Inspection on 14/10/05 for The Willows Care Centre

This inspection was carried out on 14th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Willows Care Centre 14 The Lant Shepshed Leicestershire LE12 9PD Lead Inspector Mrs Gillian Adkin Unannounced Inspection 14th October 2005 10:00 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.V259741.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Willows Care Centre Address 14 The Lant Shepshed Leicestershire LE12 9PD 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) 01509 650559 01509 650362 the.willows@ashbourne.co.uk Exceler Healthcare Services Limited 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.V259741.R01.S.doc Version 5.0 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. Date of last inspection Brief Description of the Service: The Willows Care Centre is a purpose built home situated in the centre of Shepshed and within walking distance of the local amenities. The home is set in its own gardens with seating available for general use. Accommodation is provided on two floors accessible by a shaft lift. There is a large lounge/dining room on the ground floor and a number of smaller sitting rooms on both the ground and first floor. The home offers specialised bathing facilities, and aids and adaptations are fitted throughout the home. 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 Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one day and commenced at 10.00 am on 14/10/05.The inspection took 6 hours. The acting care manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of the accommodation occupied by those case tracked took place and the inspector viewed internal records, and care plans. The inspector spoke to residents, nurses, care and ancillary staff, No relatives were available during this inspection for comments. There were 42 service users accommodated at the time of this inspection of which 17 were residential and 25 nursing, most of whom had been assessed as having medium dependency needs. Comments were received from a number of residents including those selected for case tracking. Comments made by residents about the service were mostly positive. Typical comments included: “Staff ask my opinion and if I am satisfied” “I am aware that I have to stay in my room when the fire alarm goes off” “I have not seen my care plan but I am not bothered” “I think they are a bit short of staff particularly at night, it takes a long time for them to answer my bell” “Rooms are very comfortable and warm” “I like my own company and choose not to attend activities provided” The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The registered provider must only accommodate service users who fall within their registered categories and must ensure that the assessment procedure is sufficiently robust to prevent service users being admitted out of category and the home being unable to meet their needs. The outcomes for service users would be improved by the registered provider ensuring that induction of staff is in line with National Training Organisation specifications.and that a training needs analysis is undertaken to ensure that The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 7 training provision is appropriate to needs of service users accomodated and staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 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.V259741.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents have their needs assessed by the manager prior to moving into the home;where inadequate information is received from external sources this can result in inappropriate placement of individuals and needs not being met satisfactorily. EVIDENCE: Three service users were selected for case tracking. All of the care records inspected included relevant assessment information including risk assessments. Where applicable social worker assessments and care plans were in place. One service user tracked said, “He had an assessment by the acting care manager whilst in hospital” One assessment indicated that the service user might have been admitted to the home outside of the current categories of registration and an agreement was made by the acting care manager to bring forward a review of the placement with the funding authority to ensure that the service user was appropriately placed in the home. An agreement was also reached with the acting care manager that additional training of staff with responsibility for assessment of new service users may be required. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10 Resident’s health, personal and social care needs were being met. Safe medication administration procedures were in place, therefore risk was minimised. EVIDENCE: Care plans for three service users were inspected; these appeared to address most assessed needs. Care plans tracked were fully audited, however evaluation did not fully reflect of outcomes of care delivered. Assessments were in place for the risk of falls, continence, and nutrition and for developing pressure sores. Records were seen of GP and community nurse visits and input. Daily records and wound management plans were reflective of care given and outcomes. Personal choices were recorded in care plans and reflected during conversation with service users tracked. Administration records for the four case tracked residents were seen and appeared to be in good order. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 11 Discussion with staff demonstrated that they were fully aware of care needs and were kept up to date by trained staff at handovers. Two staff stated that if they needed to know anything they would look at the care plan. Concerns were raised with the acting care manager regarding the use of a sling used on a service user case tracked who had pressure sores. It was noted that the sling was permanently in place under the service user throughout the day for moving and handling procedures however no evidence was found in the care plan to indicate if this had been discussed with a tissue viability nurse and if their were any contra-indications to this with regard to the efficiency of the pressure cushion also being used. Staff indicated that this was common practise. Residents spoken with said that staff administered their medication accurately and on time. Residents indicated the staff treated them with respect and their privacy and dignity was maintained. One service user did indicate that call bell response times particularly at night were sometimes longer than usual. The inspector tested this in the room of a service user in bed, the call bell was answered in 7 minutes. Qualified nurses and trained care assistants administer medication; the acting manager assesses their competency, Medicines related to those service users tracked had been appropriately administered and records seen were well maintained. A registered nurse and a care assistant were observed undertaking the midday lunchtime drug round. Both staff informed the inspector that they had recently completed recent training with the contracted pharmacist. Trained staff have responsibility for monthly ordering of medicines. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Service users are satisfied by routines that enable them to maintain control and experience a lifestyle that matches their expectations and best interests. EVIDENCE: Two-service users case tracked were able to voice their opinions regarding the lifestyle they experienced in the home. Overall residents appeared to be happy and content with the systems and routines of the home. Residents indicated that staff were friendly and professional and that they had key workers to help with personal issues such as shopping etc. One service user said “staff are very good at meeting my needs” A long standing service user said” staff are very kind, I have never had to make a complaint and staff always ask me if I am satisfied” The activities programme is on display in the foyer this details weekly activities Two service users tracked voiced their opinions about activities and both indicated that they preferred not to take part. A news round session was in progress during this inspection and service users were invited to take part in discussions about current affairs. Discussions with additional service users regarding the current programme indicated that activities were varied and interesting. Photographs were seen of a recent harvest festival in the home. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 13 One service user confirmed they had opportunities to attend religious services in the home. A recommendation has been made to the acting care manager to assess the numbers of service users who are seated at the dining table in wheelchairs to ascertain if this is personal choice as this was not indicated in any of the care plans tracked. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 core standard 18 was inspected during the last inspection. The home has a complaints procedure that is available to all service users and visitors to the home. The registered providers respond to complaints in a robust and professional manner. EVIDENCE: Discussions with a number of service users including two of the three tracked indicated that all were aware of how to make a complaint. One service user confirmed that she had never had to make a complaint but would speak with Caroline, Janet or Glenda. (staff) The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.26. Both core standards were inspected during the last inspection. Service users live in a comfortable, homely and satisfactorily maintained environment. Insufficient attention to routine maintenance and repairs may possibly result in the premises falling into disrepair and failing to meet the Statement of Purpose and more seriously putting service users at potential risk of harm or injury. EVIDENCE: The accommodation of those service users tracked was inspected and appeared to be comfortable, homely and satisfactorily maintained. Communal areas were clean and tidy. It was noted that some bedroom carpeting has` been replaced however carpeting in the main corridor was in need of cleaning this was discussed with the acting care manager who agreed to action. Immediately. A service user was informed by the cleaner that their carpet had been cleaned during the inspection. Service users who smoke may use the smoke room provided, one service user was noted to be in this room after lunch The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 16 Overall furniture and fixtures were in satisfactory condition and discussion with the acting care manager regarding the replacement of divan beds indicated that a rolling programme of replacement was due to commence. The acting care manager said that it was expected that more appropriate nursing type beds would replace divans. Observation of maintenance records demonstrated that a number of regular checks including water temperatures and fire records were out of date and had not been appropriately maintained. Discussion with the acting care manager demonstrated that this had been due to the maintenance position being currently vacant and issues with the previous employee. An agreement was made with the acting care manager that routine maintenance checks would be brought up to date immediately following the inspection by a maintenance person from another Ashbourne Home. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.29 A thorough recruitment and induction process and sufficient numbers of suitably skilled and trained staff ensures that the needs of service users are usually met. EVIDENCE: The duty roster for the week in which this inspection took place was inspected. At the time of this inspection 42 service users with medium dependency needs were living in the home. Rosters seen and a calculation of staff hours indicated that the home were meeting the recommended minimum staffing hours. One qualified nurse is on duty on both the day shift and night shift, there were seven care staff on duty during the morning, and in the afternoon/evening and three care assistants at night. The acting manager is supernumerary and the residential manager has one half-day supernumerary day per week. Discussions with the acting care manager indicated that the home have experienced some recent recruitment problems in relation to care and ancillary staff but have maintained full staffing despite under occupancy. The registered provider is commended for this. Call bells appeared to be answered in a reasonable time during this inspection. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 18 Discussions with two service users tracked indicated that in the main care needs are attended to in a timely manner however night time is an area of concern. This was discussed with the manager who will monitor. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32.33.35.38. EVIDENCE: The home is currently managed by and acting manager who is a qualified nurse and has many years management experience. An application has been made to the Commission for Social Care Inspection to register her formally. Staff spoken with felt supported by the management team and confirmed that staff meetings are regularly held. Discussions with service users tracked indicated that staff seek their views` and opinions and service users stated that they enjoyed the residents meetings. Other service users stated that they discuss issues with Caroline the activities organiser. The manager said that she routinely walks about the home to chat to residents and give them the opportunity to express views. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 20 The manager said that there were plans in place to implement a newsletter and possibly an annual survey. Discussions with the acting care manager/senior administrator took place regarding the management of service user finances and it was evidenced that an internal non -profit making system is in place where service users may deposit money. Records seen were appropriately managed and service users who were involved stated that money was available to them Monday to Friday. Policies and Procedures require that money held is reconciled two weekly. The service user guide was seen this document details roles and responsibilities regarding storage of money and valuables but does not detail management of risk associated with service users who wish to keep money or cards etc on their person. Observation of the premises and inspection of internal records demonstrated that although the home was overall satisfactorily maintained, basic routine maintenance was not being undertaken and /or satisfactorily recorded including water temperature checks and fire records. Water temperatures were last recorded In June 2005 and were registered between 39 degrees C and 41 degrees C therefore not putting service users at risk, but being below recommended temperatures (43 degrees C) The acting care manager said that this was due to recruitment issues and that the registered provider intended to send an independent maintenance person into the home after the inspection to bring maintenance and records up to date. All staff spoken with had received (or were due to receive) manual handling training during induction; moving and handling practises were observed and appeared to be safe. Staff and service users appeared to be aware of fire procedure. The acting care manager stated that two sessions had been arranged to bring staff’s mandatory training up to date, these included Moving and handling, Fire and Food hygiene. The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 X X 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 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? 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 OP30 Regulation 18 Timescale for action All staff must receive appropriate 30/11/05 induction and foundation training in line with National Training Organisation specifications. (Not met from previous inspection) The registered provider may only 14/10/05 accommodate service users who fall within their registered categories. The registered provider must 30/11/05 ensure that suitable arrangements are made to complete routine maintenance checks and complete documentation. The registered provider must 30/11/05 ensure that staff are provided with fire training at least annually and fire drills at least quarterly. Requirement 2 OP3 14 3 OP19 13.23. 4 OP30 18(1)C(1) The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP7 Good Practice Recommendations Care plan evaluation must be reflective of outcomes of care delivered. It is recommended that staff with responsibility for administration of medicines be given the opportunity to have a copy of the current medicines policy for reference. Where it is assessed that a service user requires a sling to be left in place permanently during the day for transfers, and where the service user is at risk of tissue damage it is recommended that advice is sought from an appropropriate professional source to ascertain the effect that this may have on the pressure relief given by a pressure relieving cushion. It is recommended that a permanent maintenance person be appointed to manage day-to-day maintenance issues. It is recommended that Records relating to the management of service user finances, including the service user guide and Terms and Conditions fully detail the roles and responsibilities relating to persons who wish to keep money on their person. It is recommended that the assessment procedure for new admissions is strengthened and that staff with responsibility for assessment are trained and competent in undertaking this procedure. It is recommended that an annual survey be undertaken to obtain service user /relatives and others views about the service. 4 5 OP27 OP37 6 OP30 7 OP33 The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows Care Centre DS0000001935.V259741.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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