with choice available. EVIDENCE: There was information displayed in the hallway concerning activities that were planned for the following days. Residents could choose whether to take part in these activities. Staff recorded activities that had been undertaken in an activities record. Examples of activities within the record included dominoes, movement to music, knitting, reminiscing, bingo, organist, clothing sale, and regular trips out. Recent trips included a pub lunch, a trip to Bakewell, Cromford and a garden centre. The 10 hour post of care assistant/activities co-ordinator was vacant and the manager was attempting to appoint into this vacancy. Until that time several care staff had been given responsibility for organising activities. One member of staff that was spoken with had been given the opportunity to organise crafts. She had requested an order of materials and had some interesting ideas. The surveys given to residents in July 2005 identified some dissatisfaction with activities. In response to this the manager has attempted to improve the situation, and it is hoped that with the appointment of the additional 10 hour post this will be further improved. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 12 All residents that were spoken with were satisfied with the meals provided. One resident said, food is out of this world, I have never known such good food, it cant be bettered. One resident particularly enjoyed the choice at breakfast time. Mealtimes were set at 9 a.m., 12:30 p.m. 5 p.m. and 8:30 p.m. Meals were taken in two dining rooms, one on each floor. The menu showed that there was a choice at each meal time and special diets were catered for. The cook would talk with each service user to ascertain whether they were happy with the main meal and if not, discuss an alternative. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Residents and visitors were given the opportunity to complain if they needed to do so. Procedures were in place to deal with any allegations of abuse, although training was not provided for all staff. EVIDENCE: The complaints procedure was displayed on both floors of the home. This included the name address and telephone number of the Commission for Social Care Inspection. Complaints were not discussed on this occasion. There were procedures for responding to suspicion or evidence of abuse to ensure the safety and protection of service users. Training record showed that not all staff had undertaken adult protection training, although new staff had received this as part of their induction. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 21, 24. The environment was safe, clean and well maintained with the provision of appropriate aids and adaptations in order to assist residents. EVIDENCE: The environment was clean, tidy and well maintained. The layout of the home was suitable for its stated purpose, fully accessible with the use of a passenger lift. Grounds were kept tidy and safe. There were three lounge areas, two on the ground floor and one on the first floor. The large lounge area on the ground floor and the lounge on the first floor doubled up as dining room areas. Lighting in communal rooms was domestic in character. The large lounge area had recently been decorated and new furniture provided. The two smaller lounge areas were ready for re decoration. Several chairs had badly scuffed legs. It was stated by the deputy manager on duty that refurbishment of these areas was planned. There were two toilet facilities on the ground floor, and two on the first floor. There were two occasions when residents were observed having to wait for a The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 15 free toilet on the ground floor after mealtimes. The two toilets areas on the first floor were in need of decoration. There was rotting wood covering piping. There were three bathroom facilities, one with an electric hoist, a second with a manual hoist and the third was a fully accessible shower. Residents spoken with enjoyed having a bath and appreciated the assistance that they received. Two bedrooms were seen. They were comfortable and had a privacy lock. Residents said that they were offered a key to their door. Each room had a wash hand basin, drawers and enclosed space for hanging clothes, a bedside cabinet and bedside lighting. Rooms were centrally heated, and radiators have low temperature surfaces. The premises were clean, hygienic and free from offensive odours. Residents spoken with were pleased with the level of cleanliness. One resident said that, the staff always keep it nice and clean. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Staff were knowledgeable, competent and committed. Training was generally of a good standard. EVIDENCE: The previous three weeks rotas were inspected. It was found that there were two care staff on duty in the morning and in the afternoon as well as a manager or deputy manager. Staff spoken with said that very occasionally there was only one carer on duty in the afternoon for example if someone had called in sick and the shift could not be covered. This was an improvement on the previous inspection that showed many afternoon shifts with only one carer. There were always two waking night staff on duty. There were times when this had been difficult due to two night workers off long-term sick. Other staff working at the home had covered these shifts. The manager/deputy managers assisted care staff at busy times. It was evident from observations of staff that they were competent, skilled and caring. One worker had agreed to come in to play bingo with residents in the afternoon on their day off. Staff were observed reminiscing with several residents and recording residents family histories to further assist care staff in understanding individuals needs. The home has over the required 50 trained care staff with NVQ 2 Care. New staff underwent a thorough induction and foundation training. They shadowed experienced staff until they had undertaken the initial induction. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 17 Two staff files were inspected. One had the required information including photograph, identification, job application form, two references and evidence that a criminal record bureau check had been obtained. The second file did not have this information in place. The file was of a new worker. It was stated that human resources department were sometimes quite slow in providing this information. Training files were inspected. It was found that staff had undertaken the initial mandatory training, however some staff required refresher training in moving and handling, first aid and fire training. As stated previously several staff had not undertaken adult protection training. As there were several residents with dementia, training in dementia awareness was necessary for staff. It was explained that this training had been requested but had been difficult to obtain. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37. The home was well run and managed by a competent management team. EVIDENCE: Although the manager was not present during this inspection visit, it had been noted at the previous inspection that she had obtained the NVQ 4 Care and Management qualification and undertakes periodic training to update her knowledge, skills and competence. Training for all managers included recruitment and selection, medication, supervision, recording, risk management and stress management. Residents spoken with said that both care staff and management were very approachable. Staff spoken with said that they were given the opportunity to have their say. One staff member said that, it is a good staff team and the nicest place that Ive worked at. Staff meetings were arranged, which gave staff and managers the opportunity to look at the development of the service. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 19 There was an excellent quality assurance and quality monitoring system in place. This included residents meetings, review meetings and annual satisfaction surveys. The last survey was given to residents in July 2005. Workers from Age Concern were on hand to assist if required. The results of the surveys were analysed by an external quality assurance manager and a full and detailed report was sent to the home. The report included percentage levels of satisfaction, what the home could do better, what works well and suggestions made by residents and relatives. When the report from the analysis of the surveys was received, the manager completed an action plan in response to any areas that could be improved upon. Suggestions made by residents from the last survey were, more activities and less shifts when staff were working short staffed. The results of the survey were available in the entrance hall. The deputy manager stated, and one care worker spoken with said that regular supervision was provided. This included individuals personal development needs, including training. Records required by regulation were in place. This included information in respect of each resident and staff. Reports by the registered provider or nominated person were required on a monthly basis. The service manager had been given this role. The last report was in January 2006 and was very detailed. However there was not a report for November or December, and there were gaps before October where reports have not been written. The registration certificate was displayed in the hallway, as was the up-to-date insurance certificate. There were records of any accidents or incidents that could be detrimental to the health or welfare of residents. There was a record of all visitors to the home in the entrance hall. Records were well organised and secured safely. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 X X 3 X X STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 2 x The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? yes 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 Timescale for action 30/04/06 2. OP10 13(2) 3. 4. OP18 OP21 13(6) 23(2) (d) 5. OP29 19 Scheduled 2 6. OP30 13(6) The temperature of the medication room must be monitored. If the temperature is regularly above 25 C, action must be taken to reduce this temperature. Not Met. Original Timescale 15.9.05 Any residents that keep their 20/02/06 own medication must be fully aware of the need to secure their medication at all times. Staff must monitor that this is taking place. All staff must receive adult 30/09/06 protection training. The toilet on the first floor must 30/08/06 be re decorated and the rotten wood covering the pipes made good. All staff files including new staff 30/03/06 must have the required records in place including two written references, identification, and evidence that a criminal record bureau check has been obtained. . Dementia awareness training 30/09/06 must be provided for care staff. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 22 7. OP30 18 (1) (c) (i) 26(4) (c) 8. OP37 All staff must undertake the required mandatory refresher training for fire, first aid, and moving and handling. The registered provider or person responsible for the home must prepare a written report on a monthly basis on the conduct of the care home. 30/09/06 30/03/06 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 Refer to Standard OP21 Good Practice Recommendations Consideration should be given to the redecoration of the two small lounge areas, as well the replacement of some worn furniture. The Willows DS0000035584.V281688.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 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 DS0000035584.V281688.R01.S.doc Version 5.1 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. 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