Inspection on 21/07/05 for Three Willows

This inspection was carried out on 21st July 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.

Other inspections for this house

Three Willows 02/01/07

Three Willows 07/02/06

Three Willows 13/09/04

Three Willows 29/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Three Willows 35 Woodberry Way Chingford London E4 7DY Lead Inspector Rob Cole Unannounced Inspection 21st July 2005 at 10:00am 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. Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Three Willows Address 35 Woodberry Way, Chingford, London, E4 7DY 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) 020 8529 1881 020 8529 1881 Mr James Deary & Mrs Catherine Deary Post Vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th September 2004 Brief Description of the Service: Three Willows is a home providing care to 21 elders, situated in the Chingford area of the London Borough of Waltham Forest. The home is in a residential area, and is in character with other homes in the area. The home is close to shops and other local amenities, and transport networks. The home is privately run. Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 21/7/05 and was unannounced. The inspector had the opportunity of speaking with service users, their relatives, staff and the homes acting manager was present throughout the inspection. Overall the inspector was satisfied that Three Willows is a well run home. Service users and relatives spoken to informed to the inspector that they are happy with the level of care and support provided. There are a few issues that need addressing, and these are highlighted within the report. What the service does well: What has improved since the last inspection? 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. Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 6 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 Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 7 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) 1,2,3,4 and 5 The inspector was satisfied that service users are given sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through documentation and the opportunity of visiting the home. EVIDENCE: The home has a clear and comprehensive Statement of Purpose, which sets out the aims and objectives of the scheme, the services and facilities available and the physical environment, including individual room sizes. There is also a Service User Guide, which gives a description of the home and the services to be provided. The Guide also sets out details of the staff team and their experience and qualifications. Both documents are written in plain English. All service users have an individual signed copy of a statement of terms and conditions. The statement includes details of fees payable, what they cover and what is extra, and facilities and services provided. Pre admission assessments are carried out on all prospective service users. At the last inspection a requirement was set that these need to be more comprehensive, and this has been met. Assessments now include health, Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 8 mobility, social and leisure and cultural needs of service users. The home has an admissions procedure, which states that service users and their relatives are able to visit the home before making any decisions as to move in or not. Relatives spoken to on the day of inspection confirmed that this was the case. Meetings are held to review the placement after the first six weeks, and these are attended by the service user, their relatives, social worker, keyworker and manager. From observation and discussion with staff and service users there was evidence that the home is able to meet the individual and collective needs of service users. Staff demonstrated an ability to communicate effectively with service users, and service users cultural needs are met through food and activities. The home does not provide intermediate care. Three Willows G56 G06 S7216 Three Willows V240907 210705 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) 7,8,9,10 and 11 The inspector was satisfied that the home is generally able to meet the health and personal care needs of service users. However, to ensure that needs are fully met, more attention must be paid to the safe storage and recording of medications. EVIDENCE: All service users have clear and comprehensive care plans in place. Plans are drawn up with the involvement of the service user, and include personal care needs, medical, mobility and social and leisure needs. Clear risk assessments are also in place. Risk assessments were thorough and well documented, for example it was identified that one service user was at risk from bed sores, a programme has been put in place to move them every two hours, and staff have to sign to indicate when the service user has been moved. All service users are registered with a GP. The acting manager informed the inspector that where practical service users were able to keep the GP they had prior to admission. Service users have access to health professionals as required, for example service users are currently working with psychiatrists and district nurses. Service users have regular eye care. Service users have not had access to regular dental care, however, the acting manager informed Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 10 the inspector that dental care arrangements have now been put in place, and that all service users will have access to appropriate dental care by the end of August 2005. At the time of inspection one service user was in hospital, the acting manager informed the inspector that the CSCI had not been notified of this, and it is required that the home notifies in writing of all incidents listed under Regulation 37 of the Care Homes Regulations 2001. The home makes use of the Continence Advisory Service, who supply advice and continence products to the home. On the day of inspection used continence products were stored in yellow bags in the front garden by the road. To help protect service users dignity and control the spread of infection it is required that used continence products are stored in yellow bags within a container with a lid fitted. The home has a medication policy in place, and all staff receive training from the supplying pharmacist before they are able to administer medications. Medications are stored in a cabinet inside a designated medication room. However, during the course of the inspection the inspector found both the room and the cabinet to be left unlocked, while no staff were present or in the immediate area. Records are maintained of medications entering the home and those that are returned to the pharmacist. MAR charts are maintained, however, hand written entries on MAR charts were left unsigned, and it is required that all hand written entries on MAR charts are signed. From observation and discussion with service users there was evidence that service users privacy and dignity is respected. Staff were observed to knock and wait before entering bedrooms, all service users were appropriately dressed on the day of inspection, and the manager informed the inspector that service users are given their own mail to open. Service users are able to use the telephone in the office if they want privacy. Screening is provided in double bedrooms. The home has a policy in place on death and dying. Service users views are sought on after death arrangements, or their family where appropriate, and these views were recorded on care plans. The inspector was informed that service users are able to stay in the home with a terminal illness, so long as the home is able to meet their medical needs. Staff have received training in bereavement issues. Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 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 standard(s) None The standards in this section were not tested on this occasion, but will be tested a part of the next inspection. EVIDENCE: The standards in this section were not tested on this occasion, but will be tested a part of the next inspection. Three Willows G56 G06 S7216 Three Willows V240907 210705 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) 16,17 and 18 The inspector believes that suitable policies and procedures are in place around complaints and adult protection. However, the potential risk to service users would be further reduced by all staff receiving training in adult protection issues. EVIDENCE: The home has a complaints log, although the acting manager informed the inspector that no complaints have been received in the past year. There is also a complaints procedure. This included timescales for responding to complaints, and made appropriate reference to the CSCI. The procedure was on display within the home. The home has a copy of the Local Authorities adult protection procedures, and also its own policy on adult protection. This has been updated since the last inspection, and now appears to be in line with current legislation. The acting manager informed the inspector that some of the staff team have received training in adult protection issues. However, staff spoken to by the inspector demonstrated only a limited understanding of the issues involved, and it is required that all staff receive adult protection training. All service users are on the electoral register, and service users spoken to confirmed that they were able to vote in elections. Three Willows G56 G06 S7216 Three Willows V240907 210705 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) 19,20,21,22,23,24,25 and 26 The inspector is satisfied that the home is suitable to meet its stated purpose. The building was well maintained, both internally and externally. Service users have adequate communal and private space to meet their needs. EVIDENCE: The home is situated in a residential area of Chingford in the London Borough of Waltham Forest, close to shops and other local amenities. The home is in keeping with other homes in the vicinity. The home was well maintained, both externally and internally, and on the day of inspection was clean and tidy. The home is built over two floors, and is accessible to service users via a lift. The communal areas consist of two dinning/sitting rooms, a visitor’s room and a garden. Service users were observed to move freely around communal areas, and the manager informed the inspector that service users enjoy sitting in the garden in good weather. The garden had appropriate furniture, and also BBQ facilities. All communal areas are non-smoking, but service users are able to smoke in the garden, and in their bedrooms subject to satisfactory risk assessments. All bedrooms are ensuite, with a toilet and hand basin. In Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 14 addition to this there are adequate numbers of toilet and bathing facilities around the home to meet service users needs. Baths have been adapted to make them accessible to service users. All bathroom/toilets were clean, tidy and free from offensive odour on the day of inspection. Since the last inspection all bathrooms now have working locks fitted to them. Bedrooms were well maintained, with adequate furniture, including wardrobes, table and chair and chest of draws. Bedding, curtains and carpets were well maintained and domestic in character. Service users were able to decorate their rooms to their personal tastes, for example with family photographs. Screening was provided in double rooms. Bedrooms meet National Minimum Standards on size requirements. All bedrooms have central heating, which is appropriately boxed in. Windows provide adequate natural light and ventilation. Electric lighting is domestic in character, and the home tests and records water temperatures in bedrooms on a weekly basis. Emergency lighting is situated throughout the home. The home has a range of adaptations to make the house accessible to service users. In addition to the lift, there are handrails situated around the home and in toilets, and baths have been adapted. Hoists are used, and these are regularly serviced. Corridors and doorframes are wide enough to allow easy access to wheelchairs, and ramps have been built to allow easy access to the garden. The home has a call alarm system installed in all bedrooms and bathrooms. The home has a policy on infection control, and on the day of inspection the home was clean, tidy and free from offensive odours. The laundry room was well maintained, and all service users have their own laundry basket to help ensure they always where their own clothes. The washing machines are appropriate to meet the homes needs, and hand washing facilities are situated in the laundry room and throughout the home. Protective clothing such as latex gloves are available for staff to wear to help control the spread of infection. Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 15 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) 27,28,29 and 30 It is the view of the inspector that the home is staffed in sufficient numbers and by sufficiently competent staff to be able to meet service users needs. However, recruitment processes need to be tightened up to ensure that satisfactory CRB checks are obtained. EVIDENCE: The home provides 24-hour support, including two waking night staff, and has an emergency on-call procedure. There was a staff rota on display, and on the day of inspection the rota accurately reflected the actual staffing situation in the home. All staff employed in the home providing personal care are over 18 years old. The home has policies in place on recruitment and selection and equal opportunities. The inspector checked several staff employment files at random. There was evidence that references had been taken up for staff, and there was proof of ID, including passports and birth certificates. However, there was no evidence that the home had received a CRB check for the most recent member of staff to start working in the home. It is required that the home receives satisfactory CRB checks for all new staff, prior to them commencing work at the home. All staff receive a structured induction programme, this includes service user issues and the environment. The home has an ongoing training programme, and recent training attended by staff includes fire safety, moving and handling, medication and dementia. The acting manager informed the inspector that of the seventeen care staff employed at the home, three have a relevant NVQ care qualification and four are currently working towards a qualification. It is Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 16 planned that a further three staff will start a qualification later this year. The acting manager said that it is the intention of the organisation that in time all staff will be given the opportunity of completing a relevant care qualification. Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 17 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) None The standards in this section were not tested on this occasion, but will be tested a part of the next inspection. EVIDENCE: The standards in this section were not tested on this occasion, but will be tested a part of the next inspection. Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 18 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 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x x x x x x x x Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 19 NO 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 OP8 Regulation 12 and 13 Requirement The registered person must ensure that used continence products are stored in a container with an appropriate lid fitted. The registered person must ensure that the CSCI is notified of all incidents specified by Regulation 37 of the Care Homes Regulations 2001. The registered person must ensure that medications held in the home are stored securely. The registered person must ensure that all hand written entries on MAR charts are signed for. The registered person must ensure that all staff receive appropriate training in adult protection isues. The registered person must ensre that satisfactory CRB checks are carried out on all new staff prior to them commencing work in the home. Timescale for action 30/11/05 2. OP8 37 30/11/05 3. 4. OP9 OP9 13 13 30/11/05 30/11/05 5. OP18 13 30/11/05 6. OP29 19 30/11/05 Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 20 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 Good Practice Recommendations Three Willows G56 G06 S7216 Three Willows V240907 210705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ 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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