Inspection on 12/12/06 for The Willows Barton

This inspection was carried out on 12th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Willows Barton 04/01/06

The Willows Barton 18/02/05

The Willows Barton 01/09/04

The Willows Barton 18/02/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Willows Barton Willow Drive Barton On Humber North Lincolnshire DN18 5HR Lead Inspector Beverly Hill Key Unannounced Inspection 12th December 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Barton Address Willow Drive Barton On Humber North Lincolnshire DN18 5HR 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) 01652 632110 Barton Medical Services Limited Mrs Susan Brumpton Care Home 39 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (39) of places The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: The Willows care home is situated in a quiet cul-de-sac close to the centre of Barton on Humber. The town is well serviced by local transport and has a variety of shops, pubs and restaurants. The home is registered to accommodate thirty-nine service users in the category of old age. The home can, within that number, admit up to twentyone people with a dementia type illness. The home provides day care facilities for two people each day. The Willows is a single storey building divided into five units, each having two toilets and either a bathroom or shower room. The bedrooms are all for single occupancy. The home has three lounges and a separate dining room with individual tables and chairs set out. From the main corridors service users can access three secure patio areas, which have water features and garden furniture. An enclosed lawned area is accessible from unit five. All areas of the home are accessible to wheelchair users. According to information received from the home on 29.08.06 their weekly fees are £327 to £399. Items not included in the fee are toiletries, hairdressing, chiropody, newspapers and transport for various activities. The homes statement of purpose and service user guide was on display in the home and available to prospective service users. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home took place over one day. Throughout the day the inspector spoke to service users to gain a picture of what life was like for people who lived at The Willows. The inspector also had discussions with the manager, care staff and catering staff. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector also checked with service users to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed the way staff spoke to service users and supported them, and checked out with them their understanding of how to maintain privacy, dignity and choice. The Commission received information about the support afforded a family member during their visits to a service user who was dying. There was no complaint about the level of care the service user received, which was actually praised by the relative, but related to the relative not feeling welcomed during late night visits. See section on health and social care. Just prior to the visit to the home the Commission had received information from a relative regarding the care their loved one received after a fall out of bed. This was referred to the Adult Protection Team for investigation and a decision made for the inspector to look at health care support to the particular service user as part of the inspection. See section on health and social care. Prior to the visit to the home the inspector had sent out a selection of surveys to service users, family members, a selection of staff members and professional visitors to the home. These were checked and comments used throughout the report. What the service does well: The home provided good information about the services it provides to new and prospective service users. The home had a staff team that knew the service users well. A core group had worked at the home for many years and there was a low staff turnover. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 6 Service users spoken to were complimentary about the staff stating they were well looked after and that staff were, ‘very good carers’. Care was provided in a way that respected privacy. The home provided lots of activities for people and staff and relatives helped in fundraising for trips out and entertainments. People liked the meals provided, ‘the meals are very good’, ‘we get plenty to eat’ and ‘if at anytime there is something I don’t like, I tell the cook and I get something different’. The home was well managed and provided a clean and safe environment for people and the atmosphere was relaxed. One person said, ‘to me the home is a very happy home’. The services provided by the home were monitored well and results of any surveys were displayed for all to see. Any complaints received had been investigated and sorted out appropriately. What has improved since the last inspection? What they could do better: There were some issues highlighted in surveys, discussions with staff, and during the examination of information on the day that must be improved. The home completed assessments and wrote care plans to meet identified needs but these were not consistently comprehensive. Also in one of the care files examined important information about how a service user was following a fall was not documented in the daily records. It was important to have full The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 7 information written down about people in order that care was not missed and staff knew exactly what they must do to support people. In one case the home could have sought advice sooner from the GP about pain control management. The home must make sure that policies and procedures are followed when administering medication as in one case tablets had been found on the floor and this could lead to people not receiving the medication they need. The home must make sure that all staff are aware of policies and procedures regarding supporting relatives during the time their loved one is dying. This will ensure that the relatives are afforded every support available at this difficult time. The home must look at the range of activities on offer for people with sight and hearing difficulties as some people could miss out on things. Although the home had enough staff on duty in terms of numbers, some people felt the home was short staffed at times. The manager must look at where the perceived shortages occur by having discussions with service users, relatives and staff and examine the deployment of staff to see if this can be resolved. The homes recruitment processes must be addressed as some checks had not been completed and this could place service users at risk. In one instance the personal allowance of a service user was not logged into the home appropriately. The manager must review the current system and address the confusion it causes. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 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 The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home produced information about their services and enabled people to have trial visits in order to assess the services provided prior to permanent admission. Service users had assessments of need completed prior to admission and the home usually obtained copies of assessments completed by care management. The assessment completed by the home did not consistently contain all the information required about the level of service users needs. This was important in order to plan care. EVIDENCE: The home had produced a statement of purpose and a service user guide with information about the services it provided. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 10 Staff advised that potential service users or their relatives were given a pack of information during any introductory visit to the home or it was sent out to people when they made initial enquiries. The manager stated this worked well and gave people the opportunity to read information at home and to come back to them with queries. Copies of the statement of purpose, service user guide, previous inspection reports and other relevant information was on display in the entrance. The home offered respite care and day care services to people. This enabled them to visit the home and sample the service prior to making any permanent decision. The first six weeks was considered a trial period, at which point a review of care was held to decide on permanent admission. The home evidenced that service users were only admitted after an assessment of need had been carried out by the manager and by care management when funded by them. On the whole the home received copies of care management assessments. The assessments enabled them to make a decision as to whether the persons’ needs could be met. The assessments were used to formulate care plans to meet service users’ needs. The homes assessments were of a tick box type with room for comments from the assessor. Those examined fluctuated in comprehensiveness. To improve in this area the home could ensure that information about the degree or severity of a problem or need and how this affected the service user was included in the comments space. For example the assessment had boxes to tick for, ‘needs assistance to dress’. The assessor could describe what this assistance was and what the service users were able to do for themselves, however minor, with dressing. It was acknowledged that this information was sometimes gained over the first few days of admission as staff members got to know the service user but this information was not always transferred to care plans. After the assessment the manager formally wrote to the service user or their representative stating the homes capacity to meet needs. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home maintained service users health and personal care but inconsistencies in care plans, daily records and risk assessments could lead to information not followed up. On one occasion staff were not proactive in seeking professional medical advice as soon as they could and the service users pain was not managed effectively. Policies and procedures were not always followed in regards to the administration of medication and this could place service users at risk of not receiving medication they were prescribed for. EVIDENCE: Four care files were examined and the home evidenced that a lot of information was gathered during the first few days of admission. For example personal profiles with a social history and likes and dislikes, risk assessments were completed for nutrition, falls, moving and handling, bed rails and the use The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 12 of the hoist. An inventory of possessions was made and an assessment as to whether the service user was able to self-medicate. Care plans were produced for each service user that were evaluated on a monthly basis. Daily records regarding the care people received were completed. However care plans and daily records fluctuated in comprehensiveness and attention from staff. For example some care plans had clear tasks for staff and were updated when needs changed. One care plan was updated regarding a persons change in diet but staff assistance to eat the meals was not included, although staff were aware of their need to assist the service user and indeed in practice did so. The same care plan mentioned the need to monitor skin and provide heel pads but made no mention of pressure relieving care such as regular position changes and specialist mattresses and cushions although these were in place in practice. The service users moving and handling assessment indicated a low risk yet they had a history of falls. Some risk assessments were not signed and dated. There was evidence that service users had access to health professionals and services such as opticians, chiropodists and dentists. Records were maintained of visits. Records were also maintained of personal hygiene tasks completed by staff and hourly checks at night. Service users spoken to stated they were well cared for in ways that respected privacy and dignity although two surveys received stated that some staff listened and acted on what they said more than others. Some comments about health and personal care were, ‘the senior care ladies are very good. If you tell them you are feeling off colour, they soon put you right with a doctor or nurse’, ‘to me they are very good carers, they listen and act’, ‘some staff don’t always talk in my ear, I can’t grasp what is being said’, ‘the staff have plenty of patience’, ’we are well looked after, we don’t want for anything’, and ‘staff close doors and care for you nicely’. One person commented in a survey that at times they were left in the toilet longer than they needed to be. Medication was generally managed well. It was stored and recorded appropriately and the inspector witnessed staff members ensuring medication was taken by service users on administration. However surveys received from a service user and their relative stated that, ‘on occasions’ tablets had been dropped and found on the floor by their chair. This would indicate that some staff did not always follow the procedure and ensure the tablets are taken at the time of administration. One relative complained that a service user could have received quicker medical attention especially pain control following a fall. On examination of records during the inspection it was clear that the service user first indicated pain during the night shift two days after the fall. The staff increased pain control during the day and the district nurse visited but the home did not seek The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 13 advice from the GP about further pain control and records reflected continuing episodes of pain until admission to hospital a day later. The incident was referred to the adult protection team and is still undergoing investigation. The home had a policy and procedure about supporting people when they are dying and had produced a palliative care plan to be used when required. A relative spoken to stated they were happy with the care provided by the staff to their loved one during this time. However they felt unwelcome when they visited late at night to sit with their relative. The homes policy and procedure positively encouraged visits by family at any time and staff spoken to stated this was adhered to although some thought there was an unwritten rule for no visitors after 9pm. The manager expressed concerns about health and safety of staff during late night visits but a risk assessment had not been completed and the policy had not been changed. This situation was discussed with the manager to seek advice and address, as the policy and procedure did not reflect the actions of some staff. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided nutritional meals and flexible routines, which enabled service users to make choices about aspects of their lives. Not all service users felt able to participate in activities, as some were not tailored to their needs. EVIDENCE: The home employed an activity coordinator for two hours a day during the week and other staff started their shift an hour early especially for social stimulation. In all the hours provided for social stimulation amounted to sixteen per week. Ten of the eleven surveys received from service users indicated that sufficient activities were provided always or usually. One person felt this was ‘sometimes’. One person did state that sensory problems prevented them from participating in a lot of activities. There was evidence of visiting entertainers, trips out to local facilities and activities provided within the home. The inspector witnessed a planned exercise to music activity in which several service users participated. The exercise involved chair games designed to activate and strengthen upper body The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 15 muscles. Afterwards one person stated they did not usually like to join in activities but they enjoyed the exercises as they kept them from getting stiff. A log was maintained regarding participation but a monthly, ‘at a glance’ record would enable staff to see who had not participated and enable them to have discussions with people in order to tailor activities even further. This would be especially important for the service user who commented they rarely joined in due to sensory problems. There was evidence that service users’ made choices about aspects of their lives for example, management of their finances, choosing the colour scheme of their bedroom and communal areas, personalising their bedrooms, the routines in the home and activities they wished to participate in. There was evidence that suggestions made were listened to for example on what to spend the comfort fund, activities and menu changes. The home had recently had a taster session with service users to see what types of juices they preferred to be served with meals. Routines were flexible with no set times for rising, retiring and visitors. Although service users and staff spoken to confirmed that visitors were welcomed at any time, one relative did not feel this in practice and it affected their experience at the home during a difficult time. A requirement covering this instance has been made for standard 11, which relates to how the home supports people and when they are dying. The cook confirmed that a dietician had seen the menus and some recommendations had been implemented. Special diets were catered for and the selection of desserts for diabetics had been increased since the last inspection. Service users spoken to were happy with the meals provided, ‘we always have a clean table cloth’, ‘we have our own glass tumblers, jug of water and sugar and milk on the table so we can help ourselves’, ‘I have a large cup as I can’t get my fingers into the small ones’, ‘we get plenty to eat and drink’, and ‘the food is very good, I’m not a big eater so they give me small portions’. Although one or two staff commented in surveys that meals could be better presented, the main meal sampled on the day was well presented and well cooked. The dining tables had clean tablecloths and the lay out confirmed service users comments. Lunch was unhurried and staff members were observed serving lunch in a friendly way. Service users were asked if they required second helpings and there was evidence of alternative choices. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to complain about services and are protected from abuse by the general openness within the home, staff members’ knowledge of policies and procedures and adult protection training. The home did not recruit staff in a sufficiently robust way and this could place service users at risk. EVIDENCE: The home had a complaints procedure displayed in the home and staff members were aware of the procedure and the documentation used to record niggles, concerns or more formal complaints. Service users spoken to knew who to speak to if they had any complaints and some named the manager in person. Surveys indicated that people had felt able to make complaints. Service users spoken to stated they did not have any complaints or concerns but would tell staff if they did. ‘ The manager is very good, if there is anything wrong or worrying you they will come into the bedroom and talk to you’, ‘we can go to the staff’. Information from the Pre-Inspection Questionnaire and discussion with the manager indicated that the home had policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of resident’s money and financial affairs. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 17 The staff on duty displayed a good understanding of the vulnerable adults procedure and were confident they would report any issues. All staff had completed training in the protection of vulnerable adults from abuse. The manager had received training around referral to the local authority and their investigation procedures. Recruitment of new staff was not sufficiently robust to ensure service users were protected. See section on staffing. A referral made to the Adult Protection Team regarding the care a service user received after a fall out of bed was still under investigation. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On the whole the home provided a safe, clean and comfortable environment for service users. Ongoing redecoration of communal areas and some bedrooms will enhance the quality of the lives for people. EVIDENCE: The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 19 The home had three lounges and a large dining room and each was furnished to a reasonably good standard, and although the decoration in some areas of the home was looking a little jaded it generally had a homely appearance. There was evidence that redecoration was in progress in one of the corridors and since the last inspection the sluice areas had been made safe and inaccessible to service users. The home had three courtyards, which were accessible to all the service users and had water features, a barbeque and raised flowerbeds so service users could join in gardening activities if they wished. Individual bedroom doors had privacy locks and service users spoken to confirmed they could bring in items of furniture to personalise their rooms. This was evidenced to varying degrees during a tour of the home. People told the inspector the home was always nice and warm, the staff cleaned it well, they were happy with their personal laundry and, ‘we always get nice clean sheets’. Service users were free to choose any area of the home to sit in. Those spoken to were happy with the home and their bedrooms. Surveys had generally positive comments about the cleanliness of the home although one service user did comment that in some areas it could improve, ‘it sometimes needs a good polish and freshening of the air and cup marks don’t always get done every day’. This was not evident on the day of the visit but it was mentioned to the manager to make the domestic staff aware. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had sufficient numbers of care staff in the home but there was still a perception of staff shortage and this affected service users care in some areas. A good staff training and induction programme ensured that well-informed carers supported service users. The recruitment of new staff was not sufficiently robust in the area of povafirst checks and this could place service users at risk. EVIDENCE: Staff rotas were examined and discussions with staff indicated that the home had sufficient staff members in place in terms of numbers. However there was a perception from some service users, some relatives and even some staff that the home did not have enough staff on duty at certain times. Comments about staffing levels were, ‘staff are a bit slow in coming at times and more staff would help’, ‘sometimes I’m left on the toilet for a long time’, ‘the staff are slow to respond sometimes’ and ‘some staff have a little chat but some are very quick to get your clothes on the chair and they go out’. Two surveys indicated that some staff members were better than others at listening to service users and acting on their comments. Four staff surveys The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 21 indicated that there were staff shortages at times and this led to not having enough time with service users. Others service users spoken to felt staff members were quick to answer buzzers and were complimentary about their patience and practice. These comments were discussed with the manager to look at staff deployment within the home to see if minor changes could address the situation. The home had a training plan, which covered mandatory and service specific training. Pre inspection information, surveys received and staff spoken to during the visit confirmed a good training programme. Staff felt skilled to complete their role and task. Induction was allied to skills for care standards and senior staff signed off the competence of new staff. The home provided information that 39 of staff were trained to NVQ level 2 or 3 and more staff were progressing through the course. The home was aiming for 50 . Three recruitment files of new staff members were examined. Application forms were in place and two references obtained for two of the staff. A third staff member only had one reference. The files did not have up to date criminal record bureau checks. One staff member had a check in place that had been completed five months previous at another home and the manager had applied for checks for two staff but had not completed checks to the adult protection register (povafirst checks). Criminal record bureau checks are not portable from job to job and povafirst checks are required prior to the start of employment. The manager and senior carer spoken to did confirm that new staff did not work unaccompanied until checks were returned. The manager must address the shortfalls in recruitment to ensure service users are protected. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provided leadership and guidance to staff and ensured the environment was a safe place to live and work. An inappropriate system of financial management for one service user could lead to confusion in their documentation. EVIDENCE: The manager had completed her Registered Managers Award. They managed the home well and staff surveys indicated that they received support and guidance from the manager. Staff supervision had improved and records and discussions with staff members indicated that the home was on track for staff to receive at least six supervision sessions per year. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 23 One staff member stated they would like to have more contact with the directors during staff meetings to discuss issues. This was mentioned to the manager to discuss with the directors. The directors completed visits under Reglation 26 of the Care Homes Regulations but reports did not indicate which staff were interviewed only if any action was required from the discussions. Service users views about the home were obtained via meetings and the homes robust quality assurance processes. These consisted of audits completed by various staff members and questionnaires sent out to service users, relatives, professional visitors and staff throughout the year on a range of issues such as meals, personal care, timeliness of staff answering buzzers, laundry and cleanliness. Action plans were produced to address shortfalls and staff were informed of the results and the action required to put things right. Results of the surveys were distributed around the home. The home had achieved the Gold Standard Award for quality monitoring awarded by the local authority. The manager and proprietors produced a business service plan on an annual basis and made this available to the home and the Commission. Generally the home managed the personal allowances for service users in an appropriate way. Individual logs were maintained for each service user and receipts obtained for purchases made on their behalf. Since the last inspection two signatures were obtained for all transactions. One financial file checked had a discrepacy in the amount of monies deposited into the home. Half the amount had been deposited into a separate file although a note was made that the full amount had been received. The manager explained that this was because the home was only covered by insurance for a set amount i.e. £50 for each service held in the safe and £100 had been sent to the home for one person. £50 of the money was deposited into the comfort fund with a handwritten note staing who it belonged to. This could lead to confusion and the service users individual log was an inaccurate account of their finances. The manager was advised to discuss this with the proprietors and insurers and suggestions made to enable a way forward. The manager was generally proactive in promoting the safety and wellbeing of the service users who lived at the home and the staff who worked there. Service records were completed and fire prevention management in place including training, drills and equipment checks. Staff completed health and safety training. The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 3 X 3 The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The registered person must ensure that assessments completed by the home especially for self funding service users are comprehensive and includes how the identified need or problem affects the service user and the level of support they need to enable maintaining skills and independence. The registered person must ensure that care plans consistently detail changes in need and tasks for staff to meet identified needs. The registered person must ensure that in future prompt medical advice is sought following concerns about pain management or other medical issues. The registered person must ensure that risk assessments consistently and accurately reflect the service users situation, are updated and signed by the author and service user or representative when appropriate. DS0000002880.V295655.R01.S.doc Timescale for action 31/01/07 2 OP7 15 31/01/07 3 OP8 12 19/01/07 4 OP8 13 31/01/07 The Willows Barton Version 5.2 Page 26 5 OP8 12 6 OP9 13 7 OP11 12 8 OP12 16 9 OP18 19 10 OP19 23 11 OP27 18 12 OP29 19 13 OP35 17 The registered person must ensure that daily recording consistently follow on important events to ensure staff are fully aware and can monitor situations. The registered person must ensure that policies and procedures are followed by all staff regards administration of medication. The registered person must ensure that family members feel welcomed and supported during their visits to the home at the end of life for their loved one as per policy and procedures. Any perceived risks regarding nocturnal visits by relatives must be risk assessed. The registered person must ensure that service users with sensory needs have the opportunity to participate in suitable activities or social stimulation. The registered person must ensure that service users are protected from abuse by robust recruitment practices. The registered person must ensure that the routine redecoration and refurbishment continues as per the plan. The registered person must ensure that the deployment of staff is meeting service users needs. The registered person must ensure that two references are obtained for all new staff and povafirst checks completed prior to employment. The registered person must ensure that money received into the home is correctly detailed on the service users financial record. DS0000002880.V295655.R01.S.doc 19/01/07 19/01/07 31/01/07 31/01/07 31/01/07 30/06/07 31/01/07 31/01/07 19/01/07 The Willows Barton Version 5.2 Page 27 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 OP12 Good Practice Recommendations The activity coordinator should make monthly, ‘at a glance’ records in order to capture information when service users don’t participate in activities. This will enable staff to investigate why and tailor particular activities. The home should continue to work towards 50 of staff trained to NVQ Level 2. The registered person should review the amount of finances insured in the safe to enable a higher amount of safekeeping money for each service user. 2. 3. OP28 OP35 The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows Barton DS0000002880.V295655.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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