Inspection on 17/11/05 for The Willows Care Centre

This inspection was carried out on 17th November 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 16/01/08

The Willows Care Centre 04/07/06

The Willows Care Centre 12/01/06

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 Mrs Caroline Roberts Unannounced Inspection 17th November 2005 1.45 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.V267496.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 DS0000065320.V267496.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Willows Care Centre Address Heathercroft Great Linford Milton Keynes Buckinghamshire MK14 5EG 01908 607613 01908 395232 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) Excel Care Holdings plc Ms Jacqueline Ann Blease 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.V267496.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 (four) Step-up beds on the nursing unit The person(s) registered must satisfy themselves that the home can meet the care needs of any person admitted prior to said person`s admission. That the home is registered to provide Nursing Care for 30 (thirty) service users. N/A 2. Date of last inspection Brief Description of the Service: The Willows care home is a residential home with nursing that is registered to accommodate 116 residents over the age of 65 years. Categories of registration include: Dementia care 43 Frail elderly 43 Nursing 30 The home is situated in the Great Linford area of Milton Keynes close to shops and transport links to the city centre. The building is set over three floors and has two shaft lifts to enable resident’s access to upper floors. All rooms are single with ensuite facilities; the home has ample communal space. CCTV is provided in the entrance area. Ample car parking facilities are available. Excelcare runs the home and the responsible individual is Mrs Diane Jay. The home has two managers Ms Jackie Blease registered general manager, and Mrs Tracey Davies care manager. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Each care home that is registered with the Commission for Social Care Inspection, receives one announced and one unannounced inspection each year and further additional visits as necessary. All inspections, both announced and unannounced are followed by a written report, which eventually become public documents. It is a requirement that inspection reports are made available within the home. This inspection was unannounced and took place on the 17th November over a three-hour period. The inspectors present were Mrs Caroline Roberts (lead inspector) and Mr Guy Horwood. The focus of the inspection was to consult with residents following the transfer from two homes, which have closed. The homes care planning process was reviewed. A second visit was undertaken on the 23rd November alongside the fire safety officer Tony Bennett to view the home and discuss fire safety issues. This visit was an advisory visit and a full inspection from the fire authority will take place at a later date. This was a very positive unannounced inspection. The inspectors found a relaxed informal atmosphere in the home. Residents consulted expressed satisfaction with the care provided. The staff impressed as motivated and knowledgeable. The inspectors met and discussed the inspection findings with both of the managers and the regional manager before leaving. This inspection has resulted in four requirements being served. The inspectors found staff polite, helpful and welcoming, and would like to thank them for their co-operation and assistance throughout the course of the inspection. The inspectors would especially like to thank the residents for their time and for allowing the inspectors into their home. What the service does well: The home has a well trained and motivated staff team whom the residents described as being kind and caring. The home only opened on the 31st October 2005, the providers have overstaffed the home to ensure the safety of residents during the transfer. At the time of the inspection the home had 3 managers: • Ms Jackie Blease (registered general manager) • Mrs Tracey Davies (care manager registration pending) • Mrs Tracey Shepherd (manager from another home) This has helped during what has been a difficult and busy period; all of the managers were present on the day of the inspection. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 6 The home provides a good standard of personal care and promotes and respects individual’s rights, privacy and independence. Residents spoke highly of the staff and comments included: “The staff are wonderfully kind” “My bedroom is lovely” “Its very different, but I am sure I will get used to it” “I am glad I still know some of the staff” A number of visitors were noted in the home during the inspection, one commented on being made feel welcome. The home is clean and free from any offensive odours. What has improved since the last inspection? What they could do better: The manager needs to ensure that care plan reviews are reflective of change and do not just become a paper exercise. The external clinical waste bins need to be locked, also the manager needs to ensure enough bins are supplied to eliminate the need for overflowing bins. Clear designated roles and responsibilities of the managers need to be clarified and fed back to the staff team. The manager needs to ensure that the maintenance team understand the need for vigilance in ensuring tools; chemicals and other items, which could potentially harm residents, are not left unattended. Self closure devices are to be fitted on to bedroom doors, if the resident wishes to have the door open, wedges are not to be used this includes propping chairs against the door. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 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 Willows Care Centre DS0000065320.V267496.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 DS0000065320.V267496.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): 1,3,4,5 The Willows has a Statement of Purpose and Service User Guide, which is available to all relevant persons to view. Prospective residents have a comprehensive pre-admission assessment undertaken prior to admission to the home. The Willows is able to meet the range of needs of persons cared for in the home. Pre-admission visits are encouraged. EVIDENCE: A statement of Purpose and Service user guide were presented at point of registration. Both documents provide a clear description of the services offered. Pre-admission assessments are conducted by one of the homes managers. A detailed assessment is formulated according to the prospective residents needs. This information then aids the home to decide if it can meet the needs of the potential resident. Immediately after admission an assessment of need is carried out and detailed, evidence of this was available for one resident who had moved into the home on the day of inspection. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 10 The Willows provides care to a range of residents, all of whom have different needs. The inspection showed that the home were able to meet the range of needs presented by persons cared for in the home. Some residents told the inspectors that they had been able to visit the home prior to moving in. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Individual care plans identify and set out how the resident’s health personal, and social needs are to be met. However the manager needs to ensure the review process is reflective of residents individual changes in health, personal and social needs and does not just become a paper exercise. EVIDENCE: The inspectors viewed a sample of four residents care plans; three of these residents were also spoken with. The assessment following admission was comprehensive within three of the care plans and was based on identified needs following risk assessments. The care plans provided detailed information on the resident’s abilities and the level of support they need and this would suggest that resident’s independence is promoted. The fourth care plan was from a resident who had transferred from The Green, this care plan did not reflect the current health care needs, and although this had been signed as reviewed with no change and audited, this care plan did not detail the needs of the resident, with specific attention to tissue viability. Care plans contained: Needs assessments Moving and Handling assessments Risk assessments The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 12 Nutritional screening Tissue viability assessments Daily Reports Medical intervention progress notes The care plans viewed were from the nursing floor only during this visit, due to the size of the home three inspectors will conduct the next inspection and a random selection of care plans will be examined from all of the groups. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: Not assessed during this inspection. The Willows Care Centre DS0000065320.V267496.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): EVIDENCE: Not assessed during this inspection. The Willows Care Centre DS0000065320.V267496.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): 19,21,23,25 Residents live in a comfortable clean environment that is well maintained and safe. Residents bedrooms are made personal by the resident’s own belongings, are decorated pleasingly and are furnished to a good standard. EVIDENCE: The Willows is a new purpose built care home located on a residential estate in Milton Keynes. The home has 116 bedrooms all with en-suite facilities; the home has been built with group living in mind and has five groups: • 1 nursing unit • 2 Specialist dementia care units • 2 residential units The inspectors had the opportunity to tour the home during this inspection, but due to the size of the home did not view all areas but focused their attention on the areas already occupied by residents. All of the bedrooms are pleasantly decorated; furnishings and flooring are of a good specification. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 16 Each group has a large communal lounge and there are adjacent kitchen/dining areas, which are well equipped. Disabled bathing facilities are provided in large communal bathrooms on each group. It was noted that the bath hoist in one of the bathrooms on the nursing unit had not been commissioned yet and was in pieces on the floor. The manager informed the inspectors that this was in hand and would be fully operational within a couple of weeks. As another disabled bathing facility is available on this unit and the nursing unit was only a quarter full a requirement will not be made however, the manager is asked to inform the inspector once this bath hoist is fully operational. Each bedroom is fitted with an en-suite facility that consists of a walk in shower, toilet and hand wash basin. Floors are non slip but washable and the walls are tiled. Communal toilets are situated within close proximity to all of the lounges. All areas of the home are fitted with wall-mounted radiators that are fitted with an integral thermostatic valve. Hot water outlets are fitted with thermostatic valves. Emergency lighting, smoke and heat detectors are fitted throughout the home. All windows that are situated above ground floor are fitted with restrictors to reduce the potential risks to residents. The communal areas of the home have tiled floors, it was commented on by a staff member that residents some times slip when trying to rise from the chair. A number of regulation 37 notifications have been received relating to falls, which have resulted in fractures however, upon investigation this does not relate to the lounge areas. The manager has been asked to monitor this situation, and take remedial action if needed. All areas of the home in use at the time of the visit were clean and tidy, there were no unpleasant odours noted. It was noted however, that due to the building being so new in some area dust and building plaster still needed clearing away, the inspectors are aware that in such a new building this is to be expected however, the manager needs to ensure that this is all cleaned prior to residents moving into these areas. Clinical waste was found to be in yellow bags on the floor in some of the ensuite bathrooms, staff said they are awaiting small bins the manager confirmed these have been ordered, this will be monitored at the next inspection. The storage external to the building of clinical waste was found to be overflowing with the clinical waste bins unlocked. (Requirement made). Refer to standard 38. The Willows Care Centre DS0000065320.V267496.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): 30 Residents are supported by sufficient numbers of suitably trained and skilled Care staff ensuring the needs of residents are met at all times. EVIDENCE: At the time of the inspection the home was well staffed, with additional management and administrational staff in place to help during the initial opening period. Staff spoken with were enthusiastic about the new home and displayed a caring approach towards the residents. The inspectors had the opportunity to speak with (Pam) senior staff member on the nursing unit who explained to the inspectors clearly and precisely the needs of the residents on the nursing unit as well as showing the inspectors around that group. The inspectors were both impressed with this individuals knowledge and clear commitment to providing high quality care. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 18 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): 31,38 The General Manager has the necessary skills and training for her role, to ensure practice in the Home is in the best interest of residents. The manager takes the Health, Safety and Welfare of residents very seriously, unfortunately some of the issues identified do present as a potential risk, and therefore residents are not always protected by the homes procedures. EVIDENCE: It is planned that this home will have two registered managers; at the time of the inspection Ms Jackie Blease holds the position of registered general manager, and Mrs Tracey Davies holds the position of care manager (registration pending). On the day of the inspection the inspectors had the opportunity to speak with Ms Blease alone, who was able to clearly demonstrate effective leadership qualities. Due to the fact that this home has The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 19 recently opened the three managers are operating an on call system for out of hour contacts. It was clear that both of the homes managers have designated responsibilities however, greater clarity of these roles is required, this in turn will then need to be fed back to the homes staff team. During the tour of the building it was noted that the homes maintenance persons had left a cupboard unlocked and open, within this area was tools, and decorating chemicals it was explained to the maintenance person on site that this presents as a hazard to the Health, Safety and welfare of residents and must remain locked, this was undertaken at once. It was very disappointing to note that on the second visit undertaken on the 23rd November 2005 this area was still to be found unlocked and open. (Requirement made) A number of bedroom doors had been wedged open; staff confirmed that this was due to the residents not liking the doors closed. A requirement is made that suitable approved hold open devices are fitted in consultation with the fire officer. The manager acted proactively and contacted the fire officer Tony Bennett who visited the home on the 23rd November 2005 along with the inspector to discuss fire safety and the fitting of hold open devices. Findings from this visit include: A clear route of escape is to be maintained within the laundry room to the external fire door. An intumescent strip is to be fitted to Heather 2 lounge door. Heather Lounge door 1 does not close fully on to its recess, this needs adjusting. (Requirements will be served on the above issues) The storage external to the building of clinical waste was found to be overflowing with the clinical waste bins unlocked. (Requirement made). The home has service agreements in place for: Boilers Lifts Hoists Electrical equipment Contractual arrangements are also in place for clinical waste. The Health and Safety policies and procedures were not fully assessed during this inspection A more thorough check of Health & Safety systems and maintenance records will be assessed at the next inspection. The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 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 X 17 X 18 X 3 X 3 X 3 X 3 X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 21 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 2 3 4 Standard OP38 OP38 OP38 OP38 Regulation 23.4(b) 23.4(a,c) 23.4(a,c) 16.2(k) Requirement A clear means of escape is to be maintained within the laundry area to the external fire door. Heather 1 lounge door needs adjusting to ensure that it closes fully onto its recess. An intumescent strip is to be fitted to Heather 2 Lounge door. The manager is to ensure that suitable arrangements for the storage and disposal of clinical waste are adopted and maintained. Timescale for action 01/12/05 01/12/05 01/12/05 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Willows Care Centre DS0000065320.V267496.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000065320.V267496.R01.S.doc Version 5.0 Page 23 - 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!