Inspection on 08/03/04 for The Willows Intermediate Care Service

Care Home For Older PeopleWillows, The Resource CentreAmbergate Road Beechdale Estate Nottingham NG8 3GDAnnounced Inspection8th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment The Willows Resource Centre Address Ambergate Road, Beechdale Estate, Nottingham, NG8 3GD Email Address Name of registered provider(s)/Company (if applicable) Nottingham City Council Name of registered manager (if applicable) Mr Stephen Upton Type of registration Care Home No. of places registered (if applicable) 16 Tel No: 0115 915 5555 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (16) Registration number C030000542 Date First registered 23rd April 2003 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 23rd April 2003 NO NO 29/12/03 If Yes Refer to Part CWillows, The Resource CentrePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 38th March 2004 10:00 am Wendy BowlerID Code75217Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Stephen Upton the time of inspectionWillows, The Resource CentrePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementWillows, The Resource CentrePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of The Willows Resource Centre. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Willows, The Resource CentrePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Willows is fully devoted to the provision of Intermediate Care. Personal care and accommodation are offered to 16 residents over the age of 50. The length of stay varies, with 6 weeks being the average. It is owned by Nottingham City Council Social Services and runs in partnership with Nottingham Health Authority. The Willows Resource Centre is a multi-functional complex situated in a residential area that has a high proportion of elderly residents. Within easy access is a range of community facilities including a church, shops and a community centre. The Willows offers a range of facilities to people 50 years old and over. The home also supports a warden system between the hours of 7.0am and 10.0pm. The community can also access laundry and bathing services from The Willows. The day centre operates 365 days a year and has places for up to 20 people Monday ­ Friday and 16 at weekends. This is due to be extended during 2004, to accommodate 40 people. The Willows also operates an older persons information service that is open to the general public between 9am and 5pm weekdays. The residential unit was opened in the 1970s and consists of a 2-storey building, (only the ground floor is used for service users) with all 16 single bedrooms now being devoted to the provision of Intermediate Care. The bedrooms do not meet National Minimum Standards size requirements but are all well furnished and comfortable. Each room has a hand washbasin and there are amply bathrooms and toilets throughout the building. The garden consists of an inner courtyard, which is receiving attention to enable service users to access in a safe manner.Willows, The Resource CentrePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Willows, The Resource CentrePage 6 This inspection took place over 1 day in March 2004. It found many of the National Minimum Standards had been met and that the overall quality of care offered was good. Residents spoken with during the inspection expressed great satisfaction with the care and the rehabilitation they were receiving. All were very positive about the support given to enable them to return home. Choice of Home (Standards 1-6) 5 of the 6 standards assessed were met. All aspects of pre admission assessments are undertaken by the discharging hospital, having established The Willows can meet rehabilitation goals. The multi disciplinary assessments continue during the service users stay at The Willows. All service users receive copies of the Welcome Pack which clearly details all they can expect from their stay at The Willows. Health and Personal Care (Standards 7-11 4 of the 5 standards assessed were met. All service users are involved in their `goal planning This process identifies all areas requiring support to enable service users to return home. The emphasis is on rehabilitation to maintain independence in as many areas as possible. Without exception, service users were very positive about all aspects of their care. Daily Life and Social Activities (Standards12-15) 3 of the 4 standards assessed were met. Daily routines and activities tend to revolve around the individuals identified goals. Service users are involved in all aspect of their rehabilitation. There was general appreciation about the quality of the meals. Complaints and Protection (Standards16-18) 1 of the 1 standards assessed were met. As part of induction and ongoing training, all staff have an understanding of protection issues. Nottingham City Social Services has policies and procedures for dealing with any incidents and staff demonstrated knowledge of these procedures. Environment (Standards 19-26) 3 of the 6 standards assessed were met. At the time of this inspection, much work was ongoing to improve the facilities in the laundry, shower room and courtyards ­ as identified in previous inspection reports. These improvements will enable Standards 25 & 26 to be met. The manager will inform National Care Standards Commission when this wok is completed. Staffing (Standards27-30) 2 of the 2 standards assessed were met. Staffing levels indicate sufficient staff to fully meet service users needs. A multi-disciplinary teamwork effectively to provide individual `goal planned rehabilitation. Management and Administration (Standards31-38) 3 of the 4 standards assessed were met. Management and general administration of the home is of a good standard with records up to date and accurate. However, the Operations manager must ensure that he is familiar with all the requirements of Regulation 26 and that reports reflect these requirements with the data provided corresponding with the records in the home.Willows, The Resource CentrePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action The building work associated with the following requirements was being undertaken at the time of the inspection: 1 16(2)(j)(k) 4(a)(b) OP26 To comply with hygiene standards, the registered person must install hand-washing facilities in the laundry room. The `open laundry must also be made safe by means of partitioning to avoid cross infection and any unnecessary health risk to either service users or staff. 2 23(2)(o) 3 13(4)(a)(b) (c) 4 13(4)(a) OP21 OP25 OP19 The registered person must ensure that the courtyard grounds are safe and appropriately maintained for the use of service users. To ensure the safety of service users and staff, the registered person must ensure that the heating system is `fit for purpose and that all radiators are suitably controlled and guarded. The registered person must ensure that the slip hazard identified in the ground floor shower room is rectified without further delay. Action Plan: The registered manager to inform National Care Standards Commission when the work is completed. Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented Willows, The Resource Centre Page 8 No.Refer to StandardGood Practice RecommendationsCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Willows, The Resource CentrePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The Operations manager must be familiar with these regulatory requirements, with monthly reports reflecting service users, relatives and staff views, alongside accurate data corresponding with that held in the home.126(3)(4)(a) (b)(c)OP37Immediate223(2)(p)OP25The registered manager must inform National 31st March Care Standards Commission when the work 2004 to enclose / make safe radiators is completed. The registered manager must inform the National Care Standards Commission when the work to make safe the laundry and shower room is completed. The registered manager must inform National Care Standards Commission when the external courtyard work is completed. 31st March 2004323(2)(k)OP26423(2)(b)OP1931st March 2004RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard *Willows, The Resource CentrePage 10 1OP21There is a long walk to the nearest toilet for some service users on one bedroom corridor. The identified extra toilet would support service users independence and in some cases, avoid the need for commodes in bedrooms. The registered manager should consider re-designating this toilet from staff to service users use.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Willows, The Resource CentrePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES YES YES YES YES YES NO YES NO YES YES YES YES NO YES NO YES NO YES 8 2 0 NO YES YES YES 21 X 08/03/04 10.0 4.5Willows, The Resource CentrePage 12 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Willows, The Resource CentrePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) X To (£) XAny charges for extrasYESIf yes, please state what the extras are: Hairdressing, toiletries etc. 3 Key findings/Evidence Standard met? The Willows now has a comprehensive Welcome Pack, which is available in all service users bedrooms. It is written in a user-friendly way, with service users confirming their knowledge of the document. Service users make no financial contribution as the services is NHS financially sourced.Willows, The Resource CentrePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Terms and conditions are included in the Welcome Pack. The financial details relating to the individual is dealt with centrally by the placing agency and Nottingham City Social Services.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? As Intermediate Care is the only provision wothin the residential part of the complex, service users tend to be admitted to The Willows via the main hospitals. If an admission is deemed appropriate, the discharging hospital completes initial assessments and faxes through to the `Gold Line (Social Work Team) for a decision as to which specialist unit is appropriate. Those service users destined for The Willows then have this assessment faxed directly to the unit. Multi disciplinary assessments and `goals are then actioned. (see Standard 7) The manager stated that in the main, this system now works well, with staff working well as a team. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? As stated in previous reports, The Willows is a specialist multi­disciplinary unit. A holistic approach is taken to meet each individuals needs. Nurses, physiotherapists, occupational therapists and rehabilitation assistants all work as a team. Staff spoken with demonstrated the full extent of the services used to meet all assessed goals. These professional services operate both within the complex and in the wider community on discharge, with some staff working in both environments.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 9 Key findings/Evidence Standard met? Not appropriate to this unit as service users tend to be discharged directly from hospitals.Willows, The Resource CentrePage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 3 Key findings/Evidence Standard met? The Willows is now a designated Intermediate Care Centre and is run as a joint project by Nottingham City Social Services and Nottingham Health Authority. The unit is well equipped to meet all the necessary rehabilitation requirements. The home has 2 rehabilitation kitchens and a range of small adaptations that can facilitate independence and be used by the individual on return home.Willows, The Resource CentrePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? Service users needs are recorded on Goal Plans formulated from multi disciplinary assessments. Each identified need has a `goal plan with a full description of the processes required to enable the goal to be met. Service users are involved with every stage of this process. Professional nurses, occupational therapists and physiotherapists formulate the goals, in consultation with the service users. Rehabilitation assistants support service users in `working towards the set goals. Weekly reviews are held, with all progress and changes well recorded. The whole process was observed to be working well with staff demonstrating good teamwork skills. Service users spoken with were very complimentary about all aspects of their care and treatment. Recommend: It would be good practice to record the reasons why some service users require extended stays at The Willows. This would enable staff to have a recorded tracking system and ensure service users are kept informed of future time scales.Willows, The Resource CentrePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)11 03 Key findings/Evidence Standard met? All aspects of service users health are assessed as part of the initial assessment. As with other aspects of rehabilitation, there are specific `goals in relation to medication and the promotion of independence wherever this can be achieved in a safe manner. All the information is clearly recorded and, alongside other areas of care, is reviewed weekly. Service users spoken with all confirmed the quality of the care they received. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? Nottingham City Council - Social Services has policies and procedures relating to the administration of medication, which all agencies involved at The Willows adhere to. Within this specialist unit all service users are assessed and the administration of medicines is individually determined, within the policy guidelines. The overall intention being to maintain individual independence skills with a view to service users returning home and self- managing as appropriate. Within The Willows, all staff dealing with medication have received training. All the bedrooms all have lockable facilities for the safe storage of personal medication as appropriate. Service users spoken with all confirmed their knowledge of the medication regime and understood the rationale behind the policy.Willows, The Resource CentrePage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The service users spoken with, without exception, had nothing but praise for the care and rehabilitation they were receiving. Staff were observed to be sensitive towards service users, working as a team to support the individuals `goals. All service users confirmed that personal care was carried out in an appropriate manner in their own bedrooms or the bathrooms. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? Nottingham City Social Services has policies and procedures relating to this standard. Not assessed on this inspection.Willows, The Resource CentrePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? For all service users the daily pattern tends to revolve around the assessment process. Service users spend time on planned rehabilitation activities and in the latter stages of their stay on home assessment visits. Residents spoken with accepted that this was the routine and were willing to participate in order to facilitate their speedy return home. Again there was much positive comments on the staff delivering the rehabilitation. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? Visitors present at the time of the inspection confirmed the `open door visiting policy. The stated they are always made to feel welcome and again shared positive comments about all the services offered by the staff at The Willows.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Not assessed on this inspection.Willows, The Resource CentrePage 20 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Menus are rotated on a 5 weekly basis, with choices offered at each meal. Specialist diets are catered for on an individual basis. The cook is currently trialling a new protein substitute, which is receiving positive comments from service users requiring soft diets. The kitchens, though old, are in good condition and well organised. All the required daily temperatures checks are recorded, cleaning rotas in place and all the dry stock rotated on a weekly basis. Service users were very positive about the choice, quality and quantity of the food. Fresh fruit is available along with snacks and drinks throughout the day.Willows, The Resource CentrePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence Not assessed on this inspection. 0 0 0 0 0 0 100 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 9 Key findings/Evidence Standard met? Service users do not hold permanent residency status at The Willows; therefore this standard does not apply.Willows, The Resource CentrePage 22 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? Nottingham City Council Social Services have policies and procedures relating to the protection of vulnerable adults. All health and social services staff receive training in this area of care, with regular updates. It is part of the induction training programme and continues as part of subsequent NVQ and ongoing staff development training.Willows, The Resource CentrePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is well located for its purpose. There is easy access to a range of local shops, pubs and community facilities. It is generally well maintained, clean and homely. Bedroom sizes do not meet the National Minimum Standards requirements but are in good decorative order. There are two enclosed courtyards, which are currently being upgraded to offer further rehabilitation and communal spaces during better weather. The external CCTV does not intrude on the daily lives of service users. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 9 Key findings/Evidence Standard met? This standard does not apply to The Willows.Willows, The Resource CentrePage 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? There are three showers or bathing facilities, one shower room has a walk in shower. This room is currently being upgraded to meet with health and safety requirements identified in previous reports. An infrequently used staff toilet at the end of one of the residential corridors could be better used for service users. There is a long walk to the nearest toilet for some service users on this corridor and the extra toilet identified would support service users independence and in some cases, avoid the need for commodes in bedrooms.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 4 Key findings/Evidence Standard met? The services offered by The Willows require a full range of adaptations both fixed and personal. Full time occupational therapists are available for assessment, advice and guidance. The 2 rehabilitation kitchens are very well designed with a variety of cooking sources and domestic appliances. Service users are able to prepare meals in these kitchens. They are also used for service users dining areas, the main dining room being used by the service users from the day centre. Service users were observed having easy access throughout the building. There are alarm call facilities in all communal rooms and all bedrooms.Willows, The Resource CentrePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 16 0 0 0 0 0 16X X 0 0Key findings/Evidence Standard met? No changes to the physical layout of the bedroom since the first full inspection. Not assessed on this inspection.Willows, The Resource CentrePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The single bedrooms all have a hand washbasin. Different colour schemes are used to enhance personalisation of the rooms. The age of the building precludes bedroom sizes meeting the current National Minimum Standards requirements, however, they are `fit for purpose and comply with equipment requirements. Service users spoken with had no complaints about their personal accommodation. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 1 Key findings/Evidence Standard met? All the radiators have now been risk assessed. New radiator covers have been ordered and will be fitted on arrival. As an interim measure, the manager has clearly labelled radiators as being `hot and alerted both staff and service users. The manager will notify National Care Standards Commission when this safety work has been completed. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 1 Key findings/Evidence Standard met? All the identified hazards associated with the laundry were being resolved at the time if this inspection. A partition wall being erected to separate the laundry from an open corridor. Windows being installed to enclose the sluice sink area and to comply with regulations, a hand washing sink being installed. The manager will notify National Care Standards Commission when this work is completed.Willows, The Resource CentrePage 27 Willows, The Resource CentrePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 328.5 X X XX 21 53 Key findings/Evidence Standard met? The staffing ratios at The Willows reflect the complex needs of the service users. As a jointly funded unit there are professional staff from both health and social care employed. Staff spoken with felt there were always sufficient staff and duty and service users did not indicate any problems in this area of their care. Observations on the day of inspection observed a hard working multi-disciplinary team. Current staff vacancies cannot be advertised as they are being held for re-deployment of staff from closing homes within Nottingham City Social Services. Shifts are being covered by existing staff.Willows, The Resource CentrePage 29 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Not assessed on this inspection. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? All recruitment follows the Nottingham City Social Services policies and procedure and the applications are held and dealt with centrally. No agency staff are currently used at The Willows.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessed on this inspection.Willows, The Resource CentrePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The registered manager has NVQ 4 Care / HND Social Policy. He will be working towards the Registered managers Award during 2004. He is also an assessor for NVQ training. He has held many positions in care working up from care assistant posts in both the private and public sector. The manager does not have a Contact of Employment for his job at The Willows, despite having developed the service over the past 4 years. The Operations manager should resolve this situation as soon as possible. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not assessed on this inspection.Willows, The Resource CentrePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Not assessed on this inspection.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 9 Key findings/Evidence Standard met? As a Nottingham City Social Services establishment, this standard does not apply.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Not assessed on this inspection. Standard met? 0 X X XWillows, The Resource CentrePage 32 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Records evidenced all aspects of recruitment, induction, training and supervision follow the local authority policies and procedures. Staff supervision in undertaken on a line management structure and occur on a 4-6 weekly rotation. Records are maintained of all aspects of these staff activities.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The Operations Manager must familiarise himself with the requirements of Regulation 26. The reports submitted to National Care Standards Commission must include interviews reflecting the views of the service users, relatives and staff. He must also ensure that statistics submitted reflect the accurate records held in the home.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The pre inspection questionnaire and evidence tracked on the day of inspection demonstrated up to date and accurate records. All aspects of daily life at the Willows are well risk assessed and these assessments well recorded.Willows, The Resource CentrePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureWillows, The Resource CentrePage 34 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsN/ASignatureIt should be noted that all NCSC inspection reports are public documents.Willows, The Resource CentrePage 35 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 08/03/04 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWillows, The Resource CentrePage 36 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNOYESOther: enter details here Willows, The Resource CentrePage 37 E.3PROVIDERS AGREEMENTRegistered Persons statement of agreement/comments: Please complete the relevant section that applies. Stephen Upton / Andrew Lowe The Willows - Stephen Upton / Andrew Lowe E.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or Stephen Upton / Andrew Lowe The Willows - Stephen Upton / Andrew Lowe E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Willows, The Resource CentrePage 38 - 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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