Inspection on 16/01/08 for The Willows Care Centre

This inspection was carried out on 16th January 2008.

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 04/07/06

The Willows Care Centre 12/01/06

The Willows Care Centre 17/11/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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 Heathercroft Great Linford Milton Keynes Buckinghamshire MK14 5EG Lead Inspector Christine Sidwell Unannounced Inspection 16th January 2008 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Willows Care Centre DS0000065320.V352879.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 DS0000065320.V352879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Care Centre Address Heathercroft Great Linford Milton Keynes Buckinghamshire MK14 5EG 01908 679505 01908 694309 jackie.blease@excelcareholdings.com 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) Willows Care Centre Ltd Ms Jacqueline Ann Blease Tracy Margaret Davis Care Home 116 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (43) of places The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4 (four) Step-down beds on the nursing unit That the home is registered to provide Nursing Care for 30 (thirty) service users. That the Registered Care Manager must commence the Registered Managers Award within 4 (four) months of registration. 4th July 2006 Date of last inspection Brief Description of the Service: The Willows Care Centre is purpose built and was completed in November 2005. The decoration and furnishings are of good quality and provide an attractive environment. The home is arranged on three floors, one floor is for frail elderly residents who need help with personal care, one is for residents who have dementia and the ground floor is for residents who require nursing care. There is a mixture of privately funded service users and service users funded by the local authority. All rooms are spacious and have en-suite facilities of a toilet, hand basin and shower. All floors have their own communal lounge and dining room. There are secure, well-maintained gardens with seating. The home is close to the centre of Milton Keynes, with a large shopping centre and other community facilities. The Willows Care Centre provides accommodation for up to 116 service users. The fees, at the time of the inspection, were in the range of £409 to £650 per week depending on the type of placement. Additional charges are made for services such as direct dial telephone, hairdressing and newspapers. The Willows Care Centre DS0000065320.V352879.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. The inspection was conducted over the course of five days and included a two day unannounced visit to the home. The key standards for older people’s services were covered. Information received about the home since the last inspection was taken into account in the planning of the visit. Prior to the visit, the manager completed an annual quality assurance self-assessment and surveys were distributed to service users, relatives, visiting health and social care professionals and staff. Fourteen residents or their families, four general practitioners, three healthcare professionals and eight staff members returned the questionnaires. Residents and families were also spoken to on the days of the unannounced visit. Discussions took place with the manager, nursing, care and ancillary staff. Care practice was observed. A tour of the premises and examination of some of the required records was also undertaken. The homes approach to equality and diversity was considered throughout. What the service does well: There is information available to potential residents and their care needs are identified with them, prior to their move to the home, to ensure that they can be met. Potential residents and their families are encouraged to visit the home before they move. A senior person visits all potential residents to assess their needs and to ensure that the home can met them. Residents’ personal, healthcare and medication needs are met, promoting their dignity and wellbeing. The care plans are comprehensive and appropriate risk assessments are undertaken. The residents spoken to said that the staff were kind and caring and that they were usually able to meet their needs in a timely manner. There are good medication support systems in the home. The home offers a flexible lifestyle, in line with resident’s expectations and abilities and supports their autonomy. The meals are of a high standard and meet resident’s nutritional and social expectations. There are innovative activities coordinators on each floor and a daily programme of activities is offered. Individual activity plans are developed for residents and people are encouraged to follow their own skills and hobbies. The food is of a good standard and residents are offered a choice and a menu that is varied. Resident’s religious and cultural needs are considered and met. Families and friends are made welcome. The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 6 The complaints and protection policies and procedures work well, giving residents and their family’s confidence that their concerns will be addressed and any safeguarding issues will be addressed. The Commission for Social Care Inspection is aware of three complaints, which have been made to the organisation, since the last inspection in July 2006 and which have been investigated in conjunction with the local authority. There have been five safeguarding referrals since the last inspection, which were appropriately reported and investigated under the local authorities safeguarding procedures. The home is purpose built, clean and well maintained providing a safe home for residents. Resident’s rooms are homely and they are encouraged to personalise them. The standards of infection control are high. There are sufficient staff, who have received relevant training to meet resident’s care needs. Residents said that staff were usually or always able to assist them when they needed help, although staff felt that they did not always have time to take people out or to sit with them for company. There is a variety of training available to staff to give them the knowledge and skills that they need. There are robust recruitment procedures in place and checks as to the suitability of staff are undertaken before they commence work. The home is well managed and there are quality assurance systems in place to ensure that residents receive a high standard of care and that their views are taken into account in the running of the home. Excelcare is an established provider of care services. The managers are experienced and there are quality assurance processes in place. Residents and family’s views are sought proactively. There are health and safety procedures in place and most staff have had training in safe working practices. The home works closely with the local authority. What has improved since the last inspection? What they could do better: No formal requirements have been made in this report. The following are recommendations to improve the quality of life and care for residents. Very frail residents on the dementia unit should have height adjustable beds if the majority of their care is given in bed, to minimise the risk of injury to them or the care staff. There is a need to ensure that staffing levels particularly on the top floor, residential and middle floor, dementia units are sufficient to enable residents to go outside for some fresh air or on an outing on a regular basis if they wish The Willows Care Centre DS0000065320.V352879.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 DS0000065320.V352879.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 DS0000065320.V352879.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, 2, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There is information available to potential residents and their care needs are identified with them, prior to their move to the home, to ensure that they can be met. EVIDENCE: The home has an up to date statement of purpose and service users’ guide. All but two of the residents, or families, who returned the questionnaire, said that they had received information about the home and two families spoken to said that they had been made welcome at the home and invited to look around before their family member moved to the home. The families also said that they understood that a trial period was possible. All residents who fund their own care have a contract and these were seen in their files. Residents who are supported by a local authority have a statement of their terms and conditions and there was evidence in the files that they or their families have a copy of the care manager’s assessment. Residents confirmed that someone had visited them to assess their needs before they moved to the home and copies of the assessment were seen in the files. Residents’ social and cultural needs The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 10 had not been identified at the initial assessment for all residents, although their religion had been identified. The manager said that the assessment documentation had been updated recently to prompt staff to consider the diverse needs of residents and their cultural and spiritual wishes in greater detail. This was seen in one of the more recent assessments. The manager also said in the annual quality assurance assessment that, as part of the home’s plans for improvement over the next year, they wished to produce a service user’s guide, which is audible and possibly a video to meet the needs of people with communication difficulties. The home does not offer intermediate care. The Willows Care Centre DS0000065320.V352879.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Resident’s personal, healthcare and medication needs are met, promoting their dignity and wellbeing. EVIDENCE: The care of eight residents in total, from the residential, dementia and nursing unit, was followed through. Their files contained comprehensive care plans and there was evidence in some files that both residents and families are involved in planning their care. The staff spoken to were knowledgeable about residents’ care wishes. The care plans had been reviewed regularly and updated when appropriate. The residents who returned the questionnaires and those spoken to on the day of the unannounced visit said that they were involved in planning their care and that the staff were responsive to their wishes. Residents in all units had had assistance with their personal hygiene. The hairdresser was in the home on the day of the unannounced visit and residents were enjoying a visit to the dedicated hairdressing salon in the home. The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 12 The risk of residents acquiring pressure damage due to immobility is assessed and appropriate equipment is made available. All residents on the nursing unit have height adjustable beds and specialist airflow mattresses where necessary. One resident on the dementia wing was nursed in bed due to extreme frailty. She did not have a height adjustable bed and although the bed was on risers, enabling the use of a hoist, the height could not be adjusted to facilitate care in bed. This should be addressed and where appropriate residents in the dementia unit should be provided with a height adjustable bed, if their care needs require it. The staff spoken to on the nursing wing said that they felt that they needed more specialist pressure relieving seat cushions. The manager confirmed that these are available. Continence assessments are undertaken and the Primary Care Trust, (PCT) provides appropriate aids. Nutritional risk assessments had been undertaken on all units. The staff and chef were aware of residents’ dietary needs and could provide special diets to meet residents’ health and cultural needs if necessary. The chef was aware of the need to provide some people who suffer from dementia with a high calorie diet. Residents are weighed regularly and those residents whose care was followed through had maintained their weight on moving to the home. There was evidence that falls assessments are undertaken and the advice of the local Primary Care Trust specialist falls prevention team is taken where necessary. Residents register with local general practitioners who visit the home weekly. Four general practitioners returned the questionnaires and all said that the home communicated clearly with him and that any specialist advice was incorporated into the resident’s care plan. One said that ‘the home has matured into a well run and caring home’. There are medication management policies and procedures in place and the staff spoken to were aware of these. Storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were accurately completed. Controlled drugs were stored satisfactorily and all entries to the controlled drug register were signed. A contract is held for the disposal of unused medication. The registered nurses spoken to said that medication was not administered covertly. If a resident refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make to the decision, the doctor and family would be informed and a way forward agreed. There is an incident reporting system in place and two medication errors had been notified to the home manager. She had taken appropriate action to ensure that the resident did not come to harm, their families were notified and the staff concerned were given additional training and their practice supervised for a period. None of the residents in the home were self-medicating at present although there is a policy to facilitate this if a resident wishes. All staff who assist residents with medication have had training to do so. The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 13 The staff were observed to be respectful towards residents and to protect their dignity. All care is given in residents’ rooms. The general practitioners and healthcare professionals said that they saw residents in their rooms. The staff on the dementia care unit were supportive of residents and all had been helped to maintain their personal hygiene and appearance to promote their dignity. They were able to walk around freely and staff were observed to monitoring their whereabouts in a discrete manner. The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home offers a flexible lifestyle, in line with resident’s expectations and abilities and supports their autonomy. The meals are of a high standard and meet resident’s nutritional and social expectations. EVIDENCE: There is an activities coordinator on each floor. They arrange a programme of activities, which run twice a day. The residents who chose to participate in the activities on the day of the unannounced visit were clearly enjoying themselves. The activities coordinators said that they undertake group activities and one to one activities with people in their own rooms if they wish. The home is a member of a national association, which promotes therapeutic activity in care homes and the coordinators said that they enjoyed this and that it gave them new ideas. There was a personalised approach to activities and residents were helped to undertake the activities that they wished. Residents who wished were involved in activities on each floor on the day of the unannounced visit. The residents spoken to said that they enjoyed the activities saying ‘it breaks up the day’, ‘I like the quizzes’. One gentleman on the nursing unit said he would dearly like to watch live football on the television, as he had been a life long fan, but unfortunately the home did not have access to the digital channels, which provided this. One resident said The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 15 that she ‘preferred to stay in her room and watch the television and read books saying ‘I am an avid reader’. There is a prayer room in the home and two of the residents spoken to said that were able to see the vicar. The organisation is implementing a structured sensory programme for people with dementia to help them communicate their needs and feel supported in a calm environment. Families and friends were seen to be coming and going throughout the day. Those spoken to said that they were always made welcome and all those who returned the questionnaires said that the home always or usually helped their relative to keep in touch with them. The residents spoken to said that the staff were polite and addressed them by the name that they preferred and that they had a choice as to how they spent their day. There is a varied menu and residents have the opportunity to influence the menu at residents meetings. A cooked breakfast is available and a choice of menu is available at the main meal and at supper. Food is freshly prepared and cakes were being prepared for afternoon tea on the day of the unannounced visit. The residents spoken to said that they enjoyed the meals and all the residents who returned the questionnaires said that they always or usually liked the food. There are additional snacks for people with dementia and finger food is available to ensure that those who lack the concentration to complete a full meal receive enough calories. The chef was knowledgeable about residents needs. One lady had special requirements to meet her cultural needs and was very particular about the food she ate and the way in which it was cooked and presented. The chef understood this and went to great lengths to meet her wishes. The dining rooms were well laid and mealtimes were observed to be a sociable occasion. The care staff were observed to be assisting those who required help discretely and sensitively. The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The complaints and protection policies and procedures work well, giving residents, and their families, confidence that their concerns will be addressed and any safeguarding issues will be addressed, in conjunction with the local authority. EVIDENCE: There are complaints policies and procedures in place. The home records complaints, both verbal and written, on a database. There were twenty-four complaints recorded since the last inspection in July 2006. All had been responded to within the timescales. All the residents who returned the questionnaires said that they knew who to speak to if they were unhappy. The residents spoken to said that they had never had to make a formal complaint and that if they were unhappy with any aspect of the service it would usually be dealt with immediately. The home is aware of the local multi agency strategy for safeguarding vulnerable adults. Most staff have now had safeguarding training and those spoken to said that they would have no hesitation in reporting any concerns about residents welfare. The Commission for Social Care Inspection is aware of three complaints, which have been made to the organisation, since the last inspection in July 2006 and which have been investigated in conjunction with the local authority. The information raised in these complaints was considered as part of the planning of this inspection. There have been five safeguarding referrals since the last inspection, which were appropriately reported and investigated under the local authorities safeguarding procedures. The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 17 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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home is purpose built, clean and well maintained providing a safe home for residents. EVIDENCE: The Willows Care Centre is a large home with three floors. There is a lift to each floor. The communal areas, i.e. entrance, corridors, dining rooms, lounges and conservatory are all tiled. One resident referred to visiting her friend ‘who was on the other ward’. The smooth flooring however did provide easier access for wheelchairs and other walking aids and there were no offensive odours in the home. The gardens are tidy and attractive and there are outside sitting areas. Residents’ rooms are carpeted and residents are encouraged to bring personal items of furniture, pictures, photographs and ornaments. Many had chosen to do so and were pleased to share their memories with staff. All rooms have The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 18 ensuite facilities and showers, which are adapted to meet the needs of those with disabilities. There are infection control policies and procedures in place, which have been updated in line with the Department of Health guidance issued in June 2006. Protective clothing is provided to staff. Residents who require a hoist have individual hoist slings and residents have individual sliding sheets. Alcohol hand rub is available at the entrance to each unit for staff and visitors. The home is participating in a project led by the local Primary Care Trust to audit and reduce the rate of urinary tract infections experienced by people who have catheters. This is good practice. The laundry is clean and well managed. It is situated away from the kitchen. There are washing machines with the appropriate sluicing cycles and a ‘red bag’ system is in place for soiled laundry to prevent cross infection. Residents’ clothes are washed, ironed and repaired regularly. The laundry team was aware of the importance of this in maintaining residents’ dignity and self esteem. The home was clean and tidy. There were no offensive odours. The Willows Care Centre DS0000065320.V352879.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There are sufficient staff, who have received relevant training to meet resident’s care needs. The recruitment procedures are robust and should protect residents from unsuitable carers. EVIDENCE: The homes staff are divided into teams and work on their individual floors to provide continuity for residents. There is a named nurse and key worker system in place to provide an element of continuity of care for individuals and a point of contact for relatives in what is a large home. The residents spoken to said that that staff were caring and could usually come to them when needed. They said that they were sometimes busy and that they may have to wait for assistance but not for long. They were appreciative of the care given saying ‘they are always so cheerful’, they are kind and I do not know what I would do without them’. One said ‘I would rather be at home but I cant so this is the next best thing’. One resident on the top floor said ‘I would like to get out a bit more, I would like some fresh air’. The staff said that in the summer they would be able to go with people to the garden although that would depend on staffing levels. The organisation should consider how best to help those residents who live in the residential unit on the top floor and wish to go outside for some fresh air, to do so. The Commission for Social Care Inspection had received a concern from a care manager to say that the staffing levels on the dementia unit may have been reduced. On the day of the unannounced visit, there were forty-three The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 20 residents in the two units. There were six carers and a team leader on duty in the unit in the morning and six carers and a team leader in the afternoon and evening, covering both units. The activities coordinator was working in one unit. All residents were up by mid morning and the staff appeared to be able to meet everyone’s care needs in a timely way. The staff spoken to said it was a quiet day and sometimes they had to prioritise the time they spent with residents. The open plan layout of the unit meant that most residents were in sight of a carer for most of the day. The carers were observed to be busy for most of the day and the time that they had to sit or walk with residents was limited. The staff also said that they sometimes went out in the garden in the summer but that would depend on staffing levels. Staffing levels should be monitored carefully to ensure that resident’s social as well as care needs can be met. The home has an active training programme. Newly appointed care staff commence a structured induction programme using the ‘Skills for Care’ accredited workbooks. Fifty-nine percent of care staff hold the National Vocational Qualifications in Care at Level 2. All staff receive a one day introduction to Dementia care and some staff have also undertaken a distance learning course to give them greater understanding of dementia. The training matrix and staff records showed that a wide range of training courses and study days are available to staff. The recruitment files of four recently recruited members of staff were reviewed. All had the required documentation to show that checks as to the potential staff member’s identity and suitability to work with vulnerable people had been undertaken. All had submitted an application from, which showed their work history. Interview records had been kept. Two references had been sought and Criminal Records Bureau checks had been undertaken before the staff member commenced work. There was evidence in the files seen that work permits had been obtained where necessary. There was also evidence in the files that equal opportunities monitoring is undertaken. The Willows Care Centre DS0000065320.V352879.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home is well managed and there are quality assurance systems in place to ensure that residents receive a good standard of care and that their views are taken into account in the running of the home. EVIDENCE: There is an experienced general and care manager in post. Both have registered with the Commission for Social Care Inspection. The general manager holds the National Vocation Qualifications in Management and Care at level 4. The care Manager is a registered nurse and also holds the National Vocational Qualifications in Management at level 4. The lines of accountability within the organisation are clear. The residents spoken to said that the management team were approachable and responsive to their requests. The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 22 The home has a quality assurance system in place. Regular resident, family and staff meetings are held. The organisation also undertakes an annual quality assurance survey, the results of which are collated and shared with residents, potential residents and other stakeholders on request. Complaints are also monitored to establish whether there are changes that can be made. A recent analysis has shown that there are higher levels of complaints from people who come to the home for respite care and an action plan to address this is being developed. Regular audit of processes takes place. Care plans, medication and recruitment files have been audited recently. The organisation monitors the quality of care by means of regular visits by a senior manager. Residents are spoken to and reports of these visits, with action points are kept. The home does not manage residents’ financial affairs. Safe storage can be provided in resident’s rooms if they wish to keep small amounts of money or valuables with them. There are health and safety policies and procedures in place. The information sent prior to the visit showed that service and maintenance records are up to date. Most staff have had moving and handling training, health and safety, food hygiene, infection control and fire safety training. The home have recognised that staff may not be up to date with their mandatory training in safe working practices and has plans to address this. Fire safety checks were up to date and regular fire drills are undertaken. The staff spoken to were aware of the fire evacuation procedures. The Willows Care Centre DS0000065320.V352879.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 3 3 3 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 4 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 X 3 X 3 X X 3 The Willows Care Centre DS0000065320.V352879.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. 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 Refer to Standard OP8 Good Practice Recommendations Very frail residents on the dementia unit should have height adjustable beds if the majority of their care is given in bed, to minimise the risk of injury to them or the care staff. Staffing levels particularly on the top floor, residential and middle floor, dementia units should be sufficient to enable residents to go outside for some fresh air or on an outing on a regular basis if they wish. 2 OP27 The Willows Care Centre DS0000065320.V352879.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT 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 DS0000065320.V352879.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!