Inspection on 10/07/09 for The Willows Care Centre

This inspection was carried out on 10th July 2009.

CQC 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 01/04/09

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Willows Care Centre 14 The Lant Shepshed Loughborough Leicestershire LE12 9PD Lead Inspector Mrs Carole Burgess Key Unannounced Inspection 10th July 2009 09:30 DS0000001935.V376455.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Willows Care Centre DS0000001935.V376455.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 Vacant 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.V376455.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) may be admitted to the home when 25 persons of these categories/combined categories are already accommodated within the home. 1st April 2009 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 residential and nursing 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 and Residents’ Guide are provided for all perspective and new residents (these provide information on how the home is organised and what services they provide). 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 individual care needs. There are some additional costs for individual expenditure such as hairdressing, newspapers etc. The Willows Care Centre DS0000001935.V376455.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 stars. 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). Any 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 the previous Inspection Report, and any information we have received since that time. The home had a Key Unannounced Inspection on 1st April 2009. However, in response to continued concerns the Local Authority (LA) and Primary Care Trust (PCT), that included four safeguarding incidents, and relating to a number of people receiving nursing care, we made a further Key Unannounced Inspection on 10th July 2009 that focused specifically on Care Planning, Complaints, Staffing and Management for persons receiving nursing care. No concerns were identified regarding those people who receive residential care. The unannounced site visit commenced on the 10th July 2009 and took place between 09:30 and 17:00. The focus of the inspection was based upon the outcomes for people who receive nursing care. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of nursing care needs and looking at how these were being met by the staff of The Willows Care Centre. We focused on those people with nursing care needs that had been identified to us by the LA. 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 or the staff, the Manager, and members of the senior management team. NB. Please read this report in conjunction with the report date 1st April 2009. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 6 What the service does well: As identified during the inspection 1st April 2009: People who are considering moving into The Willows Care Centre have the opportunity to visit before moving in, and individuals can be confident that their needs can be met when they move into the home. A comprehensive assessment of a person’s 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. We found that everyone who lives at home has a care plan that details the care and support they need, and 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. The home was managing four safeguarding referrals well, and has acted upon the advice and guidance made by CQC, and health and social care professionals, to address the issues raised, and has responded to complaints in a timely manner. Interventions for potential healthcare emergencies were well documented in the care plans. On the 10th July 2009 we found the home was clean and pleasant and had a bright and friendly atmosphere. Staff were observed to interact well with the people who live at The Willows Care centre and were helpful toward visitors. What has improved since the last inspection? The home has responded and addressed all of the requirements and recommendation made at the last Key Inspection in April 2009 and the Pharmacist Inspection in May 2009. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Willows Care Centre DS0000001935.V376455.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.V376455.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This outcome was inspected on 1st April 2009 and it was judged that: 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. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.& 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are clear and detailed and insure that 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 six people who required nursing care. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 11 We found care plans and risk assessments to be comprehensive. They provided nurses and carers with detailed information about the health and personal care needs of the people who live at The Willows Care Centre. The Project Manager told us that the organisation to which The Willows Care Centre is part, is reviewing the format of documentation, including care plans, which would enable peoples’ preferences to be more clearly recorded to support Person Centred Care. All of the care plans seen had been regularly reviewed, revised and updated. They included people’s personal preferences such as bathing/showering times and frequencies as required following the inspection April 2009. We specifically reviewed the care plans of six people who received nursing care in relation to National Minimum Standards for Care Homes for Older People and in relation to those issues identified by the LA and PCT. We looked at concerns raised by an unidentified relative who noted that staff were unavailable to take someone to the bathroom when requested. However, this was not followed up as the persons involved could not be identified. Another relative reported that carers were not answering a specific ‘nurse call’ bell in an adjacent room. In a similar incident two people had raised a concern about their relative having to wait to be taken to the bathroom. The relatives and person concerned were spoken with and said that this had happened on one only occasion. They were unaware that this was at the time when staff were dealing with an emergency. The individual and her relatives said that better communication would have ameliorated the situation. This was discussed with the Manager, who had investigated the complaint, and acknowledged that there was a lack of information and poor communication between staff and the person involved and this could leave people feeling as if they had been forgotten. The staff involved, including domestic staff, were reminded of their responsibilities regarding good communication and that they all must work as a team to ensure that people are provide with a good standard of care. We looked at a similar situation with someone calling to go to the bathroom and not being taken on request. The care plan was reviewed and it was noted that this person wore continence pads day and night. The Manager said that there was a regime to take the person to the toilet every few hours but this had not been documented in the care plan. The Manager said that this person asked for the toilet every hour or so but often changed her mind when she got there. It was also noted that the person constantly called out for the toilet, requiring constant attention and at times could be verbally aggressive to staff. Appropriate psychiatric help and advice had been obtained. However, the care plan should reflect any continence care provided and reassurance should be given to the individual, and to any visitors/onlookers who observe someone The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 12 who apparently needs the toilet but is not taken. It was also discussed that appropriate diversion activities should be arranged to provide a distraction for repetitive behaviours which may help to improve that person’s daily life. We observed that, throughout the day of the site visit, call bells were answered promptly and those people who were reviewed and were bed-bound had call bells within easy reach so that those people who were able could call for attention when needed. We also discussed this with a visitor who spent most afternoons in the lounge. She said that staff were friendly and helpful and always came promptly when called. We reviewed the care plans of those people where the LA & PCT had concerns: An identified person’s care plan reviewed showed that there was a detailed care plan and risk assessments in place that included risk assessment for bedrails, pressure care management etc, and a good plan of care to identify that the person was at risk of choking. This included advice for carers that when feeding to - sit the person up, give them time to swallow, if there were any signs of choking to inform a senior carer, provide small frequent meals and complete monthly weights. A nutritional assessment had been undertaken and monthly weights recorded: the person had been referred to the dietician 21/04/09. However, the person had lost weight over the following month: On 24/05/09 weighed 39.4kgs and on 13/06/09 weighed 37.1kg. Although the care plan noted the weight loss and stated ‘offer more drinks and food; it did not detail what further actions had or should be taken to ensure that the person’s nutritional wellbeing was maintained. This was discussed with the Area Manager who agreed that the necessary actions, interventions and outcomes had not, on this occasion, been adequately recorded and that she would follow it up with appropriate action. We looked at a second person with weight loss between November 2008 45.7kgs and 30th April 2009 – 39.6 kgs did not appear to have had any specific action taken until the end of April 2009. However, since that time they had been referred to the Speech and Language Therapist (SALT) team, placed on a nutritional and fluid balance chart, provided with Fortisip supplement drinks and thickened fluids and were weighed fortnightly to ensure their weight remained stable, which it had. We spoke with a person identified as not having received showers as frequently as he wished. He said that this had been a ‘one off’ and all of his basic, personal care needs were met (also see notes under Complaints and protection). The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 13 We reviewed a request that had been made by the LA & PCT that a person’s individual care plan and fluid management was updated and reflected any refusal of fluids. We attended a review meeting with the providers, LA, PCT and the person’s relative. The managers had worked hard and produced a detailed and explicit care plan that addressed, in detail, the persons specific care need, particularly in relation to food and fluid intake. A nutritional assessment had been completed 20/06/09 which determined that the person was ‘high risk’. As the persons appetite was poor five small meals a day were offered, and carers were to return and try again after half an hour if food had been refused on the first occasion. Supplements were prescribed and given. The dietician was present and provided advice and support that was included in the care plan. All of the relative’s suggestions were added to the care plan. The person’s weights were recorded every two weeks and were stable, although there was a ‘blip’ in the middle of June showing a weight gain from *48.2kgs at the beginning of the month to about 48.5kgs, dropping back to 46.7kgs. It was also agreed that carers would record if the person refused to wear their dentures as this could affect their dietary intake. Additional care plans for personal care, continence and catheter care were equally detailed to ensure that all of the person’s care needs and preferences were met. The person’s daughter stated that her mother ‘was doing really well at the moment’ and the LA and PCT appeared satisfied with the progress made. We discussed a concern raised by a relative that staff were unaware of how to use a particular wheelchair. The Manager stated that this was a new wheelchair and staff did need to look at information about the controls, which she would expect them to do. There had been a lap belt in place but it appears to have been undone. There were concerns that this person who had slipped in the wheelchair and staff had lifted her under the arms instead of using a hoist in the accepted way. The Manager stated that the underarm lift was done in response to the emergency to stop the person slipping to the floor. Staff had refuted any wrong doing. Nevertheless, the Manger had arranged for the carers involved to undertake full Moving and Handling training to ensure that they were aware of the correct moving and handling procedures in the future. There were concerns about the person having a pressure ulcer on her heel. On the day of inspection the nurse-in-charge said that the Tissue Viability Nurse had visited and that the ulcer had healed. There were pressure care, mouth care and fluid balance charts in the room and these were completed to date. * New ‘sit on’ scales were purchased in March 2009 The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 14 We checked the care plans of all of the people ‘case tracked’ and found them to be satisfactory and in most instances very detailed. People who were diabetic had detailed diabetic care plans which also described how to recognise a diabetic emergency and what nurses and cares should do. All of the fluid and pressure care charts that were in the rooms of the people who were ‘case tracked’ were complete and accurate at the time they were reviewed to ensure that peoples’ care needs had been met. Care plans had been signed and agreed with the individual and/or their representatives to show that people were involved in and agreed with their personal plan of care. Contact with healthcare professionals such as GP’s, District Nurses, hospitals and Podiatrists were recorded to ensure that healthcare needs and treatments were addressed. Medication policies and procedures were satisfactory. Requirements and recommendation from the Medication Inspection dated 1st May 2009 had been implemented. For people who receive residential care, their medication was administered by a senior member of care staff, who had received recent 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. Medication trolleys and the medication cupboards and fridge were locked and secure when not in use. This safe practice ensures that people receive their medication safely and as prescribed. Observation during the inspection showed that staff had a good awareness of how to protect peoples’ privacy and dignity and staff spoke to everyone in a respectful, friendly, quiet and helpful way. Four residents, and three relatives, spoken with during the inspection said that staff were caring, although two relatives said that they thought that there should be more staff. One person said that all of his basic, personal care needs were met but he would like more activities. However, further investigation of his care plan and photographs on display in the home showed that the person did take part in many of the home’s organised activities and outings. Two other people said that liked the home and felt well cared for. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This outcome was inspected on 1st April 2009 and it was judged that: 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. The Willows Care Centre DS0000001935.V376455.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of 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 advocacy services, 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. The Complaints Procedure was displayed on the notice board in the entrance foyer, and was also contained within information documents given to people when they move into the home. Information regarding advocacy services was available so that people who live at The Willows Care Centre or their relatives can access independent support and advice if required. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 17 We reviewed the home’s complaints file and noted that since the last key Inspection in April 2009 the home had received seven concerns/complaints all of which had been investigated and dealt with in a professional manner. At the time of the inspection visit we had not received any complaints from the general public since the previous inspection. We were aware of four safeguarding alerts, whereby four people who lived at The Willows Care Centre, were considered to be at risk by the LA and PCT. We have attended several meetings along with representatives of the service, LA and PCT to discuss these issues. These persons provided the focus for our inspection. All but one of the people who were subject to safeguarding procedures were unable to give their opinions about the care they received. Those people who were spoken with, both people who lived at The Willows (and four relatives) said that they were aware of how to complain but had no complaints and said that they were well cared for. One person, subject to safeguarding regarding lack of personal care choices/times, said that all his basic care needs such as regular showers/baths had been met. His personal preferences were detailed in his plan of care. However, on one occasion he had had to wait a number of hours for a shower as he required three carers to undertake the task. Three people were not available at the allotted time, but and had not been told this so assumed that he had been forgotten. Staff should make every effort to keep people informed when there are unforeseen delays in preferred care routine to provide so that people do not become distressed. The Willows Care Centre DS0000001935.V376455.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This outcome was inspected on 1st April 2009 and it was judged that: The Willows Care Centre provides a comfortable and homely environment, which is well maintained. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are well trained and sufficient in number to meet the needs of the people who currently live at The Willows Care Centre. EVIDENCE: We wanted to find out whether there were sufficient staff on duty to meet the needs of the forty–three people living at The Willows Care Centre on the day of the inspection visit, seventeen of which required nursing care. There were ten staff on duty during the day, which include two Nurses and a senior carer. The staff were 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 there were two Nurses on duty, with three care staff. The number of staff on duty was the same as that noted when we undertook a Key Inspection on the 1st April 2009. There were additional ancillary staff – cooks, maintenance and housekeeping personal. The Manager The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 20 said that she had recruited another Nurse and was awaiting her Criminal Records Bureau (CRB) check, and she felt that she had sufficient staff to meet the assessed needs of the people in her care. The management do employ agency staff on occasions to cover emergency shortfalls to ensure that staffing levels remain appropriate to meet peoples’ needs. The nursing office had been moved close to the main entrance so that staff now found it easier to observe people in the lounge and dining area. It was noted that during the inspection there were always staff available in the lounge area and call bells were answered promptly and people were not observed to be left unattended when they required a member of staff. It had been raised as a concern by the LA that some staff had not been using correct Moving and Handling procedures. This was discussed with the Manager. She stated that this was in relation to an emergency incident when two carers had stopped a lady slipping out of her wheelchair (see Health and Personal Care). However, in response to the concerns the Manager, who had two ‘in house’ Moving and Handling trainers, had arranged that all staff should have Moving and Handling updated training, commencing the following week, so that she could be confident that all staff knew how to move people safely. Standard 29 was inspected on 1st April 2009 and it was judged that: Staff have undergone a robust recruitment process. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager, who is fairly new in post, provides a good standard of leadership for staff and 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 the care. EVIDENCE: The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 22 The Providers have appointed a new manager who works in a supervisory and management role in addition to the nursing and care staff numbers. The new manager is in the process of applying for registration with the CQC, which ensures that she has the necessary skills and is ‘fit’ to manage a care home. The area manager and two project managers were supporting the manager to enable and assist her in the revision of care plans which meet the criteria and approval of the LA and PCT. Throughout the day we saw people who live at the home, staff and visiting professionals speak with the Manager and other members of the Management Team. All were able to deal with queries well and were positive and helpful in their approach. We spoke with several visitors who gave mostly positive views about the effectiveness of communication between staff and relatives; we found that there were opportunities for people who live at the home, and their relatives and friends to discuss issues, which was confirmed by people spoken with. Information provided by the previous Registered Manager in the AQAA prior to the inspection visit in April 2009 detailed the regular maintenance of equipment and systems in the home, including health and electrical systems along with fire fighting equipment and systems. Other areas of management such as Quality Assurance were reviewed during the Key Inspection 1st April 2009 and found to be satisfactory. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X 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 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 24 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 OP8 Regulation 13 (1) Requirement Care plans must show what actions are being taken to address a person’s weight loss, and where necessary that appropriate and timely professional advice is sought and acted upon. To ensure that peoples’ optimum nutritional status is maintained. Timescale for action 10/10/09 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 OP7 Good Practice Recommendations Staff should make every effort to keep people informed when there may be delays in their preferred care routine due to unforeseen events. The care plan should reflect any continence care provided including toileting regimes to ensure that people have their DS0000001935.V376455.R01.S.doc Version 5.2 Page 25 2 OP8 The Willows Care Centre continence care needs supported. The Willows Care Centre DS0000001935.V376455.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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