Inspection on 09/11/05 for The Willows

This inspection was carried out on 9th November 2005.

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 07/05/08

The Willows 15/05/07

The Willows 30/10/06

The Willows 21/09/04

The Willows 26/04/04

The Willows 26/01/04

The Willows 12/05/03

The Willows 28/10/02

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

CARE HOMES FOR OLDER PEOPLE The Willows Dangerfield Lane Darlaston Walsall West Midlands WS10 7RT Lead Inspector Richard Eaves Announced Inspection 9th November 2005 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.V256556.R01.S.doc Version 5.0 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.V256556.R01.S.doc Version 5.0 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 Ms Christine Lynch Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 38 frail elderly over the age of 60 years who require nursing care 10 frail elderly over the age of 60 years who require social care Number specific Date of last inspection 18th May 2005 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. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the unannounced inspection in May 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire, comment card responses from service users and relatives and records held at the home. The inspection involved a full tour of the bedrooms, communal rooms and service areas and provided an opportunity to speak with most of the service users. What the service does well: What has improved since the last inspection? While the home has not been able to recruit an activities co-ordinator care staff have taken on the responsibility to provide activities on a daily basis, organise outings and bring in entertainers on a regular basis. The shower rooms flooring has been replaced and new liquid soap dispensers fitted around the home. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 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 DS0000020785.V256556.R01.S.doc Version 5.0 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.V256556.R01.S.doc Version 5.0 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): 1–5 The homes Statement of Purpose combined Service User Guide is not sufficiently detailed, and it is difficult to find information to present the services of the home in the positive manner which would be encouraging to prospective service users. The pre-admission assessment, confirmation that needs can be met and visits all assist the prospective resident and their families to make an informed decision about entering the home. EVIDENCE: In the absence of the manager staff were unable to source a copy of the statement of purpose, the previous requirement remains to be seen as addressed. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 9 Senior staff at the home undertake pre-admission assessments using a comprehensive assessment tool covering all topics listed in standard 3.3 and including a range of risk assessments such as pressure areas, nutrition and falls as included in standard 7. A requirement is made to keep the assessment under regular documented review and to always address the issues of spiritual and dying needs. Prior to admission and following assessment prospective residents are invited to visit the home and participate in the daily life. A letter is given confirming that the agreed needs can be met by the home. A written contract/statement of terms and conditions is provided on admission and this provides for a trial period. Copies of these documents are kept on file. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 11 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. There remains scope to further develop the direction to staff and be more informative. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld but staff require to be further developed to provide care at the time of service users dying if they are to be sure that they will be treated with sensitivity and respect. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 11 EVIDENCE: A sample of 4 case files from each floor were case tracked and found to be well developed with evidence of service user and supporters involvement in the assessment and care planning process. Each file is set out in a consistent way with the assessments, care plans and evaluations and a range of health risk assessments and monitoring records, these comprehensively direct care requirements. Contingency planning for specific conditions such as epilepsy and diabetes have generally been addressed although the inspector considers these still not to be sufficiently detailed. The Home has a good supply of pressure relieving equipment including pro-pad overlay foam mattresses, alternating airwave and two complete high-risk systems, with provision for hire should there be a need for more systems. Continence assessment is included in the admission procedures with involvement of continence advisor as appropriate. A number of local General Practitioners provide medical care at the Home and other therapeutic services are made available to service users. The Home uses the Boots Monitored Dosage system for the administration of medicines and the local Pharmacist undertakes frequent checks that the system is implemented correctly. The storage and administration of medicines are undertaken separately on each floor with full administration undertaken by staff on each floor. Since the previous inspection some staff have received training in the care of the dying. This now should be rolled out to include all care staff. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 Social activities in the home are not well-planned or creative leaving service users with little to interest or divert them. Some service users benefit from contact with the local community and visitors are encouraged. The meals at the home are nutritious and presented well encouraging service users to take a good diet, however some service users found the menu boring and repetitive detracting from what should be a focal interest of the day. In general, choices that can be made by service users are limited. EVIDENCE: Social activities continue to be very limited due to the absence of an activities co-ordinator although care staff make considerable effort to provide suitable activities in addition to their care duties. Currently able individuals are accessing social outlets in the community two attend a day centre regularly, others attend College, some go to local facilities during the day and evenings. In house events have been regular bingo sessions, a fireworks display, table games are popular with some and weekly visits by the hairdresser is sufficient to meet personal wishes. The mobile library attends the home regularly. A group of service users visited the Walsall illuminations and singers visit fortnightly. The local school choir sang at the home for harvest festival and plan to return for carols. A combined church service is held on alternate Sundays. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 13 A number of visitors were observed to visit over the day and were happy to express satisfaction generally. One visitor commented that the quality of finish of laundry was not always of a good standard such as food stains apparent, and shirts not looking as if ironed. The inspection of a sample of case files show these to include a section that identifies personal likes and wishes. In conversation with service users and in responses from the comment cards they feel that these wishes are fully taken into account by care staff in the assistance they provide. Meals are provided using a 4 week rolling menu that includes choice which some service users continue to described as predictable and boring with little account taken of previous expressions of dissatisfaction, not with the meals but with the variety. Previous recommendation to seek service users views has been addressed but little change is noted to have resulted to date. The lunch observed to be served was noted to use both choices on the menu and further alternative to meet personal preferences. The food was described as bland and no condiments were available. The kitchen is well equipped but it was noted that the fan oven was unserviceable either not achieving temperature or alternatively too hot. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home complaints procedure is robust and there is evidence that service users feel they can voice concerns and that these will be listened and responded to. EVIDENCE: The Homes complaints procedure is readily available by way of the service user guide and notices displayed around the Home. The procedure includes timescales to ensure prompt response and provides details of how to contact the Commission. Since the previous inspection the home has received three complaints one from a concerned relative, which is current and two anonymous in respect of staffing levels. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home provides a good standard of décor, furnishings and managed services providing a safe environment and a comfortable, attractive, and homely place to live. The home is clean and hygienic and free from odours. EVIDENCE: Purpose built, the premises are maintained in good condition and decorative order. The external areas of gardens, parking and footpaths provide a pleasant facility and outlook for service users. A tour of the building confirms that the premises are maintained and cleaned to hygienic standards. The en-suite bedrooms are spacious and personalised and including some own furnishings, one service user had a refrigerator and said that the room was comfortable. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 16 An inspection in the dining room identified that the underside of the dining tables had some sign of debris and this was addressed immediately and will be included in the cleaning schedule. Since the previous inspection both shower rooms have had the floors replaced and the soap dispensers changed. A new storage unit is being built on part of the car park. The laundry is modern and well equipped to meet all aspects of bed linen and personal clothing. The home uses disposable bottles and bedpans for most situations, one service user was seen to have a plastic urinal, the cleansing of which, specific arrangements must be developed. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The home has a good mix of staff but overall numbers are insufficient to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: At the time of inspection the dependency levels on the first floor are described as particularly high with a large number of service users requiring hoisting for all transfers and staff describe the work load as exhausting and is thought to impact on staff absenteeism. The homes position in regard to NVQ training of care staff is that 43 hold the qualification and those undertaking and due to complete will bring the number qualified in excess of the 50 standard when it comes into force. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 18 Other training includes all mandatory, which were observed to be up to date and include; fire safety, moving and handling, food hygiene, health and safety, first aid and infection control. Other training undertaken includes, protection from abuse, death and dying, understanding Alzheimer’s and managing challenging behaviour. Induction of staff is to TOPPS standard. A sample of staff files were inspected including recent starters and were seen to comply with good employment practices and includes all necessary checks such as CRB, POVA and nursing registration. Staff files also show that two references are obtained and a record kept of the interview. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 36 – 38 Leadership of this home remains good in the absence of the manager and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. Staff receive supervision and direction but requires to be more practice based if is to ensure that the service users receive consistent quality care. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. The environment, management and staff training in respect of health and safety ensures service user safety and welfare are protected. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 20 EVIDENCE: The previous manager retired during October and the acting arrangements are functioning well with good morale among staff who are supportive of one another. In conversation with those who wished to meet with the inspector it was clear that they all were concerned that the arrangements would be unable to respond to the heavy workload currently being experienced on the first floor. They were aware that a replacement manager had been appointed. Supervision is established at the home but on inspection it was observed to be appraisal orientated including such items as timekeeping and appearance, in discussion it was agreed to place more emphasis on aspects of work. An inspection of a sample of records required by regulation and the schedules show these to be maintained, kept up to date and secured. The home ensures safe working practices through good staff training and monitoring of activities of work and the environment and services. The range of risk assessments for the environment is good and include fire safety, security, catering, rooms and furnishings. The risk assessments identify monitoring requirements and these were seen to be thoroughly completed and up to date. The previous emergency lighting fault has been corrected. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X X 2 3 3 The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 22 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 OP15 Regulation 16(2)(i) Requirement The registered person must survey service users wishes in respect of the menus and provide meals suited to the individual. Timescale 30/09/05 not met. The registered peron must review the statement of purpose and service users guide and present them as separate documents and include those items as listed in the regulations and schedule 1. Timescale 30/09/05 not met. The registered person must implement a system of reviewing the quality of care at the home, including seeking the views of service users and supply the Commission with a report of the findings. Timescale 30/09/05 not met. The registered person must ensure that staff supervision covers all practice, philosophy of care and career development needs. Timescale 30/09/05 not met. Timescale for action 31/01/06 2 OP1 4&5 31/01/06 3 OP33 24 31/01/06 4 OP36 18(2)(a) 31/01/06 The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 23 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 OP15 Good Practice Recommendations The manager should seek service users views on ways to address their wishes in respect of overcoming monotomy within the menu considered by a small number of service users. The Willows DS0000020785.V256556.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 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 DS0000020785.V256556.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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