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Inspection on 04/04/05 for The Willows Care Centre

Also see our care home review for The Willows Care Centre for more information

This inspection was carried out on 4th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users spoke very highly of the relationship they shared with staff members. Staff spoken with were clearly committed to providing a good service and to improving quality of life for service users. Staff work hard to ensure that a variety of social and recreational activities are on offer and that service users are given the opportunity to take part in social activities outside of the home. Service users with high dependency needs appeared comfortable and well cared for at the time of this inspection. All areas of the home seen appeared comfortable, well maintained and homely. Service users spoke highly of the standard of meals provided. Catering staff work hard to meet the individual needs of service users. The registered providers respond positively and swiftly to complaints and work hard to resolve any problems.

What has improved since the last inspection?

Since the last inspection management procedures have improved and this is reflected in a clear improvement in the quality of care provided. Staff feel better supported by the management team and report a great improvement in the management style and provision of equipment and resources.

CARE HOMES FOR OLDER PEOPLE The Willows Care Centre 14 The Lant Shepshed Leicestershire LE12 9PD Lead Inspector Debbie Williams Unannounced 4 April 2005 10:00 am 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 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 C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service The Willows Care Centre Address 14 TheLant Shepshed Leicestershire LE12 9PD 01509 650559 01509 650362 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home 60 Old Age Physical disability Physical disability - over 65 Terminally ill 60 25 25 25 Category(ies) of OP registration, with number PD of places PD(E) TI(E) The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 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 29/10/04 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 Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection there have been four complaints made against the home regarding care practices, staffing and general management of the home. The registered providers have responded positively to these complaints and taken robust action to rectify any problems identified. This inspection was unannounced and took place over one day and was facilitated by the home’s acting manager. The inspector selected four service users and tracked the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Staff members were spoken with regarding training and support What the service does well: Service users spoke very highly of the relationship they shared with staff members. Staff spoken with were clearly committed to providing a good service and to improving quality of life for service users. Staff work hard to ensure that a variety of social and recreational activities are on offer and that service users are given the opportunity to take part in social activities outside of the home. Service users with high dependency needs appeared comfortable and well cared for at the time of this inspection. All areas of the home seen appeared comfortable, well maintained and homely. Service users spoke highly of the standard of meals provided. Catering staff work hard to meet the individual needs of service users. The registered providers respond positively and swiftly to complaints and work hard to resolve any problems. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 8 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 standard(s) 1, 2, 3 and 5. Service users are provided with the information required to make an informed decision about moving into the home. Assessment procedures ensure that service user needs are assessed. EVIDENCE: The inspector saw a copy of the home’s Statement of Purpose/Service Users guide. A copy of these is kept in a folder in every service users room. Service users spoken with confirmed they had received a copy of the home’s Statement of Purpose and terms and conditions and that the home’s acting manager had carried out an assessment of their needs prior to them moving into the home. The home’s acting manager said that all service users would be assessed before being admitted to the home. Assessment records were seen for four service users, these included risk assessments and social history/personal preferences. A four-week trial period is offered to all service users. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 9 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 standard(s) 7, 9 and 10. Service users care needs are identified and a plan of care is in place for staff to follow. Medication procedures appeared safe. Staff appeared to treat service user with respect and to maintain their privacy and dignity. EVIDENCE: Care plans for the four case tracked service users were inspected, these appeared comprehensive and to meet all assessed needs. The inspector was able to speak with two of the case tracked service users, both confirmed that staff treated them with respect and maintained their privacy and dignity. One service user said that all the staff are ‘very helpful and kind’. One service users said ‘you can have a laugh with all the staff’ and that staff members Clive, Jackie, Glenda and Caroline are very special and should be commended’. The inspector observed interactions between staff and service users and these appeared positive. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 10 Service users spoken with said that their medication is administered to them correctly and at the correct time. Medication administration records for the four case tracked service users were inspected, these appeared in good order. The home has medication policies and procedures. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 11 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 standard(s) 12, 13 and 15. Routines of daily living, social, religious and cultural needs are respected. Service users are enabled to maintain links with family and friends. A wholesome and nutritious diet is on offer and catering staff work hard to meet individual needs and preferences. The home’s ability to meet social, cultural and dietary needs at the time of this inspection was having a positive effect on the quality of life experienced by service users. EVIDENCE: An activities organiser is employed at the home. A schedule of activities on offer was seen on the home’s notice board. Service users spoken with confirmed that activities were in place to meet their needs, these included trips out, shopping, bingo and quizzes. Service users spoken with felt that routines of daily living were made flexible to meet their needs. Visitors are welcome at anytime and can be seen in private. Call bells are in place in all service user accommodation, service users said that staff usually respond to these promptly. One service user confirmed they had opportunities to attend religious services. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 12 Menu records were inspected, these appeared to offer a wholesome and nutritious diet with choice available. Service users spoke highly of the quality and quantity of food provided and confirmed a choice was always available. Supper is provided and snacks and drinks are available at all times. At the time of this inspection the home were also providing diabetic and soft diets. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 13 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 standard(s) 16 and 18. Robust policies and procedures for the protection of vulnerable adults were in place and appeared to be followed by the registered providers. Not all staff had received formal adult protection training. Service users were not afforded full vulnerable adult protection as a result of this. EVIDENCE: 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 thorough and professional manner. Adult protection and whistle blowing policies and procedures are in place. One staff member spoken with had not received any adult protection training but was aware of the correct procedures to follow in the event of suspected abuse. Records of staff training were seen and these included adult protection training, however, at the time of this inspection not all staff had attended. The acting manager was aware of and was taking steps to address this staff training shortfall. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 14 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 standard(s) 19 and 26. Service users were provided with a comfortable, homely and well maintained environment. EVIDENCE: The private accommodation of the four case tracked service users was inspected and appeared to be comfortable, homely and safe. A fire officer last visited the home October 2004. A fire risk assessment was in place. All areas of the home seen, appeared clean and hygienic. Infection control policies and procedures were in place. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The service was unable to fully demonstrate that the numbers and skill mix of staff were sufficient to meet service users needs. EVIDENCE: The staff duty roster for the week in which this inspection took place was inspected. Staffing levels appeared to be meeting requirements as set by previous regulatory authorities. Service users spoken with felt that staff were employed in sufficient numbers to meet their needs. The registered providers did not take service users dependency levels into account when planning staffing ratios. A recommendation was made regarding this. Staff training records were inspected. Training undertaken included fire, resident welfare, moving and handling, health and safety and food hygiene. Not all staff had attended this training. The acting manager said that a two day induction was provided to all new staff, this is followed by a six week induction programme which is compatible with National training Organisation specifications. One staff member spoken with confirmed that training and support was provided on an ongoing basis. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 and 34. Service users and staff benefit from the leadership and management approach of the home. EVIDENCE: The acting manager is a qualified nurse and has many years management experience. Staff spoken with felt supported by the management team and confirmed that staff meetings are regularly held. Resources appeared to be supplied in sufficient quantities to meet service users needs and to enable staff to do their jobs. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x 3 x x x x The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 18 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 30 Regulation 18 Timescale for action All staff must receive appropriate June 30th induction and foundation training 2005 in line with National Training Organasiation specifications. Requirement 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 27 Good Practice Recommendations It is recommended that service user dependancy levels are taken into account when planning staffing rosters. The Willows Care Centre C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 19 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire 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 C51 S1935 Willows Care Centre V218323 040405.doc Version 1.20 Page 20 - 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. 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