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Inspection on 08/02/06 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 8th February 2006.

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

The Willows provides a good standard of accommodation that is comfortable and well maintained. Residents comments about the home were positive. Residents said staff provided good standards of care and were sympathetic and thoughtful.

What has improved since the last inspection?

The staffing position has stabilised and a training programme is underway, including fire safety training for night staff as required at the last inspection. Recommendations highlighted at the last inspection have been worked on, e.g. planned training for sensory impairment. Some maintenance has been done, including some drains which have been replaced.

What the care home could do better:

Feedback from quality assurance questionnaires has still not taken place, but the company has introduced a comprehensive quality assurance system which should address these issues. Some new emergency lights were needed, and some minor decoration is due, particularly in the upstairs corridor.

CARE HOMES FOR OLDER PEOPLE Willows, The Nursing Home 7 Norbriggs Road Woodthorpe Mastin Moor Chesterfield Derbyshire S43 3BW Lead Inspector Denise Bate Unannounced Inspection 8th February 2006 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willows, The Nursing Home Address 7 Norbriggs Road Woodthorpe Mastin Moor Chesterfield Derbyshire S43 3BW 01246 280539 01246 280799 the.willows@craegmoor.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Parkcare Homes Limited Helen Joan Hopkinson Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 PD (E) Physical disability for service users over 65 years of age. The registration is subject to the completion of training in joint agency procedures for the protection of vulnerable adults within 3 months of registration. 1st September 2005 Date of last inspection 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. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took approximately four hours. On the day of inspection there were 39 residents at the home, with an equal split between nursing and residential. Some of the inspection methods used included discussions with residents and the manager, and examining records including care plans, staff records, staff rotas, records of residents’ finances, health related records, and records relating to health and safety. Communal areas of the building and one bedroom was seen. This inspection followed up standards not covered at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Feedback from quality assurance questionnaires has still not taken place, but the company has introduced a comprehensive quality assurance system which should address these issues. Some new emergency lights were needed, and some minor decoration is due, particularly in the upstairs corridor. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 6 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. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 the following standard(s): No standards were inspected. EVIDENCE: Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 10 Care planning was clear and comprehensive with evidence of regular reviews, thus providing staff with the information they need to satisfactorily meet residents’ needs. EVIDENCE: Two care plans were examined. They were based upon the identified needs of service users including the assessed needs for assistance to carry out activities of daily living. These were detailed care plans and risk assessments with evidence that plans were reviewed regularly. 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. There was a communication sheet for relatives. Detailed daily logs were kept. Residents confirmed that they were treated with respect and dignity, and that staff working in the home responded quickly to their needs. There was evidence on one care plan that indicated that discussions regarding care had taken place with the resident, but there were no signatures from the resident or their advocate to indicate that the plans had Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 10 been formally discussed and agreed. The home carry out internal care planning audits. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 Activities are provided that generally suit the expressed preferences of residents. Most residents have regular visitors who are made welcome. This assists in contributing to a pleasant atmosphere and the overall quality of life for residents. EVIDENCE: Residents said there are some activities that caterer for their interests. The manager said that sometimes residents were not very motivated to join in activities and the activities organiser is working to improve the range of activities available. The activities organiser is doing some Age Concern based training to provide extra guidance. There is a board displaying future events. The home hope to revitalise the ‘Friends of the Willows’ group. It is the Inspectors view that feedback from resident/relatives questionnaires may assist in this process. The home now have access to a minibus which can be used for outings. Some residents have relatives who visit daily and are made to feel welcome. Residents described their daily routines, and it was clear that, as far as possible, they had a choice over their day to day routines. Some residents are very frail, and staff were observed dealing with day to day needs in an appropriate and kindly way. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 the following standard(s): 16 There are policies and procedures in the home to ensure that residents had confidence in the home’s ability to deal effectively with complaints. EVIDENCE: The home had a formal complaints procedure. Although awareness of the formal procedure was not high amongst the residents spoken to, all said that they would discuss any matters of concern with the manager or staff and felt confident they would be dealt with appropriately. The complaints book had no recent complaints, and no complaints had been received by CSCI in relation to the home. Although this standard was not formally assessed it was noted that the manager is waiting to attend Protection of Vulnerable Adult training with Derbyshire County Council. A study day has been booked in February 2006 for care and nursing staff on the protection of vulnerable adults. The home had a copy of Derbyshire’s Multidisciplinary Procedures for the Protection of Vulnerable Adults. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 the following standard(s): 19 The home is generally well maintained and comfortable. EVIDENCE: Communal areas seen were comfortable and homely. Residents like their bedrooms, some of which have pleasant views, and feel the home has good standards of cleanliness. There is a programme of routine maintenance and work has recently been done to improve the drainage system. Some minor decoration is needed, particularly in the upstairs corridor. One handrail needs sanding and revarnishing. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Residents are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs, with a clear plan in place for mandatory training. EVIDENCE: The organisation provides detailed policies and procedures on all aspects of the employment of staff. Staff files were seen and contained appropriate personal information (application forms, references) including evidence of CRB checks and POVA First checks having taken place. The home have achieved the Investors in People Award. Staff turnover has stabilised and staff are keen to undertake training. There is a clear plan for ensuring that mandatory training takes place. Records are kept on the computer for ease of access, as well as on staff records. A training day had been arranged for staff dealing with matters relating to sensory awareness. Over 50 of staff either have, or are undertaking, NVQ qualifications. The manager is doing her registered managers award. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 36, 38 There has been no formal feedback from the quality assurance questionnaires. There is a system in place to safeguard residents’ financial interests. Effective procedures are in place to ensure that staff are appropriately managed and supervised, in turn protecting service users health and safety. EVIDENCE: As identified at the last inspection, 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. The organisation has now introduced a system of quality assurance, which introduces new policies and gives guidance to managers on matters relating to these issues. The policies and procedures are detailed and informative and when implemented should fully meet this standard. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 16 The home have a system for recording residents’ personal monies, including a safe place for valuables, records of monies received and paid out, and double signatures for payments into residents ‘accounts’. The paper system is backed up by a computer system and monthly statements are issued to residents or their representatives. Care plans seen covered information relating to residents’ finances. Regular supervision takes place, and the home have recently introduced a policy to cover supervision for all staff, not just nursing and care staff. The home takes a responsible attitude towards health and safety and the home have a good administrative system for recording matters relating to health and safety. A fire training session was due to take place the following week, and fire safety records seen indicated that checks are made at the appropriate intervals. Fire extinguishers have been serviced. Safety checks indicated that 5 emergency lights may need to be replaced/updated. The electrical hard wiring certificate dated 7.4.03 indicated that some work needed to be carried out, but it was not clear from the records whether this had been done. There is a designated member of staff who deals with issues relating to the environment and who carries out appropriate tests, e.g. hot water testing. The organisation has a central system for organising routine maintenance. A selection of records were looked at and found to be in date, e.g. for hoists, lift, etc. The home has carried out environmental risk assessments, which are clear and well presented and in the process of being updated. The home has recently carried out a safety audit and have identified a number of areas to be prioritised, e.g. the garden area. It has been identified that the ramp from the living room to the conservatory needs replacing. The Environmental Health Officer had been in January 2006 and identified two matters, which were attended to in the appropriate timescale. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 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 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 X 3 X 3 Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 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 OP33 Regulation 24(2) Requirement The results of service user surveys must be made available and a copy of the report provided to the Commission. (Previous timescale 31/12/05) Safety checks indicated that 5 emergency lights may need to be replaced or updated. Checks must be made with Fire Officer to ensure that emergency lights are fit for purpose. The electrical hard wiring certificate dated 7.4.03 indicated that some work needed to be carried out. Confirmation must be given that this work has been done. Timescale for action 31/03/06 2 OP38 23 (4) (b) 31/03/06 3 OP38 23 (2) (b) 31/03/06 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 OP7 Good Practice Recommendations The home should make arrangements for residents or their DS0000002092.V279083.R01.S.doc Version 5.1 Page 19 Willows, The Nursing Home 2 OP19 advocates to sign care planning documentation. The ramp from the living room to the conservatory should be replaced. Willows, The Nursing Home DS0000002092.V279083.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Derbyshire Area Office 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. 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