This inspection was carried out on 30th January 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.
CARE HOMES FOR OLDER PEOPLE
The Willows Residential Home 89 London Road Hinckley Leicestershire LE10 1HH Lead Inspector
Martin Hefferman Unannounced Inspection 30th January 2006 12:25 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 Residential Home DS0000001713.V280681.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. The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Willows Residential Home Address 89 London Road Hinckley Leicestershire LE10 1HH 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) 01455 615193 01455 616228 Southern Cross Care Centres Limited Mrs Sylvia Ann Jones Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (10), Physical disability of places over 65 years of age (10) The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. No one under 55 years of age, falling within category PD to be admitted to the home. Service User Numbers. No-one in category PD or PD(E) to be admitted to the home if 10 persons in total in these categories/combined categories are already accommodated within the home. 4th August 2005 Date of last inspection Brief Description of the Service: The Willows is a care home providing personal care and accommodation for up to forty older people which includes people who have a physical disability. The home is owned by the Southern Cross group of care homes. The home is located close to the town centre of Hinckley, close to shops, pubs, the post office and other amenities and is easily accessible by private or public transport. The home is a purpose built two-storey building with level entry access and access to both floors by use of the passenger lift or stairs. A range of amenities is available to residents namely washing, bathing and toilet facilities which includes a choice of dining and lounge space. The home has thirty-one single bedrooms, twenty-six with ensuite facilities and five without. There are two double bedrooms one with ensuite facility and one without. The home has a garden to the rear of the building which is well maintained and which is accessible to all residents residing in the home. The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the establishment’s capacity to meet regulatory requirements & minimum standards of practice and focuses on aspects of service provision that need further development. This inspection took place over the course of approximately three and a half hours. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, discussion with them (where appropriate), staff and observation of care practices. Three residents were interviewed during the course of this visit. The registered manager was present for part of the inspection. What the service does well: What has improved since the last inspection?
Staff members have received training regarding the completion of care plans. The home has reviewed its staffing levels with the result that the manager is now able to increase care hours in line with an increase in resident numbers or dependency levels. The home has revised its fire evacuation procedure and staff members have received updated training. The Fire Officer has expressed concern about the ability of two members of staff to evacuate the home at night. The registered manager agreed to forward a copy of the revised procedure to the Fire Officer for his consideration. This issue will be followed up in separate correspondence.
The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 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 Residential Home DS0000001713.V280681.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 The Willows Residential Home DS0000001713.V280681.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): Not applicable EVIDENCE: None of the Standards in this section were inspected on this occasion. The Willows Residential Home DS0000001713.V280681.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 Care planning practices are effective ensuring that staff members have the information they need to meet residents’ needs. EVIDENCE: Individual plans were available for the residents who were chosen for the purposes of case tracking. It was noted that the format used by the home encourages staff to record strengths as well as needs. This is seen as good practice. Staff members have received training regarding the completion of care plans since the date of the last inspection. Two of the care plans that were inspected had been reviewed recently. The registered manager stated that she would ensure that the third was reviewed at the earliest opportunity. She also agreed to remove part of a care plan, identified at the time of the inspection, which was no longer applicable. The requirements of Standard 9 (Medication) were not fully inspected on this occasion. Medication administration records relating to the residents who were chosen for the purposes of case tracking met relevant requirements. The registered manager stated that she would ensure that a rail - which was no longer needed - was removed from a resident’s bed.
The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 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 the following standard(s): 14 Arrangements relating to the daily life of residents appear to be well managed. EVIDENCE: Residents stated that they are able to determine their own daily routine, deciding, for example, when to get up & to go to bed and how to spend their day. They reported that help is available if needed. Whilst the requirements of Standard 15 (Meals & Mealtimes) were not inspected on this occasion, residents stated that they enjoy the meals that are provided. They reported that a choice of meals is always available. The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 11 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): Not applicable EVIDENCE: None of the Standards in this section were inspected on this occasion. The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 12 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 Residents are provided with comfortable surroundings in which to live. EVIDENCE: The parts of the home that were inspected were decorated and furnished to a satisfactory standard. They were clean and free from offensive odours. Residents expressed satisfaction with the environment in which they live. The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 13 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 Staffing arrangements are generally well managed. EVIDENCE: The registered manager stated that since the date of the last inspection the home has reviewed its staffing levels. She reported that as a result she is now able to increase care hours in line with an increase in resident numbers or dependency levels. The rota for the week in which the inspection took place indicated that there were four members of staff on duty from 08.00 to 20.00 (increasing to five from 08.00 to 14.00 on Mondays) and two from 20.00 to 08.00. Residents stated that staff members always respond quickly to requests for assistance. The Fire Officer has expressed concern about the ability of two members of staff to evacuate the home at night (see Standard 38). The registered manager stated that two of the fourteen members of care staff have completed National Vocational Qualification level 2 and that all bar two of the rest were in the process of completing the award. The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 14 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): 31 & 35 The home appears to be generally well managed. EVIDENCE: The registered manager stated that she has obtained a qualification in supervisory management. She reported that she was in the process of identifying a training provider to establish whether she will need to complete all or part of the level 4 National Vocational Qualification in management & care. Progress regarding this issue will be checked at the next inspection. The home maintains records of any money it handles on behalf of residents. Two members of staff had signed the records that were inspected. It was not possible to check residents’ balances at the time of the inspection as all valuables had been removed from the home due to a problem with the safe. Since the date of the last inspection, the home has revised its fire evacuation procedure and staff members have received updated training. The Fire Officer
The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 15 has expressed concern about the ability of two members of staff to evacuate the home at night. The registered manager agreed to forward a copy of the revised procedure to the Fire Officer for his consideration. The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 16 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 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations The Willows Residential Home DS0000001713.V280681.R01.S.doc Version 5.1 Page 18 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
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