Inspection on 01/04/09 for The Willows Care Centre

This inspection was carried out on 1st April 2009.

CSCI found this care home to be providing an Good service.

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 Care Centre 10/07/09

The Willows Care Centre 02/04/08

The Willows Care Centre 12/10/07

The Willows Care Centre 03/10/06

The Willows Care Centre 14/10/05

The Willows Care Centre 04/04/05

The Willows Care Centre 29/10/04

The Willows Care Centre 04/05/04

The Willows Care Centre 03/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE The Willows Care Centre 14 The Lant Shepshed Loughborough Leicestershire LE12 9PD Lead Inspector Linda Clarke Unannounced Inspection 1st April 2009 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 Care Centre DS0000001935.V374767.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 Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Care Centre Address 14 The Lant Shepshed Loughborough Leicestershire LE12 9PD 01509 650559 01509 650362 thewillowsnh@schealthcare.co.uk 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) Exceler Healthcare Services Limited Miss Irene Lata Chand Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (25), Physical disability of places over 65 years of age (25), Terminally ill over 65 years of age (25) The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers. No one falling within categories PD, PD(E) or TI(E) may be admitted to the home when 25 persons of these categories/combined categories are already accommodated within the home. 2nd April 2008 Date of last inspection Brief Description of the Service: The Willows Care Centre is a purpose built home situated in the centre of Shepshed. It can provide care for up to sixty older people with a range of needs including physical disabilities. A registered nurse is on duty in the home at all times. Accommodation is provided on two floors accessible by a passenger lift. There is a large sitting/dining room and activities room on the ground floor and a number of smaller sitting rooms on both the ground and first floor. There are a small number of double rooms and some rooms have en suite facilities. There are specialised bathing facilities, with aids and adaptations fitted throughout the home. The home is set in its own gardens with seating available for general use. The home is accessible by public transport and is close to a number of public amenities such as the local library, churches and the community centre. The Statement of Purpose, Service Users Guide & Inspection Report are available on request (these provide information on how the home is organised and what services they provide). The Statement of Purpose and Residents’ Guide are provided for all new residents. A copy of the Care Quality Commission Inspection report is available and is displayed in the foyer of the home. At the time of the inspection the weekly fees ranged between £336.00 and £1000.00 per week dependent upon an individuals care needs. There are additional costs for individual expenditure such as hairdressing, newspapers etc. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to ‘The Care Quality Commission. (CQC). References to The Commission for Social Care Inspection (CSCI) should be taken as CQC, who now hold the legal responsibilities previously held by the CSCI, as of the 1st April 2009. The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service, reviewing previous Inspection Reports, and any information we have received. We sent surveys to people who use the service, their relatives, staff who work at the home and health and social care professionals. We received five surveys from people living at the home, and four from relatives along with five from staff who work at The Willows Care Centre. The unannounced site visit commenced on the 1st April 2009 and took place between 09:30 and 18:00. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff of The Willows Care Centre. Four people accessing services were selected, and included people with nursing and residential care needs. Discussions were held with the people who live at the home, as well as people who were visiting on the day of the site visit. We also spoke with some staff, along with the Registered Manager, and their line Manager. What the service does well: People who are considering moving into The Willows Care Centre have the opportunity to visit before moving in, and individual can be confident that their needs can be met when they move into the home, as a comprehensive assessment of a persons needs is carried out by a representative of the home, and in some instance an additional assessment is completed by a health or social care professional. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 6 We found that everyone who lives at home has a care plan, which details the care, and support they need, which is regularly reviewed. Staff complete a range of assessments for different identified needs, which are then used to develop care plans specific to the individual, which includes actions staff need to take, including a range of health care emergencies, and significant health care support. We found that people who live at the home are encouraged to take part in a range of activities, which are organised and facilitated by the Activities Organiser. The home has managed two safeguarding referrals well, and has acted upon the advice and guidance made by the then CSCI, and health and social care professionals, to address the issues raised, and has responded to complaints in a timely manner. What has improved since the last inspection? What they could do better: People choices, and expectations of care could be better documented within care plans, by including their preferences with regards to preferred daily routines, such as what time they wish to get up and go to bed, and how and where they prefer to spend their day, along with information about hobbies and interests, and activities of interest. Aspects of personal care people receive needs to improve by consulting with people as to their preferences with regards to the frequency that they wish to have a bath or shower. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 7 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 Care Centre DS0000001935.V374767.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 Care Centre DS0000001935.V374767.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 4. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Willows Care Centre enables people who require care to make an informed decision as to whether the home is appropriate to their needs by providing information about the services it provides and through its assessment process. EVIDENCE: We wanted to look at the information provided to people who live at The Willows Care Centre to find out whether it was detailed and answered all their questions, and to find out how the service passed on the information. The home has produced two documents which provide the relevant information, which are referred to as The Statement of Purpose and Service User Guide, both documents provide information about the services provided, staffing arrangements, the homes philosophy of care, and how it engages with people The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 10 who live at the home. We found that a copy of the information about the home was located in individuals bedrooms. Information supplied within the self assessment tool, (AQAA) completed by the Registered Manager before our site visit, told us that there is a marketing team of staff, who show individuals the facilities the home has to offer and answers their questions. We spoke with people who live at the home and their relatives, a majority of people had visited The Willows Care Centre before moving in, or a relative or friend had visited on their behalf. People told us that they were given information about the home, and the services it provides. We sent surveys to some of the people live at the home and their relatives, surveys told us that they had received enough information about the home before moving in. One person in their survey wrote The staff were very helpful on our visit, we had a very good tour of The Willows, our questions were answered fully. We wanted to find out how the Registered Manager of the home, can be confident that the service it provides can meet the needs of people, before they move into the home. The Registered Manager said that everyone has their needs assessed by a senior member of The Willows Care Centre staff team, usually themselves. People, whose care is funded through health or social services, will have an additional assessment carried out by the authority funding the persons care. We looked at the records of four people living at the home, which included people who were receiving residential and nursing care. We found that assessments were comprehensive, and provided a good level of information to determine whether the needs of the person could be met, these assessments are used to develop a care plan, which is in place for when the person moves into the home. The Willows Care Centre DS0000001935.V374767.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs, and is regularly reviewed. EVIDENCE: We wanted to find out how the health and personal care needs of people living at The Willows Care Centre were met. We spoke with people living at the home along with visiting relatives and friends, and observed the care and support provided by staff, we also looked at the care plans and records of four people. We found care plans to be comprehensive, and included the preferences of the individual person, the views of the individual should be expanded upon to include individuals wishes as to how they would prefer to spend their day, for example what time they wish to get up and go to bed, where they would like to eat their meals, along with information about how often they would like to The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 12 have a bath or shower. The Registered Manager told us that the organisation to which The Willows Care Centre is part of, is reviewing the format of documentation, including care plans, which would enable peoples preferences to be recorded and would support Person Centred Care. A care plan was in place for each identified need, and was reviewed monthly. We found that a variety of assessments were undertaken to develop and review care plans, which included nutritional assessments, pressure area assessments, falls assessments along with moving and handling assessments. Where assessments identified a risk, a care plan was developed, which provided comprehensive information for staff to follow. The daily notes which are completed and support care plans, showed that care plans were followed, and any actions identified were taken, which included referrals to Tissue Viability Nurses and Dieticians. One visitor told us, that there friend was much better since she moved into the home, and was more alert. We found that people are supported to make an End of Life Care Decision, which enables the individual to remain at the home, and not be admitted to hospital in specific circumstances, which enables people when they become ill to be cared for and supported by people they know, in familiar surroundings. We spoke with several visitors on the day of our site visit, and views were mixed about the care provided at the home, whilst some felt that the care fell short of their expectations, others were complimentary. One gentleman, who lives at the home, told us that they felt well cared for, and that staff were kind and supportive. We spoke with two relatives who said they were concerned that their relatives fingernails were long and dirty, this was supported by our observations, and that people did not receive regular baths and showers. We looked at the records in people bedrooms, which detailed personal care; we found that whilst everyone was receiving a thorough wash or bed bath, people were not receiving a bath or shower regularly. This issue was identified at the previous Key Inspection, which took place in April 2008. The Registered Manager said that she had been informed that people were receiving baths/showers. The Registered Manager needs to ensure that people are receiving baths/showers at a frequency of their choice, and that systems are put into place to monitor this. People living at the home are supported by a range of external professionals, in addition to those employed by the home. We read the care plans and records of four people and found that additional health care support was provided by General Practitioners, District Nurses, Speech and Language Therapists, Dieticians, Physiotherapists and Tissue Viability Nurses. The involvement of professionals is dependent upon the needs of the individual The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 13 person, and care plans detail when referrals to external health care professionals are to be made. We sent surveys to people who live at the home and their relatives and asked them about the care they received, views were mixed from relatives, whilst a majority of people indicated that they receive the care and support they need, one person wrote I am looked after well. Observation during the inspection showed that staff had a good awareness of how to protect residents privacy and dignity. However, two members of staff were seen to be standing up feeding someone at lunchtime rather than sitting unobtrusively at their side. Nevertheless, staff spoke to people living at the home and visitors in a respectful, friendly, quiet and helpful way. We observed that people, who remained in bed due their health care needs, had the call bell placed next to them, so that they could call for assistance if required. Training records reflect that staff have attended a variety of courses in the first three months of this year, which directly support the care people at the home require, training received includes moving and handling, nutrition, safe handling of medication, pressure care and care planning. For those people who receive residential care, their medication is administered by a senior member of care staff, who has received training, whilst people who receive nursing care, have their medication administered by a Nurse. We observed a senior carer administering medication; they followed good practice guidance, and wore a tabard asking people not to disturb them whilst administering medication. We looked at the medication and medication records of some people who receive nursing care and support and found them to be in good order; we also looked at Controlled Drugs and records, which were also found to be in good order. The Willows Care Centre DS0000001935.V374767.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities are available for people to engage in activities and take part in recreational events as a group. The Willows Care Centre provides a wholesome and varied diet and meets the individual and specialist needs of people. EVIDENCE: We wanted to find out how people spend their day, and how the staff working at the home support people to make decisions and stay in contact with relatives and friends, we did this by observing people throughout the day, talking with people living at the home and by looking at the care plans and records of four people. The Willows Care Centre has a relaxed atmosphere, with people getting up and spending time where they choose, dependent upon their health and needs, for some this meant staying in bed, whilst others sat in their bedroom or lounge. We spoke with relatives and friends who were visiting, who gave us mixed views at to whether they were made to feel welcome, a majority said they were made to feel welcome, and this was confirmed by our observations. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 15 The home has an open plan lounge and dining room, which leads into the Activities Room. On the day of our site visit we were unable to speak with the Activity Organiser, as they were unwell on the day of our visit and were not at work. We did speak with people who live at the home and visitors, who spoke highly of the Activity Organiser - Caroline, saying that she did a wonderful job and was brilliant with those living at the home. Relatives told us about the activities available, which included reading articles from a newspaper, watching television programmes, cross words, flying carpet - (which is an imaginary day out), exercises whilst sitting in a chair, sing a longs, and themed events such as St Patricks Day, Valentines Day, Easter, Ascot, Halloween to name some. Relatives told us that the home is decorated with these themes in mind, and activities take place dependent upon the event, all the ladies wearing a hat on Ascot Day for example. We noted that the notice board contained a Mothers Day tribute, with people recording what they most remembered about their mother within a home made card. External trips to attractions also take place; destinations include a barge trip on the canal, visiting Ulverscroft Grange and garden centres. We were also told that Church Services are held in the home, which people attend, one person told us that members of their faith visit, whilst someone else told us that they attend Holy Communion. We sent surveys to people living at The Willow Care Centre and asked them whether they took part in activities in the home, and whether they were satisfied with the meals provided, they told us that people were satisfied and took part in some if not all of the activities. One person wrote the activities are very good, I cannot join in everything, Caroline makes sure what I can do I do. Whilst someone else wrote, she looks after us like her own family. A majority of surveys expressed satisfaction with the meals provided. Activities for the month are displayed on the notice board in the entrance hall, and specific events such as themed events and day trips are included in the quarterly newsletter. The newsletter provides information about the mobile library, which is part of the Leicestershire County Council Mobile Library Service, which visits regularly. We spoke with people who live at the home, and their visitors and asked them about the meals provided, a majority of people were satisfied, one visitor commented that it would be good if fresh vegetables were used as opposed to frozen. The Chef told us that fresh vegetables are used on a Sunday. We sat with people whilst they ate their lunchtime meal, people were supported where support was required, but additional staff in the dining room would mean that people could be served more promptly. Meals are in the main homemade, as are cakes and biscuits, for tea. The menu is displayed on a board in the dining room, and we observed people making a choice as to what they wanted to eat. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 16 Nutritional assessments were in place for people, which had been used to develop a care plan, where needs had been identified, and were comprehensive providing clear information about the needs of the person and the role of staffing in providing the support and continued monitoring. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. People living at The Willows Care Centre are able to express their concerns, and have access to a complaints procedure, and are protected from abuse by a knowledgeable staff team. EVIDENCE: We wanted to find out how the staff at The Willows Care Centre promote the safety and welfare of people living at the home, written information supplied by the Registered Manager prior to our visit and discussions during our visit confirm that the home has received twenty-two complaints or concerns in the last 12 months; we have received one concern in the same period. The Complaints Procedure is displayed on the notice board in the entrance foyer, and is also contained within information documents given to people when they move into the home. We were notified of two safeguarding alerts, whereby two people who lived at The Willows Care Centre, were considered to be at risk. We have attended several meetings along with representatives of Social Services and the home to discuss these issues. We also carried out a Random Inspection on 27th November 2008, where we considered the information we had received. The Random Inspection found The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 18 the Registered Manager was addressing the issues raised, and that requirements made at the previous Key Inspection has been met. We made no additional requirements as a result of the Random Inspection, but made recommendations, which have been considered as part of this Key Inspection. We looked at the training records for staff, and found that sixteen staff in the first three months of this year has received guidance and training in protecting vulnerable adults from abuse. Discussions with the Registered Manager and a follow up telephone conversation with a representative of Social Services, confirm that both safeguarding issues have been concluded, and issues raised have been addressed. We sent surveys to people who live at the home and their relatives, they indicated that most people know who to speak with if they have a concern, and two people living at the home made additional comments. I have never had to make one. And I usually tell my daughter and she sorts it out for me. We asked people living at the home if they knew how to raise a concern, those that we spoke with said that they did. We spoke with one person living at the home, and they told us that Irene (the Manager) visits her regularly and asks them if they have any concerns. The Registered Manager holds a Surgery three times a week, for people who live at the home, their relatives and friends, to discuss any issues they wish to raise. Quarterly groups meetings are held with people who live at the home and their relatives/friends, the purpose of these meetings is to discuss general issues, meetings from these minutes are circulated to participants. Several people we spoke with said that they attended the meetings. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 19 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, 21 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Willows Care Centre provides a comfortable and homely environment, which is well maintained. EVIDENCE: We had a look around The Willows Care Centre; all communal areas were decorated to a good standard, and provided people with light and airy rooms in which to relax. Information supplied by the Registered Manager prior to our visit told us that there is an ongoing programme of decoration and refurbishment, which has included the decoration of communal areas, and the purchasing of new furniture and soft furnishings. The entrance to the home is level access, and opens into an entrance foyer, where the notice board can be found. The main office has recently relocated to The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 20 the front of the building, and leads off from the dining area. The ground floor has a large open plan dining room and lounge, and benefits from large windows which provide ample natural light, as well are providing views of the garden. The garden is well-maintained and benefits from flowers and trees giving points of interest for people to view. There is a designated activities room, leading off from the lounge/dining room, which is mainly used by the Activities Organiser. The recently vacated office on the ground floor to the rear of the building is to be converted into another communal area for people to use. There is also a communal lounge and dining room on the first floor. Bathing, shower and toilet facilities are located on the ground and first floor, with bathing and showering facilities available for people who require the use of equipment for support, such as hoists. We sent surveys to people living at the home and their relatives and friends, which told us that a majority of people find the home to be fresh and clean. One person wrote the home is usually cleaned very well, but what I find is that little things are forgotten, like the wheelchairs are never cleaned, they are left with dried food on them. On the day we visited wheelchairs did not appear to be dirty, the Registered Manager said they would monitor this. We noted that staff wore aprons and gloves, and that infection control procedures were in place, which included hand gel dispensers located throughout the home, for staff and visitors to use, to prevent the risk of infection. One relative told us that she had noted on one occasion that dispensers had been empty, on the day we visited this was not the case, and we observed staff using them as they went about their duties. There is a dedicated laundry within the home, several relatives we spoke with expressed dissatisfaction with the laundry service, stating that items of clothing frequently went missing or were damaged through incorrect washing. We advised the Registered Manager of the concerns raised. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Staff who have undergone a robust recruitment process and who have access to training meet the needs of people who live at The Willows Care Centre. EVIDENCE: We wanted to find out whether there were sufficient staff on duty to meet the needs of people living at The Willows Care Centre, there are ten staff on duty during the day, which includes a Nurse and two senior carers. The staff are split into two teams of five, one team caring for people receiving residential care, and the other team supporting people requiring nursing care. During the night a Nurse is on duty, along with a Senior Carer and three care staff. The number of staff on duty has increased since we undertook a Random Inspection on the 27th November 2008. Our observations were that staff were busy, and in some instances people were left unattended in the lounge, dining room, we found that call bells were responded to within a reasonable period time. The Registered Manager told us that they are looking to appoint additional staff; a factor in this decision is the number of people who live at the home who require a high level of nursing The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 22 care and support. The moving of the office will mean that staff will find it easier to observe people in the lounge and dining area, due to its location. We sent surveys to people who live at the home and their relatives and asked them whether staff were available when they needed them, majority indicated that they were usually available. Information supplied by the Registered Manager prior to our visit told us that 30 of care staff has attained a National Vocational Qualification (NVQ) in Care, with a further 23 working towards the award. Training records showed that a number of staff have received training on a variety of topics during the first three months of the year, as referred to health and personal care. Information supplied within the self-assessment tool, completed by the Registered Manager told us that there is a robust recruitment and selection policy for staff, which is supported by structured induction and training. Surveys we sent to staff confirmed that they had undergone a robust recruitment practice, which included attending an interview, the obtaining of two written references and having a Criminal Record Bureau (CRB) disclosure obtained prior to commencing work. We looked at two staff files, and found them to contain all necessary pre-employment checks, along with confirmation as to the persons identity. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 23 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of The Willows Care Centre encourages and includes people who live at the home and their relatives to share their views to ensure that the home is run in the best interests of people who receive a service. EVIDENCE: The Registered Manager of The Willows Care Centre, Irene Chand, has worked at the home for fourteen months; she is a qualified nurse and has a qualification in management. The Registered Manager has a clear understanding of the home, and has worked to improve the service the home provides. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 24 The information supplied within the self-assessment tool (AQAA) was clear and contained relevant information, which included identifying areas for continued improvement. Throughout the day we saw people who live at the home, staff and visiting professionals speak with the Registered Manager along with other members of the Management Team, including nursing staff, all were able to deal with queries well, including the questions we raised. We spoke with several visitors who gave mixed views about the effectiveness of communication between staff and relatives, we found that there are opportunities for people who live at the home, and their relatives and friends to discuss issues, which was confirmed by people we spoke with. Quality Assurance questionnaires have been distributed to people who live at the home, to establish their views about the care and the service they receive, these have been sent to Head Office for collation. Meetings are regularly held with heads of department, in the home, as well as meetings with members of staff. We sent surveys to staff and asked them whether they receive support from a manager, a majority said that they regularly receive support, one person wrote I do meet up with my Manager and discuss how I am working and if there are any problems. Information provided by the Registered Manager in the AQAA prior to our visit detailed the regular maintenance of equipment and systems in the home, including health and electrical systems along with fire fighting equipment and systems. We looked at training records and found that staff have received training linked with health and safety, training included fire safety, food hygiene, COSHH and health and safety. The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 25 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP7 Good Practice Recommendations Care plans include the preferred daily routines of people, for example what time they prefer to get up and go to bed, and where they choose to spend their time. Care plans to include the frequency that people who live at the home would like to receive a bath or shower, which should be monitored to ensure peoples wishes and expectations are met. Staffing levels for both nursing and care staff are reviewed, to ensure that the needs continued to be met, and that there is adequate supervision. 3 OP27 The Willows Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Care Centre DS0000001935.V374767.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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