Inspection on 07/02/06 for Three Willows

This inspection was carried out on 7th 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.

Other inspections for this house

Three Willows 02/01/07

Three Willows 21/07/05

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 10:00 7 February 2006 th 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 Three Willows DS0000007216.V274234.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. Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Three Willows Address 35 Woodberry Way Chingford London E4 7DY 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) 020 8529 1881 0208 529 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 DS0000007216.V274234.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 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, including transport networks. The home is privately run. Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 7/2/06 and was unannounced. The inspector had the opportunity of speaking with service users and staff from the home. The homes acting manager and proprietor were present throughout the inspection. Overall the inspector believes this to be a well run care home, and that service users receive high levels if individualised care. Service users spoken to informed the inspector that they were generally very happy with the level of care and support provided, and commented that they found staff to be very friendly and helpful. What the service does well: What has improved since the last inspection? What they could do better: Three requirements have been set in this report which must be addressed. The home must ensure that all service users have access to appropriate dental care, guidelines need to be produced for the administering of any medications prescribed on a PRN basis and the home must ensure that all staff receive regular formal supervision. Three Willows DS0000007216.V274234.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. Three Willows DS0000007216.V274234.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 Three Willows DS0000007216.V274234.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): None The standards in this section were not tested as part of this inspection, but will be tested as part of the next inspection. EVIDENCE: The standards in this section were not tested as part of this inspection, but will be tested as part of the next inspection. Three Willows DS0000007216.V274234.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): 7,8,9,10 and 11 The inspector was satisfied that the home is generally able to meet the health and personal care needs of service users. However, the home must ensure that all service users have access to dental care as appropriate. EVIDENCE: All service users have individual care plans in place. At the time of inspection the home was in the process of introducing a new care planning format. This format presents plans in a clear and accessible format. Plans were comprehensive, and included needs associated with mobility, medication, culture and social and leisure needs. Plans are drawn up with the involvement of the service user, their relatives where appropriate, and the homes acting manager. Service users who are publicly funded have an annual review meeting in conjunction with their placing authority, and all care plans are subject to regular review. All service users are registered with a GP, the inspector was informed that service users could keep the GP they had prior to admission where practical. Records are kept of medical appointments. These indicate that service users have access to a variety of health care professionals, including district nurses, Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 10 opticians and a consultant psycho-geriatrician. However, the home could not evidence that all service users have had access to dental care in the past year, and it is required that service users have access to regular dental care. The home has a comprehensive medication policy, and all staff undertake medication training before they are able to administer it. Service users have an annual review of their medication in conjunction with their GP. No service users currently self medicate or are on any controlled medications. Medications are stored in a cabinet within a designated locked medication room. Records are kept of medications entering the home and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained, those checked by the inspector appeared accurate and up to date, and since the last inspection all hand written entries on MAR charts are now signed. However, there are no guidelines in place around the administration of medications prescribed on a PRN basis, for example one service user has been prescribed quinine bisulph on a PRN basis, but there were no guidelines in place on how or when this should be given, and this must be addressed. 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 acting 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 DS0000007216.V274234.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 and 15 It is the inspector’s view that service users are supported to live valued and fulfilling lives. There is a varied activities programme in place, and service users are able to access the local community. Food served in the home is of a good standard. EVIDENCE: The home provides a variety of social and leisure activities, both in house and in the community. There was a poster on display in the home advertising the activities programme. Recent activities have included professional singers visiting the home, theatre trips, trips to the local pub and parks, shopping visits and parties to celebrate Christmas and birthdays. On the day of inspection a gentle exercise class was in process, this was well attended, and service users appeared to be enjoying it. A pastor visits the home weekly to give communion, and one service user regularly attends church. The home has a visitors policy, and service users informed the inspector that they are free to receive visitors at any time, and can see visitors in private if they so wish. Service users are provided with information about local advocacy services available, and indeed, some service users have an independent advocate. Service users are able to bring their own possessions with them when the move into the home. Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 12 Service users are involved in planning the weekly menu, and records are kept of menus. These evidenced that service users are offered a choice of meals, and that meals are varied, balanced and nutritious. On the day of inspection service users were offered a choice of chicken stew or a fish dish for lunch, both of which appeared appetizing and healthy. Service users are offered three meals a day, including a cooked breakfast, and drinks and snacks are offered throughout the day. The kitchen was clean and tidy, and food was stored appropriately. There was evidence that service users ore offered fresh fruit and vegetables as part of their daily diet. Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 13 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): 16,17 and 18 The inspector was satisfied that the home has taken reasonable steps to ensure that service users are protected from the risk of abuse, and that their legal rights are protected. EVIDENCE: The home has a complaints log. This evidenced that complaints received are appropriately recorded and investigated. There was also a complaints procedure, this was on display within the home, and made appropriate reference to the CSCI. The home has a copy of the Local Authorities adult protection procedure, and also its own adult protection procedure. This appeared to be in line with current legislation. Since the previous inspection most of the staff at the home have received training in adult protection issues, the acting manager informed the inspector that it was planned that the remaining staff would be undertaking this training in the near future. The inspector was satisfied that service users legal rights are protected, for instance all service users are on the electoral register, and some service users informed the inspector that they were indeed able to vote in elections. Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 14 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): 19,20,21,22,23,24,25 and 26 The inspector was satisfied that the home is suitable to meet its stated purpose with regard to the physical environment. 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 acting 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 Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 15 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 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. 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 DS0000007216.V274234.R01.S.doc Version 5.1 Page 16 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 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. Staff receive appropriate training, and demonstrated a good understanding of the collective and individual needs of service users. 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, and since the last inspection the home has met requirements on obtaining CRB’s for new staff. The home holds regular staff meetings, and all staff can contribute to the agenda. All staff undertake an induction programme on commencing work in the home, this includes service user issues and the environment. There is an on going training programme for staff. Recent training has included dementia, diabetes and food hygiene. Of the sixteen care staff employed at the home eight have obtained a relevant care qualification. The acting manager informed the Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 17 inspector that it was the intention of the organisation that all care staff will be given the opportunity of completing a relevant qualification. Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 18 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): 31,32,33,36,37 and 38 The inspector was satisfied that this is a well run home. Health and safety is managed effectively, and there are appropriate quality assurance systems in place. EVIDENCE: At present the home is run by an acting manager, supported by the proprietor. The proprietor informed the inspector that they intend to appoint a permanent manager in the near future, and apply for their registration with the CSCI. Staff and service users spoken to informed the inspector that they found the acting manager to be approachable and accessible. On the day of inspection staff were observed to interact with the acting manager in a relaxed manner. Staff meetings and care plan reviews contribute to the quality assurance within the home. Copies of previous inspection reports are available to view in the home, and there was evidence of monthly unannounced Regulation 26 visits Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 19 taking place. All service users have an annual review meeting with their family, which reviews general house issues such as staffing and the environment as well as care needs. Questionnaires are issued to service users and their relatives to gain their feedback on the home. Those completed questionnaires seen by the inspector were generally very positive. Record keeping was of a good standard. Confidential records are stored securely, and staff and service users can access their records as appropriate. All staff receive formal supervision, and have access to their supervision records. Supervision covers performance, training and service user issues. However, not all staff have had regular supervision, for example records checked by the inspector indicated that staff had only received three supervisions over the past twelve months, and it is required that all staff receive regular formal supervision, at least six times a year. The home has various health and safety policies in place, for instance on fire safety and COSHH. Staff undertake health and safety training, including on food hygiene and moving and handling. Fire fighting equipment was situated around the home, this was last serviced in October 2005, fire exits were free from obstruction on the day of inspection. Fire alarms are tested weekly, and were last serviced on the 12/10/05, and the home holds regular fire drills. COSHH products were stored securely, and the home has a well stocked first aid box. Fridge/freezer and hot water temperatures are routinely checked and recorded. The home has in date certificates, for gas safety, PAT and electrical installation. The home has in date employer’s liability insurance cover. Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 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 X X X X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 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 3 3 3 X X 2 3 3 Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 21 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. 1 Standard OP8 Regulation 13 Requirement The registered person must ensure that all service users have access to dental care as appropriate. The registered person must ensure that clear guidelines are in place for the administration of all medications prescribed on a PRN basis. The registered person must ensure that all staff employed at the home receive regular formal supervision, at least six times a year. Timescale for action 31/05/06 2 OP9 13 31/05/06 3 OP36 18 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford 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. Extracts may not be used or reproduced without the express permission of CSCI Three Willows DS0000007216.V274234.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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