Inspection on 09/05/06 for The Willows

This inspection was carried out on 9th May 2006.

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 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 21/09/09

The Willows 25/03/09

The Willows 24/07/08

The Willows 31/10/07

The Willows 11/05/07

The Willows 20/11/06

The Willows 19/01/06

The Willows 28/06/05

The Willows 11/11/04

The Willows 13/09/04

The Willows 03/03/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Willows, The 2 Tower Road Barbourne Worcester Worcestershire WR3 7AF Lead Inspector Andrew Spearing-Brown Unannounced Inspection 10:00 9 and 16th May 2006 th 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 Willows, The DS0000018692.V291174.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. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willows, The Address 2 Tower Road Barbourne Worcester Worcestershire WR3 7AF 01905 20658 * 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) Mr Tony Harborne Mrs Vivien Anita Harborne Mrs Lynda Jennings Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14), Physical disability over 65 years of age of places (14) Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Home may also accommodate a maximum of 4 people over the age of 65 with a dementia illness The Home may also accommodate one person over the age of 65 with a learning disability The home may also accommodate one named person who has needs which fall within the category MD, ie mental disorder, excluding learning disability or dementia. Date of last inspection 19th January 2006 Brief Description of the Service: The Willows is a large, detached, adapted property situated in a residential area near to Barbourne Park in Worcester. The home provides a residential care service for a total of 14 people over the age of 65 years who may also have a physical disability. The home may also accommodate a maximum of 4 people over the age of 65 years with a dementia illness and one person over the age of 65 years with a learning disability. Accommodation is located on two floors, with access to the first floor gained via a staircase and or a stair lift. Handrails are fitted throughout the home. Accommodation comprises of 14 single bedrooms. The home has one large lounge with a smaller room leading off it and a dining room. The registered providers are Mr and Mrs Harborne. The registered manager is Mrs Lyn Jennings. The fees at The Willows are currently £445.00 per week. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. A pharmacy inspector joined the inspector on the first day of the inspection. The focus of inspections carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection to the service offered at The Willows two visits to the home were undertaken. The visits to the home were unannounced and lasted a total of about 14 hours. Previous unannounced inspections have taken place at The Willows including visits by the pharmacy inspector. This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. Prior to the visit a pre inspection questionnaire was posted to the registered manager requesting certain information. The inspector received the part completed document on the first day of this inspection. A number of questionnaires were also sent to the home requesting information from residents, their families / representatives and visiting professionals such as GP’s. A total of eight questionnaires were returned with residents names upon them. One questionnaire had a note completed by a resident stating that she did not wish to complete the form. The remaining seven questionnaires were completed by persons on behalf of residents. Six questionnaires were returned from G.P surgeries and two from relatives / visitors. The findings and some comments received are included within the report. The registered manager was on duty throughout the inspection. A focus was placed on assessing the key standards and re assessing the requirements and recommendations from the previous inspection. In addition to the manager discussions took place with one of the owners, senior carers, carers and 1 relative. Discussions also took place with a number of residents although some of these were brief. What the service does well: The Willows generally provides a warm welcoming environment. Many favourable comments were received especially regarding the registered manager and her commitment to the home. One relative commented on a questionnaire: ‘ The Willows is a lovely friendly and caring home . . great care and respect. The staff are always cheerful and helpful and the home is well managed and well run.’ Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 6 Open visiting is encouraged. One visitor spoke of the home having a family feel about it. The home was clean and without any offensive smells. The grounds are well maintained. The home is by and large well maintained although some improvements are necessary. Information is available for potential residents and their representatives. Care plans were not sufficient in detail however carers did have a good knowledge of the care needs of residents. The medicine charts were clear and well documented. This means that there is a record to show that medicine prescribed for a resident is recorded. What has improved since the last inspection? What they could do better: As highlighted above a significant number of requirements from previous inspections remain unmet – improvement has taken place regarding the management of medication. In all other areas significant improvement is needed; failure to comply with requirements may result in the CSCI considering commencing more formal enforcement action. The information available to residents needs to be reviewed and amended. Training provided is lacking in a range of areas, this includes mandatory training such as fire awareness as well as good practice training such as dementia care. Care planning and risk assessments continue to fail to meet the required standard. Insufficient evidence was available to demonstrate that care plans are reviewed and up dated. A number of pro forma documents were blank and Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 7 daily notes failed to show action taken to meet an identified need or concern. The terminology used was at times inappropriate to the situation. Although improvement was evident in the management of medication further improvements are necessary. Following the last inspection and a follow up visit made by the pharmacy inspector a meeting was held with the registered persons at the Worcester office of the CSCI to formally discuss the seriousness of the concerns. That meeting was the second such meeting to be held regarding medication. All medicine must be securely stored in order to protect residents from harm. Care staff who give medicines to residents must ensure that the medicine has been taken before signing the medicine chart. Some concern was expressed regarding an identified member of staff not knocking before entering residents bedrooms. It was of serious concern to discover that a named individual was involved in a potential vulnerable adult abuse incident within the home. The registered persons failed to inform the relevant authorities such as the CSCI and the Vulnerable Adults Coordinator as the matter should of resulted in a strategy meeting involving a range of professionals. Activities provided need to be improved. Activities need to be meaningful and purposeful to meet the social and recreational needs of residents. A review of arrangements around breakfast time needs to take place. Staffing continues to present a number of serious concerns. The lack of a rota and apparent insufficient staff on duty at certain times must be addressed. An immediate requirement notice was issued to ensure that the home has sufficient and suitable staff on duty. Recruitment procedures remain weak. Infection control measures need improvement. A range of health and safety matters gave cause for serious concern and must be addressed. 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. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 4. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is available to provide details to potential residents and their representatives to assist in their choice of home however this needs to be reviewed and amended. The identification of a training shortfall regarding dementia care needs to be addressed to ensure that residents care needs can be fully met. EVIDENCE: The registered manager has compiled both a Statement of Purpose and Service Users Guide. Copies of both documents are held by the CSCI as required. Both documents contain information for potential residents and their representatives to assist them in making an informed choice regarding the care provided at The Willows. Although informative both documents are in need of further review and amendment in order to meet the required standard. Copies of revised documents need to be sent to the Worcester office of the CSCI. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 10 The majority of the residents questionnaires returned to the CSCI stated that individuals believe they had received sufficient information prior to moving into the home. One resident was able to confirm that she had a copy of the Service Users Guide. One of the conditions of registration states that the home may accommodate a number of residents with specific heath care diagnoses, the registered manager demonstrated a good awareness of the registration conditions and was able to identify individuals to whom they applied. The Willows is registered to care for up to four (4) persons who have a diagnosis of dementia. Although an assessment of each individuals primary care needs was not conducted the registered manager confirmed that four individuals have a dementia type illness. The care of persons with dementia is specialist and therefore suitable training needs to be provided for all members of staff. The training of staff in this subject area is insufficient and needs to be addressed with a degree of urgency. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are insufficient in that they fail to give up to date and necessary detail regarding residents care needs to ensure that staff are able to provide the level of care required. There has been some improvement in the control and handling of medication since the last inspection. Clear comprehensive arrangements have been installed to ensure residents medication needs are met in most instances. Further improvement is needed to ensure that residents are not at potential risk. EVIDENCE: Individual care plans were available. The previous inspection report noted that earlier progress regarding improvements in care plans to ensure that all aspects of heath, personal and social care needs of residents had not continued. Some improvement was seen on this occasion for example one Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 12 care plan was detailed in its contents however further development is necessary. A risk assessment showed that a resident was ‘At Risk’ of pressure sores this was not included within the care plan. The risk assessment tool on another care plan was blank. Evidence existed that care plans are reviewed however the need to review them at least once a monthly or more frequently in line with changing care needs was not evident. Evidence that all care plans were drawn up in consultation with residents and or their representatives was not sufficient and needs improvement. Residents weights were recorded, action taken needs to be improved in the event of changes to weight. The nutritional screening tool was blank on occasions and needs to be developed. The registered manager was confidant that staff knew the likes and dislikes of residents and stated that a list was held in the kitchen. Information recorded for example ‘as required’ under chiropody fails to guide staff to the treatment which may be required regarding the action to be taken to ensure foot care is carried out. The daily notes of one resident indicated that some concern over ‘puffy’ legs was noted. Although it was recorded that a G.P would be needed if the legs remained the same it was evident that it was two weeks later when medical advice was finally sought. Some terminology within the daily notes gave cause for concern. One entry in particular evidenced an opinionated viewpoint rather than factual information. Other terms used such as ‘ snappy’ and ‘bowels open everywhere’ indicate further lack of insight into appropriate recording. Risk assessments although improved are generally insufficient in there content, including areas around falls and moving and handling. Involvement of residents or their representatives in the reviewing of care plans needs to be developed. Staff members consulted were able to describe the care needs of residents in sufficient detail. One relative commented upon the questionnaire / survey card out to the home with the pre-inspection questionnaire. ‘ The Willows is a lovely friendly and caring home . . great care and respect. The staff are always cheerful and helpful and the home is well managed and well run.’ Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 13 A visiting professional commented upon a questionnaire / survey card ‘Residents always seem well cared for’. A small number of residents were consulted as part of the inspection. One resident commented that the home is ‘very good.’ A visiting relative stated that the home is ‘well run’ and that she had ‘no criticisms.’ Staff have worked hard to improve the medicine management within the home. Following the last inspection a meeting was held at the CSCI with the registered persons to discuss the serious concerns, which were discovered during the last inspection and a follow up visit undertaken by the CSCI’s pharmacy inspector. This meeting followed an earlier meeting, which was also to discuss the shortfalls identified over a number of previous inspections. Since the last meeting and before this inspection the manager had introduced further procedures to make sure that medicine was given to service users safely. The majority of the audits undertaken to assess whether medicines had been given as prescribed were correct. Information relating to the healthcare needs of service users was not always up to date in the care plans. Medicine was not always stored safely. Care staff did not always make sure that service users had taken their medicine. In between the two visits to the home the registered manager prepared a memo to staff in relation to the above matters. One resident commented that a member of staff does not knock on the bedroom door before entering the room and therefore raised concerns about a lack of awareness regarding privacy and dignity. Following the conclusion of this report the CSCI received a comment stating that staff displayed no kindness in the way they addressed a resident. This however was not the sentiment of a visiting relative seen during the inspection process. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 14 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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to see visitors, which can add to their quality of life. Activities remain insufficient, the provision, range and frequency of activities needs to be developed further to occupy and stimulate residents. Favourable comments were received regarding the food provided however some areas around the choice and routines around meal times need to be reviewed. EVIDENCE: Open visiting is in place whereby no restrictions exist. Residents can choose to see their visitors in their bedroom, one of the lounges, in the dining room or outside. One visitor was consulted during this inspection who spoke highly of the care provided and that the home had a family feeling about it. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 15 The previous inspection report concluded that activities within The Willows were provided on an add hoc basis. As part of the previous inspection it was apparent that no planned events were in place. Music and movement sessions were no longer taking place due to a reported loss of interest amongst the residents. During this inspection it was evident that one carer now undertakes some light exercise, these are carried out as part of her care assistant role. No activities organiser is in place. Some other activities were mentioned including board games, matching pairs and beetle drive, these items were stored within the smaller lounge. A hairdresser visits the home once per week. Religious needs are meet by means of a minister from a local Church of England visiting the care home on a monthly basis. As far as persons consulted were aware no Roman Catholics residing within the home required a priest to visit. Residents consulted made positive comments regarding the food provided. Breakfast is served by the night staff and taken to residents in their bedrooms which means that breakfast is completed by 8.00 a.m. One resident mentioned that s/he had got used to this arrangement. Although it could be seen that residents may prefer having breakfast in bed some concern was raised regarding the lack of choice as well as the timing of breakfast. No cooked breakfasts are provided and what residents have for breakfast is not recorded. The breakfast arrangements need to be reviewed by means of consultation with residents. Arrangement must be made in order to meet residents requests and not to be convenient to the staffing levels on duty. The dining room is used for lunch and tea. The mid day meal is plated up in the kitchen by staff who therefore decide upon the portions. At the time of this inspection nobody required any special diets and nobody required assistance in feeding. The food was described as ‘well cooked and homely’. The tea menu was noted to contain a high number of sandwiches. Throughout this inspection routines observed were relaxed and unhurried. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 16 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): Standards 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Procedures for notifying authorities of concerns regarding the protection of vulnerable adults are insufficient and can leave residents at risk. EVIDENCE: Although the residents questionnaires were filled in by staff members in consultation with residents it was nevertheless of concern that 3 out of 7 stated that they did not know how to make a complaint. In discussion with one resident during the actual inspection it was however clear that she would speak to the manager if she had any concerns or complaints. Examination of daily notes and the request to view another file referred to within these notes brought about an issue of serious concern. As a result of these findings and with the permission of the registered manager copies of these records were taken. It was evident that an incident had recently taken place, which was not referred to either the CSCI or the Adult Protection Coordinator employed by Worcestershire adult service. Since the above incident had taken place the home had received along with all providers within the County a number of posters regarding types of abuse and reporting procedures. Staff have received no training regarding adult protection, advise regarding suitable training as stipulated by the local protection coordinator was given. The registered provider must supply a training plan to the CSCI. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home is comfortable and homely however some carpeting is in need of replacement to further improve the appearance and safety within the home. EVIDENCE: The communal lounge and smaller lounge are well furnished. The smaller lounge was however a bit cluttered and contained too much furniture as well as items such as board games. The dining room is bright and suitable for purpose. Lighting provided in communal areas is domestic in character. Some additional seating is provided in the hallway, this is a pleasant area and frequently occupied by a couple of residents. The carpet in the hallway and leading into the dining room is in need of replacement or stretching due to a number of ridges. This was noted within Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 18 the previous inspection report; no action to improve the carpet situation has taken place. Attention is required before this becomes a health and safety matter. A visiting professional commented upon a questionnaire / survey card ‘The home is always clean and smells fresh.’ One resident commented about her bedroom ‘lucky to get the room – it’s warm and comfortable’ further comments were made regarding the outlook from the room. Another resident also made positive comments regarding her room stating that it is ‘warm and clean’ It was evident that one bedroom had a new carpet in place. A stair lift is provided to enable access to the first floor of the building. A hoist is provided over the ground floor bath. On the first day of the inspection clothing was hanging from the hoist to dry, as this is not the purpose of a hoist it must not be used for such purposes. The servicing of these items of equipment is highlighted elsewhere. Throughout this inspection the home was clean and free of any offensive odours. The laundry was not viewed as the light had blown lead down to the cellar and was awaiting repair. A risk assessment regarding the disinfection of commode pans has not taken place. A bar of soap was within the staff toilet, this is not in line with local infection control procedures. One communal shower room / toilet contained a bar of soap and no means of drying hands. Carers do however carry anti bacterial hand gel on their person. The grounds to the rear of the home were briefly viewed. They were well maintained and can be accessed by individuals within a wheelchair or with limited mobility. The registered persons were previously required to ensure that suitable environmental risk assessments are carried out. Two previous timescales have not been met although the registered manager has started to compile this document. Thorough risk assessments must be completed; these can be generic and then individualised to be relevant to particular individuals. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Insufficient staff are on duty at certain times of the day. The lack of staff rotas results in the homes inability to demonstrate suitable staffing levels and is a source of serious concern. The homes recruitment procedures and a lack of training are further areas of concern, which can potentially place residents at risk. EVIDENCE: Despite continual requirements to provide a staff rota no rotas existed at the time of the inspection. The registered manager stated that she was attempting to draw up rotas retrospectively. However at the time of this inspection the registered manager was not able to demonstrate that sufficient staff are on duty. Using the timesheets it appeared that only one person was within the care home between 1.00pm and 6.00 pm on Sunday 30th April 2006. During the second visit of this inspection insufficient staff were on duty. Two carers and the registered manager were the only staff within the care home, therefore no cook and no domestic. As a carer had to undertake catering duties this resulted in only one carer on duty. An immediate requirement sheet was left with the registered manager stating that the registered persons must ensure that the home has ‘sufficient and suitable staff’ on duty at all Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 20 times to meet the identified care needs of residents. Failure to comply with an immediate requirement may result in the CSCI considering enforcement action. Recent inspections have highlighted concerns regarding recruitment processes at The Willows. The file of a newly appointed member of staff was seen; although evidence of a suitable Protection of Vulnerable Adults (POVA) first and Criminal Records Bureau (CRB) disclosure were in place other concerns were evident. Only one written reference was in place and the home had failed to seek information regarding work history as required. As a result of the shortfalls The Willows procedures remain to be insufficient and therefore fail to safeguard residents. At the time of this inspection one member of staff held a NVQ (National Vocational Qualification) level 2. Although other staff are undertaking this training currently the home did not manage to achieve the expectation that 50 of carers would have achieved a level 2 by the end of 2005. One member of staff consulted stated that she hopes to complete her NVQ during the summer of 2006 Previous inspections have highlighted training shortfalls. Although a significant number of training event took place during February 2005 involving staff this level of training has not continued and remains to be of concern. Staff do not have individual training and development profiles in place. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls remain in relation to staff supervision and training therefore the home fails to promote safe working practices. Limited progress in quality assurance systems can assist in seeking residents comments regarding the care provided. The majority of the heath and safety shortfalls identified as part of the previous inspection remain unmet placing residents, staff and others at potential risk. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 22 EVIDENCE: The registered manager has extensive experience of working within the care sector. A number of different persons were consulted during the inspection process. All who made comments regarding the registered manager spoke highly of her and of the commitment shown to residents such as visiting while in hospital. The Willows has previously had no Quality Assurance systems in place. Although the situation remains primarily the same the registered manager has now compiled a policy on quality management this covers the National Minimum Standards. The registered manager has devised a questionnaire to obtain some feedback on the service offered at The Willows. At the time of this inspection 2 questionnaires had been returned. The comments on these were favourable. Consultation needs to be extended to other parties such as GP’s and other professionals. Once the period of consultation is over the results need to be collated and published. The published results need to be available to current and prospective residents (included within the service users guide) in addition a copy should be available to the CSCI. No annual development plan is in place, the principals of a systematic cycle of planning, action, review and reflection of outcomes was discussed. No minutes from staff meetings were available. Resident meetings were reported to consist of ‘chats’ – no records were available. Despite continual requirements on the registered provider to carry out visits to the home and prepare a report upon the finds to the registered manager these are not taking place. Reports from these visits must commence and the reports must be available upon request to the CSCI. No business or financial plan exists. A certificate evidencing employees liability insurance was seen. The home does not provide any system for the safeguarding of residents monies or valuables. If any valuables are held by residents they need to provide their own insurance. The requirement that staff receive formal supervision at least six times per year remains unmet. As recorded earlier within the report an incident took place within The Willows, which was a notifiable event; the registered persons failed to notify the CSCI as required. Window restrictors were not in place on two identified upstairs bedroom windows. The registered provider felt that they were not necessary due to the Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 23 height of the windows; this should be discussed with a heath and safety officer at the local city council. Any discussion reached must however be fully risk assessed and recorded. The weekly testing of the fire bell was generally satisfactory. Other monthly checks on fire safety equipment were in order. Concern was expressed regarding the fire risk assessment whereby one question within it enquired ‘do all employees know what to do in case of fire’ the answer was ‘no’ Records of fridge and freezer temperatures are not maintained every day. One fridge showed that it was consistently warmer than the food safety agency would advise recording temperatures of around 9 ° C however this is used to store fresh vegetables. As highlighted earlier within the report the CSCI remains concerned regarding the lack of training including mandatory training available to staff. The training undertaken by the carers on duty was studied and found to have considerable gaps. One person last undertook training in moving and handling during February 2002 (over 4 years ago) while another carer had no training in this area recorded. Shortfalls were noted in fire safety, control of substances and infection control It was of serious concern to establish that the stair lift and bath hoist was not serviced as required within the previous inspection report. Copies of test certificates must be sent to the CSCI. All hoisting equipment must be serviced under the Lifting Operations and Lifting Equipment Regulations 1998. Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 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 2 X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 3 X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 2 3 1 1 1 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4 Requirement The registered persons must revise the current statement of purpose to ensure it covers all areas covered within Regulation 4 and Appendix 1. A copy of the revised document must be sent to the local office of the CSCI. 2. OP1 5 A service users guide, that includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service users. (The time scale of 30/06/05 not fully met. An extended time scale is given by which time this requirement must be met in full) 30/09/06 Timescale for action 30/09/06 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 26 3. OP2 5 The service users contract (statement of terms and conditions) must be amended so that it includes all of the information detailed in Standard 2.2 of the National Minimum Standards. (This standard was not assessed as part of this inspection) 09/05/06 3. OP4 18 (1) (a) The registered persons must ensure that staff both individually and collectively have the skills to deliver the care, which the home offers to provide. Dementia training must therefore be provided for all members of staff. Residents care plans must be recorded in a style accessible to the service user, agreed and signed by the service user wherever capable and/or representative (if any). (Previous timescale of 31/05/05 31/08/05 and 31/03/06 not met. A short but extended timescale is given by which time this requirement must be fully met) 31/08/06 4. OP7 15 31/07/06 5. OP7 15,16 (2) (n) Daily records must demonstrate how residents have spent their day including activities that they have taken part in. (Previous timescale of 31/08/05 and 31/03/06 not fully met – an improvement in activities is needed in order to meet this requirement. A short but extended timescale is given) 31/07/06 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 27 6. OP7 15 Risk assessments must be in place covering all areas of care, including falls and moving and handling. These must be reviewed on a regular basis. The registered person must ensure that service user plans cover all aspects of care as set out in Standards 7 and 3. Care plans must be reviewed on at least a monthly basis or more frequently in line with changing care needs. 16/05/06 7. OP7 15 (1) 16/05/06 8. OP8 15(2)(b) 17(1)(a) Schedule 3 (p) The registered manager must ensure that risk assessments in relation to pressure care prevention are carried out. (Previous timescale of immediate and on going at the time of previous inspections not met. Pressure care prevention risk assessments must be completedthis information must be included within the care plan) The registered manager must ensure that residents chiropody care needs are assessment, met and fully recorded. (Previous timescale of immediate and on going set on 28/06/05 and 20/02/06 not met. This requirement must be met without further delay) 16/05/06 9. OP8 13 (1) (b) 16/05/06 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 28 10. OP8 17 (1) (a) The registered manager must ensure that a photograph of each resident is held for means of identification. (This requirement was not assessed as part of this inspection.) 16/05/06 11. OP8 17 (1) (a)3 (o) The registered manager must ensure that Residents care plans contain information regarding nutritional care needs. (Previous timescale of immediate and on going set on 28/06/05 and 20/02/06 not met. This requirement must be met without further delay) 16/05/06 12. OP8 15 (2) The registered manager must 16/05/06 ensure that suitable action is taken and recorded regarding events highlighted upon the daily notes as giving cause for concern. Terminology used within daily notes must be appropriate. The registered manager must 09/05/06 ensure that carers administer medication as prescribed The reason for any nonadministration of prescribed medication to residents must be clearly entered onto the Medication Administration Record sheets. The registered manager must ensure that the care plan accurately reflects the medication currently prescribed to each resident. 09/05/06 13. OP9 13 (2) 14. OP9 13 (2) Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 29 15. OP9 13 (2) The registered manager must ensure that medication is secured at all times. 09/05/06 16. OP10 12 (4) (a) The registered person must ensure that all persons working within the home afford residents dignity, respect and due kindness at all times. 16/05/06 19. OP12 16 (2) (n) The registered persons must consult residents regarding a programme of activities. Previous time scale of 31/03/06 not meet. A revised timescale is given 31/08/06 20. OP12 16 (2) (n) The registered manager must ensure that a record is kept of meaningful and purposeful activities, which take place within the home. (Previous timescale of 31/08/05 and 31/03/06 not met. An extended timescale is given) 31/08/06 21. OP15 16 (2) (i) The registered persons must review the current routines within the care home regarding breakfast time and the ready plating of meals. A review of the menu should also be carried out. The registered person must take appropriate action and inform appropriate persons without delay of any actual or potential allegations of abuse in line with DS0000018692.V291174.R01.S.doc 31/07/06 22. OP18 13 (6) 09/05/06 Willows, The Version 5.1 Page 30 adult protection policies and procedures. 23. OP19 13 (4) The registered manager must ensure that environmental risk assessments are carried out and available for future inspections. (Previous timescale of 31/07/05 and 31/03/06 not fully met. This requirement must be met without further undue delay) 24. OP19 13 (4) The hoist must not be used as a means of hanging clothing to dry. A risk assessment must be carried out regarding the handling of soiled linen, the disinfection of commode pans etc. and a sluicing facility provided, if necessary. (Previous timescale of 31/05/05 31/07/05 and 31/03/06 not met. This requirement must be met without further undue delay) 26. OP26 16 (2) (j) Appropriate facilities must be 16/05/06 provided throughout the home to manage infection control. A duty roster of all the persons working at the home (including their names and designations), that is dated and a record of whether the roster was actually worked, must be maintained, in accordance Regulation 17 and Schedule 4. (Previous timescale of immediate and on going set on 28/06/05 and 20/02/06 not met. This Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 31 31/07/06 09/05/06 25. OP26 13,16 16/05/06 27. OP27 17 (2)4 (7) 16/05/06 requirement must be met without further delay.) 28. OP27 18 (1) The registered manager must 16/05/06 ensure that all times suitable and sufficient staff are on duty to ensure the heath and wellbeing of residents. (Previous timescale of immediate and on going set on 28/06/05 and 20/02/06 not met. This requirement must be met without further delay.) 29. OP29 19 Recruitment procedures must be 16/05/06 developed in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. (Previous timescale of immediate and on going set on 11/11/04 28/06/05 and 20/02/06 not met. This requirement must be met without further delay) 30. OP30 18 All staff must have individual training and development assessments and profiles. (Part met, an extended timescale given) 31/07/06 31. OP33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31/08/05 not part met, a short but extended timescale is given) 31/07/06 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 32 32. OP33 26 The person carrying out the 30/06/06 monthly visit on behalf of the registered provider must prepare a written report on the conduct of the care home and supply copies to the Commission, the registered manager and the registered provider in accordance with the requirements of Regulation 26. (Previous timescales of 31/05/05 31/07/05 and 31/03/06 not met. A new timescale is given by which the requirement must be met) 33. OP36 18 (2) Care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. (Previous timescales of 31/05/05 31/07/05 and 31/03/06 not met. A new timescale is given by which the requirement must be met) 31/07/06 34. OP37 17 All the records required by regulation must be fully and accurately maintained within the home in accordance with Regulation 17 and Schedules 1, 2, 3 and 4 (Previous timescale of 30/06/05 and 31/03/06 not met, a short but extended timescale is given) 31/07/06 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 33 35. OP38 13,18 All staff must be provided with updated training on moving and handling, food hygiene, fire safety and infection control. (Previous timescale of 31/05/05 31/08/05 and 30/04/06 not fully met. An extended timescale is given by which time all staff must of received the required mandatory training) 31/07/06 36. OP38 13 (4) The registered persons must ensure that a suitably competent person services all lifting and hoisting equipment in line with the relevant regulations. (Previous timescale of immediate and on going not met. This requirement must be met immediately and be on going. The wording of this requirement is slightly changed from the previous report.) 16/05/06 37. OP38 13 Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3. (Previous timescale of 31/05/05 31/08/06 and 31/03/06 not met, a short but extended timescale is given) 31/07/06 38. OP38 13 Evidence must be provided to demonstrate the homes compliance with all of the relevant legislation referred to in Standard 38.4. (Previous timescale of 31/05/05 31/07/06 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 34 31/07/05 and 31/03/06 not met, a short but extended timescale is given) 39. OP38 13 The Fire Risk Assessment must be reviewed at regular and frequent intervals, signed and dated. (This standard was not fully assessed as part of the previous inspection however the requirement is seen to be unmet, a short but extended timescale is given) 40. OP38 13 The registered provider must 16/05/06 ensure that suitable risk assessments are in place regarding the no fitting of restraints to some bedrooms windows. Suitable action must be taken following the findings of the risk assessment to ensure the health and safety of all concerned. The registered manager must ensure that the local office of the CSCI is notified without delay of all incidents as required under regulation 37. 09/05/06 31/07/06 41. OP38 37 Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 35 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 OP13 Good Practice Recommendations Relatives, friends and representatives of service users should be given written information about the homes policy on maintaining relatives and friends involvement with service users at the time of an admission to the home. This information should be included in the service users guide (This information should be included within the revised service users guide) 2. OP14 Information on the service users right of access to their personal records, in accordance with the Data Protection Act 1998, and how this is facilitated for them should be included in the service users guide. (This information should be included within the revised service users guide) 3. OP18 The homes policies and practices regarding service users money and affairs should ensure service users access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and advice on personal insurance, and preclude staff involvement in assisting in the making of or benefiting from service users financial wills. 4. OP26 A detailed cleaning schedule for all parts of the home, including the kitchen, should be provided. (Partly done – no further action taken since the previous inspection) Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 36 5. OP31 The job description of the registered manager should be reviewed in order to ensure that it includes all of the duties and responsibilities that are commensurate with her position and status within the home. (Recommendation remains in place from previous inspection reports) 6. OP34 A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. (Recommendation remains in place from previous inspection reports – no business and financial plans exist) 7. OP37 A statement to the effect that the service users have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records, should be included in the service users guide. (This information should be included within the revised service users guide) Willows, The DS0000018692.V291174.R01.S.doc Version 5.1 Page 37 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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