Inspection on 14/02/06 for Willersley House

This inspection was carried out on 14th 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

Willersley House 09/03/07

Willersley House 27/10/05

Willersley House 08/03/05

Willersley House 16/09/04

Willersley House 04/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Willersley House 85 Main Street Willerby Hull East Yorkshire HU10 6BY Lead Inspector Ann Day Unannounced Inspection 15.00p 16 March 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 Willersley House DS0000019772.V278426.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. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willersley House Address 85 Main Street Willerby Hull East Yorkshire HU10 6BY 01482 653353 01482 659668 homehul@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged 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) Mrs Gillian Elizabeth Bottomley Care Home 34 Category(ies) of Dementia (34), Old age, not falling within any registration, with number other category (34) of places Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: Willersley House is situated in the village of Willerby, the home is operated by Methodist Homes For The Aged; a voluntary organisation specialising in the care of older people. The home is close to amenities and has shops, pubs, banks, hairdressers and the post office all within walking distance. Public transport is accessible. The Home is a Victorian house that provides accommodation for thirty-four older people, and all bedrooms have en-suite facilities. The communal areas include a lounge, an attractive oak panelled quiet room and a large dining room. This care home has retained many of its original features. All areas of the home are accessible to service users via the provision of a passenger lift and ramps. Outside there is a ramp down to a well-maintained garden with numerous trees and bushes, and an enclosed courtyard. There is a small car parking area adjacent to Willersley House. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one afternoon and into the evening of 16th March 2006. The inspection consisted of interviews with residents, a member of staff and Gillian Bottomley, the Registered Manager; a tour of the premises and examination of documentation. Sue Rocks, Service Manager was visiting the home to meet with night care staff on the evening of the inspection. What the service does well: What has improved since the last inspection? Care Plans and risk assessments are regularly reviewed and in response to changes in individual service user’s needs as appropriate. The home has a robust system of self -audit to ensure the safe handling and administration of medication. Willersley House DS0000019772.V278426.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. Willersley House DS0000019772.V278426.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 Willersley House DS0000019772.V278426.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): 3,5,6 Service users’ needs are fully assessed prior to their admission to the home, enabling the home’s staff to meet their individual needs. EVIDENCE: Care records of service users were examined. The Registered Manager of the home assesses prospective service users prior to their admission. Service users/relatives are able and encouraged to visit the home prior to admission to meet with staff and see their prospective room before making a decision to come into the home. Information about service users’ health and personal care needs had been documented and information gathered from relatives and other health professionals giving a good picture of the care that needed to be provided. The home does not provide intermediate care. Willersley House DS0000019772.V278426.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 Service users’ needs are met and they are treated with respect and their right to privacy is upheld; they are generally well protected by the practices for the administration of medication, however one record was not entirely accurate. EVIDENCE: Care records of residents were found to be well kept and comprehensive. Care plans were detailed; reviews were documented and key workers recorded monthly evaluation of the care provided for each individual resident. All aspects of health, personal and social care needs are addressed. Individual care records included risk assessments and documented the monthly check of mobility aids. The home has a robust system of self -audit to ensure the safe handling and administration of medication. Members of staff were seen knocking on bedroom doors and awaiting an invitation before entering. Members of staff were seen to have good relationships with the residents. Willersley House DS0000019772.V278426.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): 12,13,14,15 Service users are provided with the opportunity to engage in a variety of activities, satisfying their social, cultural and religious needs. Service users maintain contact with family and friends as they wish; they are helped to exercise choice and control over their lives; and they receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: An activity co-ordinator is employed by the home, one to one activities with service users and group activities are undertaken. Residents meet in the mornings for coffee before activities commence. There was a notice board in the reception area listing all the entertainment and events happening for the week. Religious services are regularly available, and the home has an open visiting policy. Many service users have their own telephone and there is an additional telephone provided for the exclusive use of residents on the ground floor. The home has several small kitchenettes available both on the ground floor and on the first floor enabling residents to make additional drinks for them selves or relatives as and when they wish. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 11 Service users said they had control over when they got up and went to bed each day, they could choose what they did with their day according to capacity, and said staff would help arrange particular activities. Service users also reported that they particularly enjoyed the food. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users and their relatives are confident that their complaints will be listened to, taken seriously and acted upon, and there are policies and procedures in place to protect them from abuse. EVIDENCE: The home has a comprehensive complaints policy and procedures. Service users and members of staff said that they would have no hesitation in raising any concern with the manager, in the knowledge that she would treat their concerns seriously. The home has not received any complaints since the last inspection. The home makes available policies and procedures and local guidance for the Protection of vulnerable adults and staff have attended training. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Service users live in a safe, well-maintained, clean environment; with their own possessions about them. EVIDENCE: The home is a Victorian house, which provides comfortable, homely and attractive accommodation for service users. The home is well maintained and there is a refurbishment and maintenance programme in place. Redecoration of a vacant bedroom and work in the garden, which included the safe felling of trees, following a survey, was being undertaken at the time of the inspection. Furnishings and décor are comfortable, domestic in nature. All bedrooms have en suite facilities; the home currently accommodates two married couples, one couple occupy a bedroom and a dayroom; and the other couple occupy a double room. The home is very well equipped with mobility aids and adaptations, “Parker Bath”, “Walk in Shower”, “Stand-Aid”, ramps and handrails. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 14 The home’s communal areas are well appointed; a quiet lounge is used for religious services, in addition there is a large communal area on the ground floor and a smaller communal lounge on the first floor. Service users’ rooms are personalised with pictures, photographs and small items of furniture they have brought from home. The home was clean and fresh smelling throughout and gloves and aprons were in good supply, infection control policies and procedures are in place. The home has a laundry, which is well equipped and located away from the dining area. The organisation is currently undertaking an audit in relation to laundering provision throughout their homes. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 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 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 Service users’ needs are met by the numbers and of competence and training of members of staff; and they are fully protected, by the home’s recruitment practices. EVIDENCE: On the day of the inspection there were 33 residents in the home. Gillian Bottomley, the Registered Manager aided care between 2pm and 5pm to cover staff sickness. Service Users, staff members and observation confirmed that care provision during this period, was not impaired. The home does not use agency staff, and generally any shortages are few and are covered by the home’s own staff working additional hours. The home is large and stretches over more than one floor, staff members carry mobile phones whilst on duty to facilitate good communication and the “Nurse Call System” ensures a rapid response to any call for assistance. The home has robust recruitment policies and procedures, employment checks, Criminal Records Bureau (CRB) checks, are stored securely, and the one staff file examined was found to be in good order. Training is a priority in the organisation and the home; a member of staff confirmed that they have the opportunity to attend training sessions in addition to induction and NVQ Level 2. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 16 On the day of the inspection, Sue Rocks, Service Manager was visiting the home to attend a meeting with the night staff regarding training. Gillian Bottomley, the Registered Manager, said that in future staff records will contain a separate training file. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 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 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): 31,33,36,37, The home is well managed and provides a safe place for service users to live and staff to work. EVIDENCE: The registered manager Gillian Bottomley is very experienced and has worked for MHA Group for 11 years and has been the manager of Willersley House for four years. She is highly committed and has completed NVQ Level 4 in management. The organisation and the home have a policy of continual self -monitoring and have a proactive approach to improving the quality of service through consultation and regular review. The organisation ensures that monitoring visits (Reg. 26) are regularly undertaken and copies of the reports are provided for the Commission. Accidents and any untoward incidents are appropriately documented and the Commission is notified. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 18 Documentation and a staff member confirmed that all members of staff receive regular supervision, and annual appraisal. Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 19 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 4 4 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 X 3 X X 3 3 X Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation Reg. 13(2) Requirement The registered person must ensure the accurate recording of the administration of medication. Timescale for action 30/04/06 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 Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Willersley House DS0000019772.V278426.R01.S.doc Version 5.1 Page 22 - 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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