Inspection on 23/08/05 for Willoughby Grange

This inspection was carried out on 23rd August 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

Willoughby Grange 04/04/07

Willoughby Grange 31/05/06

Willoughby Grange 06/02/06

Willoughby Grange 03/03/05

Willoughby Grange 18/11/04

Willoughby Grange 16/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Willoughby Grange Willoughby Road Boston Lincs PE21 9EG Lead Inspector Kathryn Emmons Unannounced 23 August 2005 10:00 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. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Willoughby Grange Address Willoughby Road Boston Lincs PE21 9EG 01205 357836 01205 356756 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) Laudcare Ltd (a wholly owned subsiduary of Four Seasons Health Care Ltd) Care home with nursing 44 Category(ies) of OP Old age (33) registration, with number DE(E) Dementia - over 65 (10) of places DE Dementia (1) Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) Service users with dementia only to be admitted to those rooms designated on the ground floor for the category DE(E) 2) The home is registered to provide personal care with nursing for service users of both sexes whose primary needs fall within the following categories: Old age not falling within any other category (OP) (33) Dementia (over the age of 65 years) (DE(E) ) (10) Dementia (DE) (1) The maximum number of service users to be accommodated is 44. 3) The category Dementia (DE) applies to the person named in the Notice of Proposal to Register dated 4th February 2005 only. Date of last inspection 03 March 2005 Brief Description of the Service: Willoughby Grange Nursing Home is situated within half a mile of the town centre of Boston. It is a purpose built two storey home, with the first floor accessed by a lift. The home has a self contained wing , which provides 11 places for residents with dementia. Car parking facilities are situated to the front of the building, and a courtyard with garden furniture is situated to the side of the home. The home is owned by Four Seasons Health Care and the manager is Ms Vivian Bateman. The home is registered to provide accommodation for 44 service users and on the day of the inspection 35 residents were accommodated. There are 6 double rooms and the remainder are single rooms. Four of the rooms have en-suite facilities.The home has its own mini bus and is also situated close to a bus route. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The homes manager and the nurse in charge assisted the inspector during the unannounced inspection. One inspector undertook the inspection spending four and quarter hours in the home .The inspector toured the building and spoke with the homes manager and 2 staff. The main method of inspection used was called “case tracking” which involved selecting clients and tracking the care they receive through checking of their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? Since the last inspection a redecoration programme has been implemented and the unit for residents with dementia had had the corridor and bathroom redecorated. Six new chairs have been purchased for the main lounge a couple of bedrooms have had new carpets, redecoration and bed linen and more furniture such as tables, chairs and blinds were on order. An application for Ms Bateman to be registered as the manager of the home has been received at the Commission. A full physical environment audit has been undertaken and this will form part of the homes business and maintenance plan for the next 12 months. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 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. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 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 standard(s) 1,3, Residents are given the information they need to make an informed decision about moving in to the home. Residents can have confidence that their assessed needs can be met based on a pre admission assessment. EVIDENCE: Residents spoken with confirmed that they had been involved in an assessment prior to moving into the home. One resident confirmed that they had received a contract and a copy of the homes terms and conditions. One of the residents case tracked had records in their care files which demonstrated that they had been assessed prior to admission and that information had been obtained to assist with this assessment from other health professionals and relatives. Two residents confirmed that they had been encouraged to visit the home before admission and that they were aware that the first couple of months living in the home were on a trial basis. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 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) 7,9,10 Care plans and risk assessment do not provide sufficient information for care to be delivered correctly and safely for residents in the dementia unit. This places residents at potential risk of not receiving the care they need. Medication arrangements ensure that medications are administered safely. Service users are afforded their dignity and their rights upheld. EVIDENCE: One resident case tracked resided in the homes dementia unit and another resident case tracked lived in the main part of the home. Service users living in the main part of the home have their care plans produced and reviewed by the trained staff. Care staff produce care plans for residents in the dementia unit. The plan for the resident in the Dementia unit did not accurately reflect the residents current needs and was in need of review and up dating. The care plan for the other resident was up to date and it was evidenced that a review of all care plans had taken place. On speaking with the resident it was also evidenced that the care plan accurately reflected the assessed needs. Medication administration records were inspected for several residents. These had been completed satisfactorily and a procedure was in place for the safe administration of medication. At the time of the inspection no residents spoken Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 10 with self-medicated, it was evidenced this was either through choice or not having the capacity to do so. Residents spoken with stated that they were satisfied with the way they were cared for. Interactions were observed between staff and residents. These interactions were valuing and residents were spoken to in an appropriate manner. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 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) 12,15 Inadequate activities are taking place, which does not enable residents to have their mental, social, and recreational needs met. The need for stimulation and occupation is important for people who have a dementia condition. Residents dietary preferences and choices are catered for. EVIDENCE: Residents spoken with, who were able to engage in conversation, gave examples of how their rights were upheld and how they were given choice over aspects of their care. Service users said they enjoyed the food and it was evidenced that specialised diets such as soft and diabetic were catered for. A four-week menu is in operation and residents had been involved in the drawing up of the menu plan. Residents in the main part of the home said activities took place however there was very limited opportunity to visit outside of the home. The manager confirmed that a review of the activities was taking place. The home employs an activities coordinator for 30 hours a week. It could not be evidenced that activities were taking place on a regular basis in the dementia unit. The residents on the unit were not able to confirm what activities they participated in and there were no records to indicate any involvement in activities. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 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) EVIDENCE: This section was not inspected on this occasion. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 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) 19,24,26 The lack of satisfactory hygiene measures and residents not having safeguards in place to protect their possessions does not provide residents with safe comfortable surroundings in the dementia unit. The continuing upgrade of the home provides other residents with safe comfortable surroundings. EVIDENCE: An adverse odour was noted throughout the dementia unit. The carpet is regularly shampooed however this only temporarily eradicates the malodour. Since the last inspection the corridor of the dementia unit has been redecorated and the bathroom redecorated and water pipes boxed in. The furniture in the lounge and dining area needs to be thoroughly cleaned. There is limited communal space in the dementia unit with the corridor being the only space available for residents to walk around in. The lounge and dining areas only have sufficient space to accommodate the required furniture. The homes building audit has made provision for some new pieces of furniture and an ongoing redecoration programme of communal areas and bedrooms. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 14 Residents in the dementia unit do not have their personal possessions protected as residents wander into the bedrooms and not all bedrooms have door locks fitted. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 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) 27,29 Residents living in the dementia unit are not cared for in a safe environment due to staffing levels. Residents in the main part of the home are cared for by satisfactory levels of staff. A training programme provides a knowledgeable and skilled care team. EVIDENCE: On occasion only one member of staff has staffed the dementia unit. The manager stated that nurses in charge of each shift know that 2 staff must be in the unit at all times but for some reason this had not always happened. The number and deployment of staff available during the daytime is not sufficient to meet the needs of the residents in the unit. The supervision aspect of residents is not satisfactory and this places residents at risk. Staff were seen to be delivering care in a sensitive manner, however on the occasions this was viewed, staff were very busy trying to assist with care tasks such as taking a resident to the lavatory but also trying to support other residents to be led away from entering other residents bedrooms. In the main part of the home staff were seen to be caring and willing to give a good service to the residents. Residents spoken with said that the care they received was “very good”,”the staff can’t do enough for you” Call bells were noted to be answered promptly and residents confirmed that this was normally the case. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 16 Staff spoken to said there were sufficient staff in the main part of the home, however the dementia unit was very busy at times and needed at least 2 staff to care for residents in a safe manner. The acting manager has implemented a training programme and is using the companies training packs and external trainers to provide relevant training. Staff were able to give examples of training they had attended. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 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) 32,33,38 Residents live in a home, which is managed to their liking. There are systems in place for residents to comment on the home and the care they receive. Record keeping is of a good standard and the health and safety and welfare of residents is promoted. EVIDENCE: Residents spoken to said that they were “happy and settled” and “enjoy living here” and “The new manager is lovely”. Since the last inspection a new manager, who was the deputy of the home has been appointed. An application to be the registered manager is being processed by the commission. Residents said that the style of management gave them “A lot of choice and I can pretty much do what I want”. The residents spoken to confirmed that residents meetings took pace and that “someone from the head office comes and talks to us” the commission receive Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 18 monthly reports from the area manager, who must visit the home on a monthly unannounced basis, and talk with staff and residents. A selection of policies and procedure were inspected such as the fire log book and servicing certificates for the lift and hoist. These documents are up to date and reflect the maintenance safety programme the home has implemented since the last inspection. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 3 x x x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 3 x x x x 3 Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 20 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 OP 7 Regulation 15 Requirement The registered person must ensure that all care plans are reviewed regularly and reflect residents current care needs. The registered person must ensure that satisfactory activities are provided for all residents and a record is maintained of participation and provision. The registered person must ensure that the Dementia unit has satisfactory numbers of staff on duty at all times to safeguard and care for residents The registered person must take action to eradiciate the adverse odour in the Dementia unit The registered person must take action to safeguard residents personal posessions Timescale for action 31 December 2005 30 November 2005 31 October 2005 2. OP 12 16(2)(n) (m) 3. OP 27 18(a) 4. 5. OP 26 OP 24 16(2)(k) 23(m) 31 October 2005 31 December 2005 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. Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 21 Refer to Standard Good Practice Recommendations Willoughby Grange C53-C04 S2575 WilloughbyGrange V244511 230805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unity House, The Point Weaver Road Off Whisby Road Lincoln, LN6 3QN 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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