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Inspection on 07/12/05 for The Willows Nursing & Residential Home

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

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

What has improved since the last inspection?

There were no requirements or recommendations made following the last inspection. The home is being refurbished in some areas with additional purchases such as new curtains and some new easy chairs for the residents. A new industrial washing machine has been purchased in the laundry with reorganisation of storage space.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE The Willows Nursing & Residential Home 105-107 Coventry Road Market Harborough Leicestershire LE16 9BX Lead Inspector Mrs C A Burgess Unannounced Inspection 7th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Willows Nursing & Residential Home Address 105-107 Coventry Road Market Harborough Leicestershire LE16 9BX 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) 01858 463177 01858 434772 Mr James Frederick Cooper Mrs Mary Violet Cooper, Mrs Jacqueline Marie Riddett, Mr John Frederick Cooper Mrs Jacqueline Marie Riddett Care Home 57 Category(ies) of Dementia (9), Dementia - over 65 years of age registration, with number (9), Mental disorder, excluding learning of places disability or dementia (9), Mental Disorder, excluding learning disability or dementia - over 65 years of age (9), Old age, not falling within any other category (57), Physical disability (36), Physical disability over 65 years of age (57), Sensory impairment (36), Sensory Impairment over 65 years of age (36), Terminally ill (36), Terminally ill over 65 years of age (36) The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers No person falling within categories MD, MD(E), DE, DE(E) may be admitted to the Home when 9 persons in total in these categories/combined categories are already accommodated within the Home No person falling in categories PD(E) & PD to be admitted to the Home when 57 persons of that category/combined categories are already accommodated in the home No one under the age of 55 falling within categories MD or DE may be admitted to the Home No person falling in categories PD may be admitted into the Home where there are 36 persons of category PD already accommodated within the home No person falling in categories SI(E) and SI to be admitted to the home when 36 persons of that category/combined categories are already accommodated No person falling in categories TI(E) & TI to be admitted to the Home when 36 persons of that category/combined categories are already accommodated Named person To be able to admit a named person under 55 years of age and falling within category LD named in variation application No. 58114 dated 13/11/03 10th June 2005 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: The Willows Nursing and Residential home is situated close to the centre of Market Harborough. The home is registered as a care home with nursing and can accommodate up to fifty-seven residents. There is a Registered Nurse on duty at all times. The property consists of two older buildings that have been linked by a new wing and stands within pleasant gardens. Accommodation is on two floors accessed by both passenger and stair lifts. There are four sitting rooms and one dining room, and bathrooms with assisted bathing facilities. The home is clean, well decorated and well maintained throughout. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through a review of their records, discussion with them, where possible, and observation of care practices. An opportunity was taken to look around the home, view records, policies and care plans and to talk to staff, residents and relatives. Many of the residents were seen during the inspection, and three residents and two residents’ relatives gave the Inspector their impressions of the home. What the service does well: What has improved since the last inspection? There were no requirements or recommendations made following the last inspection. The home is being refurbished in some areas with additional purchases such as new curtains and some new easy chairs for the residents. A new industrial washing machine has been purchased in the laundry with reorganisation of storage space. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 6 What they could do better: There are no requirements. The Responsible Person(s) are recommended to: • Ensure that all the details of residents’ care are recorded in their individual care plan and include significant events, interventions and outcomes, thereby providing a comprehensive and accessible overview of the care provided. It was noted that, in most cases, this information was available in other places and formats. Ensure that all employees are Criminal Record Bureau (CRB) checked at the point of employment, even when recruited from overseas with a valid police check from their country of origin, to make sure, as far as is possible, that residents are fully protected from possible abuse. Revisit their practice of ‘pooling’ residents’ personal allowance money to fully comply with NMS 35.3. It was noted that comprehensive and satisfactory records are maintained. • • 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 & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 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 The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 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): 1, 2, 3, 4, 5 & 6. The admission process is satisfactory and the pre-admission process ensures that the residents’ health and welfare needs are met. EVIDENCE: There is a comprehensive Statement of Purpose/Service Users’ Guide and a signed copy of the residents’ Terms and Conditions is retrained for those residents who are self funding. The Statement of Purpose/Service Users’ Guide reflects the care provided. The pre-assessment process is satisfactory and reflective of the health and welfare needs of the residents. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 9 Residents and/or their relatives are able to visit the home prior to taking up residency to assess the suitability of the home. A resident’s relative said that she had visited the home prior to her relative’s occupancy and had been made very welcome and shown round by a member of staff and that there had been a trial period to ensure that the resident was happy with her choice of home. Intermediate care is not provided. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 10 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. Residents are very well looked after in respect of their individual health and personal care needs but care should be taken to ensure that all significant events are recorded in the residents’ files. EVIDENCE: Care plans and risk assessments are satisfactory and generally of a good standard. However, care tends to be difficult to track because information relating to the health and welfare needs of the residents appears to be kept in a number of places. Discussions with a relative demonstrated that a minor injury, which required dressing, had not been recorded – therefore there was no information to demonstrate how the injury had occurred or provide information relating to the injury to the relative (or the Inspector): a requested by a relative for a resident to receive a GP visit had not been recorded or followed through. Although the concern had been resolved by the nursing staff the relative was unaware of the outcome. Significant event, interventions and outcomes should be recorded in the resident’s personal files to provide a meaningful profile of the resident’s daily life. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 11 Although one resident spoken with was rather ‘grumpy’ and said that everything was ‘rubbish’ her relative said that that was her usual response and that the care was satisfactory. Two residents and a relative said that staff were very kind and caring and that the standard of care was ‘very good’ and that they were ‘very happy to be living at The Willows’; that staff ‘were caring’ and always treated the residents with respect and dignity. Relatives said that they were always made to feel welcome and that the home had a pleasant atmosphere. Standard 9 was inspected in June 2005 and found to be met The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 12 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): 13 & 14. The staff appear to work very hard to ensure that residents experience a safe, homely life style and exercise choice and control over their lives wherever possible. EVIDENCE: Residents are supported in maintaining their autonomy and independence as much as possible. Individuality and choice is supported at all levels enabling residents to retain control over their lives. One resident said that staff are prompt in their responses to requests and supported her choices and decision making. Visitors came and went throughout the day and the home has a friendly and warm atmosphere. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 13 In reviewing notes made in the residents files it was noted that staff demonstrate a proactive approach in encouraging residents to interact with the wider community, supporting individual choice, and are genuinely pleased with positive responses. One resident said that if she did not like any of the meal choices staff would provide an alternative meal of her choice. Residents are able to participate in the democratic process via postal votes. Standards 12, 13 & 15 were inspected in June 2005 and found to be met The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Arrangements for receiving and responding to complaints are satisfactory. EVIDENCE: The home has a complaints policy and procedure, which is available to residents and their relatives both in the Service Users’ Guide and displayed in the home. The home has received one minor complaint since the last inspection which had been addressed. The CSCI has not received any complaints about the home. Standard 18 was inspected in June 2005 and found to be met The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 & 26. A comfortable, homely, clean and safe standard of accommodation is provided for the residents. EVIDENCE: The home is safe and well maintained with adaptations to suit residents’ needs. It is decorated and furnished to a high standard that creates a comfortable, pleasant and homely environment, and there is a system of maintenance and refurbishment. Residents’ rooms are spacious, well decorated and maintained and were personalised with photographs, ornaments and furnishings. Bed linen and towels are provided. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 16 Residents have access to attractive safe gardens and all areas of the home are fully accessible for wheelchair users. The home is clean and hygienic throughout and has domestic, kitchen and maintenance staff in addition to the nursing, care and administrative staff. The Responsible Individual, Mr Cooper, stated that home is currently being refurbished in some areas and some furniture and soft furnishing are being replaced. The home was attractively decorated for Christmas. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30. Staff at the home are trained and supported and employed in sufficient numbers to meet the needs of the residents. The recruitment process is generally robust but overseas staff are not initially CRB checked at the point of employment. EVIDENCE: Staffing levels, at the point of inspection, were in accordance with the minimum standard, as advised in Department of Health Residential Forum Guidelines. There are Registered Nurses on duty day and night with additional domestic, maintenance and kitchen staff. Residents and their relatives said that they felt staff were capable and very caring, and that there were sufficient staff on duty to meet the needs of the residents. There is a comprehensive induction programme. Training is planned and supported to ensure that the varied needs of the residents are met. The recruitment process is generally satisfactory and Registered Nurses Personal Identification Numbers (PIN’s) are checked to ensure that they are registered to practice. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 18 Staff recruited, on entry to the UK, from abroad are not PoVA First or Criminal Record Bureau checked when taking up employment but the providers do ensure that all overseas staff have police checks (from their country of origin) and Work Permits (UK). Current advice from the CSCI is that all staff should have a PoVA First & CRB check, when appointed, regardless of status. For further information contact www.crb.gov.uk or T. 08709090811. The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 19 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): 35. The Registered Manager is a Registered Nurse and manages the home effectively and ensures that the residents’ rights are protected. EVIDENCE: Residents’ monies are not managed by the home. Small personal allowances are kept as petty cash: deposits and withdrawals are recorded in triplicate. Residents’ money is pooled as petty cash rather than maintained separately for each resident, as advised within the National Minimum Standard 35.3. This was discussed briefly with the Responsible Individual, Mr Cooper. The administrator stated that they had tried keeping residents’ personal money separately but found the current method easier to manage. Standards 31, 33 & 38 were inspected in June 2005 and found to be met The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 3 3 3 N/A 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 X 13 4 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 4 X X X 3 X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations The Registered Provider(s) are recommended to ensure that all the details of residents’ care are recorded in their individual care plan and include significant events, interventions and outcomes. The Registered Provider(s) are strongly recommended to ensure that all employees are CRB check at the point of employment. The Registered Provider(s) are recommended to revisit their practice of pooling residents’ personal allowance to fully comply with NMS 35.3. 2 3 OP29 OP35 The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows Nursing & Residential Home DS0000001934.V261541.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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