Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 01/09/05 for The Willows Nursing Home

Also see our care home review for The Willows Nursing Home for more information

This inspection was carried out on 1st September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 and family members reported that the standards of care in the home were good and they were positive about staff attitudes to residents. Staff members were said to respond quickly to any request for assistance by residents. Similarly satisfaction with food provided in the home was high.

What has improved since the last inspection?

Repairs had been completed to a first floor bathroom, which had been damaged through a roof leak. The manager and staff members had undertaken training on adult protection.

What the care home could do better:

The home had a very high staff turnover and this had included turnover of catering staff. As a result there was a need to further update mandatory training although there was evidence that progress was being made. As at previous inspection there was no evidence of training on sensory impairment, although significant numbers of residents had hearing loss. The former activities organiser had left the home and her replacement had yet to take up the post. There was a clear programme of outings and activities for residents but some outings had been cancelled due to lack of supporters for residents. As the home had previously enjoyed an active programme of activities, work was required to re-instate activities to their previous level. Although the home provided questionnaires to residents and their families, the resulting surveys did not result in a report identifying the findings and there was no feedback to the people who completed the surveys.

CARE HOMES FOR OLDER PEOPLE The Willows Nursing Home 7 Norbriggs Road Woodthorpe, Maston Moor Chesterfield Derbyshire, S43 3BW Lead Inspector Eileen McHale Unannounced 1 September 2005 10:00 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 Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Willows Nursing Home Address 7 Norbriggs Road, Woodthorpe, Mastin Moor, Chesterfield, Derbyshire, S43 3BW 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) 01246 280539 01246 280799 Parkcare Homes Limited Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43 of places The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 PD (E) Physical disability for service users over 65 years of age. 2 The registration is subject to the completion of training in joint agency procedures for the protection of vulnerable adults within 3 months of registration. Date of last inspection 15/12/04 Brief Description of the Service: The Home is located in the village of Woodthorpe, near to Staveley where there are amenities such as a supermarket, church, post office and library. The Home offers single accommodation, some of which are en suite. There is a dining room, lounge and conservatory on the ground floor and a dining / lounge room on the first floor. There is access to the enclosed garden and car parking space is provided to the front of the building. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector sampled care files and was able to speak to two residents and family supporters for one resident as part of the case tracking process. In addition more informal discussion took place with 3 other residents and a visitor. Information was provided by the manager on staffing levels and staff training. A brief inspection of the premises took place. What the service does well: What has improved since the last inspection? Repairs had been completed to a first floor bathroom, which had been damaged through a roof leak. The manager and staff members had undertaken training on adult protection. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 6 What they could do better: 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 Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 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 Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 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) 3,6 The needs of service users and their preferences were identified. EVIDENCE: There was evidence in service users files of pre admission assessment information which included transfer information from other establishments where appropriate . On admission assessment information was collected which included, personal histories, assessment of activities of daily living and resident preferences. Assessment material included moving and handling information tissue viability assessments, nutritional assessments and risks of falls. The home did not provide intermediate care. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 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) 7,8,10 Residents needs were met promptly by staff. EVIDENCE: Three care plans were examined. All were found to be based upon the identified needs of service users including the assessed needs for assistance to carry out activities of daily living. Care plans addressed the needs for activities and the involvement of an activities organiser. Attention was paid within the care plan to moving and handling and where appropriate care and equipment required to maintain tissue viability. Records were maintained of visits by health care professionals, and referrals for health care services, including chiropody and optical services. From these records it was clear that action was taken to address identified health care needs. Residents confirmed that they were treated with respect and that staff working in the home responded quickly to their needs. Staff members were said to be very friendly and very nice. New residents identified services delivered by visiting professionals. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 10 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) 12,13,14,15 Residents are able to maintain good links with their family and social contacts as well as to exercise choices of routines. EVIDENCE: Since the last inspection, an activities organiser who had been well established in the home had left to take up other employment. Her replacement was due to start some 12 days after the inspection. The new activities organiser would be employed to work 5 days per week. Some residents could describe a range of outings and activities that they had been involved with. Residents who had been more recently were less aware of the range of activities available. It was noted that some arranged outings had been cancelled for lack of helpers. The manager noted that there had been difficulties in getting the active support of relatives in the provision of activities, entertainment and outings, but attention to this was also continuing. There was ample evidence at the time of the inspection that visitors came to the home regularly and this had also been the case at previous inspections. Visitors were positive about services in the home and the welcome extended to them. They confirmed that staff were very friendly and very nice. One staff member was particularly commended as being very good, with nothing too much trouble and offering a very quick response. These views were passed on to the manager. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 11 Residents spoken to identified instances where they exercised choice about their routines, contact with family and food. Staff were said to be responsive to their choices. There was evidence within care plans of nutritional assessments and nutritional needs were addressed. Residents confirmed that food offered in the home was very good and that alternatives were always available. One family confirmed that they brought in their own treats for the resident. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 12 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) 18 There was a commitment to increased training on adult protection in the home EVIDENCE: Since the last inspection there had been a change of registered manager in the home. She had booked to undertake training on adult protection organised by Derbyshire County Council. However certificated training on the protection of vulnerable adults had taken place in the home, provided by an external trainer. At the time of the inspection, the home’s administrator was on annual leave and financial issues were therefore not inspected. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 13 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) 19,26 The home has a programme of maintenance. EVIDENCE: The home was maintained to a clean standard and was in good order. Since the last inspection work to repair the first floor bathroom had been completed. This had been damaged by water ingress as a result of blocked guttering. The inspector pointed out to the manager that the re-growth of weeds and shrubs in the gutter suggested that the matter required further attention. The manager indicated that work on the external and internal building was on-going . She indicated that the upstairs lounge was due to be redecorated next. Windows in the home were restricted and exterior lighting was in place. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 14 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) 27,30 Work was underway to ensure staff training met standards in spite of high staff turnover. EVIDENCE: The rota seen at the time of the inspection demonstrated that the manager was supernumery on the rota. The rota provided for one nurse on duty at all times, with four or five care staff in the day and two or three at night. The home’s standard was 2 nurses and 5 carers in the day and 1 nurse and 3 carers at night. There were 39 residents accommodated at that time. The rota was examined for a period in August when significant numbers of staff were seen to take annual leave. The manager indicated that staff picked up extra shifts and agency staff were not used frequently. The home had experienced high staff turnover. In particular there had been recent staff turnover of catering staff and two new staff were due to start on the next week. The manager indicated that the home was not staffed to Residential Forum standards but to Craegmoor’s own internal standard. It was At the time of the inspection, 55 of care staff had completed or were registered for NVQ training. Some staff had undertaken NVQ3. The manager was undertaking the Registered Manager’s Award. The home’s induction and foundation Course was said by the manager to be to National Training organisation standards. The manager maintained full records of Statutory training which indicated that progress was being made to ensure that staff were received training to the correct frequency. It was note that the records for fire training were annual whereas the requirement of the Fire Officer was that staff working at night must undertake training twice a year. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 15 Recent additional training for nurse included venopuncture and male catheterisation. The home had appointed some overseas nurses and these were being supported to undertake training in ESOL (English for speakers of other languages) courses. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 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) EVIDENCE: These standards were not assessed on this occasion. On following up previous requirements ,it was note that although the views of service users had been surveyed ,coded and scored, no analysis had resulted from the surveys. No useable information appeared to have arisen as a result of the activity and there was no feedback to service users or their supporters. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 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. 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 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 x x 3 x x x x x x x x The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 18 yes 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 23(4)(d) Requirement The registered manager must ensure that staff members providing night care receive fire training twice per year as required by the Fire Officer. The results of service user surveys must be made available and a copy of the report provided to the Commission. This matter was first raised at inspection in 2003. Timescale for action 31 March 2006 2. 33 24(2) 31 December 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 8 12 27 27 30 Good Practice Recommendations The manager should ensure that staff have access to training on the needs of service users with sensory impairments. The manager should ensure that new residents have access to the range of activities available The manager should ensure that staffing levels in the home meet standards set by the Residential Forum. The manager should seek assistance from the provider in establishing staff retention measures. The manager should continue work to ensure that all staff C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 19 The Willows Nursing Home receive relevant mandatoriy training. The Willows Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT 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 Nursing Home C52 C02 S2092 The Willows V247480 010905 Stage 4.doc Version 1.40 Page 21 - 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!