Inspection on 27/10/05 for Willersley House

This inspection was carried out on 27th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 14/02/06

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 Denise Rouse Unannounced Inspection 27th October 2005 10.30 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.V255580.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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 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) Methodist Homes for the Aged 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.V255580.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: Willersley House is situated in the village of Willerby. Methodist Homes For The Aged, a voluntary organisation specialising in the care of older people, operates it. The home is close to amenities and has shops, pubs, banks, hairdressers and the post office within walking distance. The public transport network is also reasonably accessible. The Home is a Victorian house that provides accommodation for thirty-four 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. The main entrance hall 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 park. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted four and a half hours, with three hours preparation prior to the visit. A tour of the building was conducted. A number of service users and staff were spoken with ; service user records, Medication Administration Records, staff files, complaint book, risk assessments and maintenance records were inspected. 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. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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 the following standard(s): Standard 3 (6 not applicable.) Sufficient information is gathered prior to admission to ensure that the home can meet the needs of prospective service users. The home manager undertakes the pre admission assessment herself. Service users are not admitted to the home if it is assessed that their needs cannot be met. EVIDENCE: The registered manager ensures that the pre admission assessment is undertaken and is current; no service users are admitted to the home if their needs cannot be met. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 Page 8 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): Standards 7 8 9 10 The quality of care provided to service users could be compromised by a failure to review care plans regularly. Service users feel they are treated with respect. EVIDENCE: Service users looked well cared for and district nurses were attending to clients as necessary. Advice is sought from relevant professionals where issues or concern about the health of service users arise. Staff were seen to knock on service users doors prior to entering. The medication system was well-managed .The controlled drugs stored on behalf of the service users could be reconciled with the register. There were lockable facilities for the storage of medications within the service users own rooms. Clients who were able to self medicate had the correct assessments in place. Care plans assessed had not all been reviewed at least once per month. Some risk assessments inspected required updating especially when the needs of the service user had changed. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 Page 9 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): Standards12 13 14 15 Service users dietary needs of are well catered for with a balanced and varied selection of food available that meets their tastes and choices. Unrestricted visiting arrangements results in service users maintaining good links with family and friends. EVIDENCE: An activity co-ordinator was employed by the home, one to one activities with service users and group activities were undertaken. The local clergy had just finished his service on the day of the inspection. There was a notice board in the reception area listing all the entertainment and events happening for the week. A shop was also available staffed by a local lady; service users could purchase toiletries, confectionary, hosiery and cards. Service users were positive about the meals provided. A service user stated “the food is excellent, we always have a choice, the cook is very good, she comes to see you, I have meals in my room .The lunch served on the day of the inspection was advertised on a menu board and the clients spoken to stated that it was “ very good.” It was presented well. A service user prior to the meal being served said Grace in the restaurant. Trays taken to service users rooms were well presented and the plates were heated prior to food Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 Page 10 being placed upon them, the trays were delivered to the rooms as soon as the food was placed upon them, this ensures the food is hot when received. Service users were able to personalise their rooms and can lock the door to their room if they wish. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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): Standards 16 18 Service users are able to utilize the complaints procedure and feel confident their concerns would be addressed. Staff have knowledge and understanding of Adult Protection issues, which protects service users from abuse. EVIDENCE: The complaint procedure, which is displayed publicly, provides sufficient information for those who may wish to complain, including how to contact the Commission for Social Care Inspection. One service user stated “ I would see Gillian (home manager) if I had any concerns.” There had been one complaint received at the home since the last inspection, which had been investigated and resolved, there was one more, being investigated at the time of the inspection. The manager provides training pertaining to abuse awareness to resident’s relatives, this is commendable. All staff receive in house education pertaining to the Protection of Vulnerable Adults. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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): Standards 19 26 The overall quality of the furnishings and fittings is adequate, this is in keeping with the character of the old house, and provides a homely atmosphere for the service users. Some furnishings will require replacing in the short term. EVIDENCE: Willersley House is a former large house with an extension. It has many pleasing period features in the main entrance and lounge areas. There is a security entry system in place so that service users are protected. The building appears to be in good structural condition and was free from any malodours. A handyman is employed to ensure that matters of routine maintenance are attended to promptly; he operates a good system for monitoring risk assessments and the recording of all necessary fire alarm tests. He files the homes documentation pertaining to Gas, electricity, and chlorination and PAT testing, this documentation was all current. The laundry area was clean and well organized, access to this area was restricted to staff only. The home was clean and tidy in all areas. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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): Standards 27 28 29 30 Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. EVIDENCE: A staff roster was available for inspection, discussion with the manager indicated that staffing at the weekends had been monitored and addressed. The relevant pre employment checks are carried out and were evidenced within the four staff files audited. New care staff receive an allocated mentor and undertake Foundation training. Staff are encouraged to undertake National Vocational Training level 2. Other training opportunities are provided for staff in order that they maintain and develop their skills and knowledge base in the care of older people. There are two staff undertaking the National Qualification in care level 2, 50 of care staff already hold this qualification at level 2 or 3. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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): Standards 31 33 35 38 The registered manager consults with staff and service users and considers their views. The home is managed in such a way that the health and safety of service users and staff are considered. EVIDENCE: The registered manager has achieved the Registered Managers Award. Staff relatives and service users stated that the manager was approachable and stated “ we would see her if we had any concerns.” Staff stated that the home was a nice place to work and the manager was supportive on a day-to-day basis. The registered manager actively seeks the views of staff, service users and families by holding meetings. Comment and suggestion cards are also available. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 Page 15 An external quality assurance process will be undertaken in November, the results to be shared with everyone at the home. The administrator keeps a record of the incoming and outgoings of service users personal allowances kept on their behalf. There is a safe for the secure storage of monies, which are held separately, and receipts are kept. The staff receive regular supervision, this is recorded and further training is provided to staff where necessary. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X 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 X X X X X X 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 3 X X 3 Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 Page 17 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 7 Regulation 14 (2) Requirement Care plans and risk assessments must be reviewed at least monthly, or as the service users needs change. Timescale for action 09/11/05 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 9 Good Practice Recommendations Medications refused by the service user should be recorded upon the Medication administration record. Willersley House DS0000019772.V255580.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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.V255580.R01.S.doc Version 5.0 Page 19 - 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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