Inspection on 31/05/06 for Willoughby Grange

This inspection was carried out on 31st May 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willoughby Grange 04/04/07

Willoughby Grange 06/02/06

Willoughby Grange 23/08/05

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 Inspection 31st May 2006 10:00 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 Willoughby Grange DS0000002575.V293509.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. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willoughby Grange Address Willoughby Road Boston Lincs PE21 9EG 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) 01205 357836 01205 356756 willoughbygrange@fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Vivienne Elizabeth Bateman Care Home 44 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (33) Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users with dementia only to be admitted to those rooms designated on the ground floor for the category DE(E) 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. The category Dementia (DE) applies to the person named in the Notice of Proposal to Register dated 4th February 2005 only. 6th February 2006 3. Date of last inspection 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 is registered to provide accommodation for 44 service users. There are 6 double rooms and the remainder are single rooms. Four of the rooms have en-suite facilities. Fees currently range from £369 - £660 per week The home has its own mini bus and is also situated close to a bus route and the centre of Boston. Willoughby Grange DS0000002575.V293509.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 during a weekday and the homes administrator assisted the inspector as the registered manager was on annual leave. A total of 6 hours was spent inspecting the home. The inspector toured the home and spoke with the 5 staff 4 visitors and 7 residents. The main method of inspection used was called “case tracking” which involved selecting residents 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? What they could do better: The statement of purpose and service users guide, which provide residents and relatives with information about the services the home provides, needs to be updated. This is a requirement from the last inspection. Care plans and Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 6 assessments needs to accurately reflect the changes in resident’s abilities and needs and there needs to be evidence that the resident or their relative was involved in the production of the plan. Recruitment records need to contain the necessary information including references and identification. Action should be taken to provide evidence that supervision sessions are taking place. Training records apart for those for COSHH, Fire Safety and Moving and Handling are not always clear to understand. It is advised that all staff should be involved in updated training in respect of Safeguarding Adults. 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 DS0000002575.V293509.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 Willoughby Grange DS0000002575.V293509.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): 1,3,5,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The procedure for assessing prospective residents is satisfactory. The statement of purpose and service user guide do not provide up to date information for prospective residents to be able to make an informed decision regarding living at the home. EVIDENCE: The homes statement of purpose and service user guide are in place but have not been updated following the requirement made at the last inspection. Most residents and visitors spoken with were not aware of these documents. One resident said “I saw a brochure when I moved in”. There was evidence from looking at care plan files that pre admission assessment forms had been completed. It was not always evident that information from social workers or health care professionals had been sent to the home when an emergency admission had taken place. One resident and their relative stated that they had “visited the home before I decided to move in to make sure it was alright for me”. Another visitor confirmed that they had been able to contact the home to ask any questions they had. There was evidence that if the home could not Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 9 offer a place to the prospective resident. This evidences that the homes manager is clear on the skills of the care team and the equipment the home has available. The home does not provide intermediate care. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all care plans provide sufficient information for staff to be clear on resident needs. Health care services provided are satisfactory. Medication records for the receiving of medication need to be improved. Care is delivered in a dignified manner. EVIDENCE: Care plans and risk assessments are updated monthly by either the trained nurse for nursing residents or the senior carer on the dementia unit. Some care plans did not contain sufficient detail regarding what level of support the resident needs. For example “needs help with washing” but did not detail if this was verbal assistance or assistance of 2 staff. Reviews often said “No change” or “care as plan”. This was not always correct. One example was a care plan saying a resident used a wheelchair to mobilise around the home and the review for the past 7 months said “No change”. This resident actually walks with a mobility aid. Other care plans had no evidence that residents or their relatives had been involved in the compilation of the plan or subsequent reviews. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 11 Since the last inspection the medication system has changed to a blister pack system. This is delivered to the home monthly and it was evidenced from inspection of medicine administration sheets that a record was not always maintained of medication coming into the home. Residents are registered with the local GP practices and those residents spoken to say they were satisfied with the services they received. No resident mentioned being registered with a dentist but records evidence that referral will be made if necessary. Chiropody services are provided when needed. Through discussion residents said they felt their privacy was respected and that the staff treated them in a dignified manner and with respect. One family spoken with raised issues, which suggested that a resident dignity was not upheld. These issues were referred to the person in charge at the time of the inspection. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 12 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities provided need to be reviewed to enable relevant activities to be provided for the dementia unit residents. Catering within the home reflects resident’s dietary choices and preferences. EVIDENCE: Residents spoken with said they enjoyed the activities that were provided. A couple of residents said they were looking forward to going for a “trip out”. A record is maintained of all activities provided and who attended these. The home employs an activities coordinator for 30 hours a week to provide activities. It was noted that on occasion the hours for activities are lost so that the activity coordinator can work as a carer. An accurate record should be maintained of actual hours spent providing activities. Residents spoke about the various activities such as dominoes, flower arranging, arts and crafts and said that entertainers also visited the home. Activities for residents accommodated in the dementia unit remain limited. The activity coordinator confirmed that he had attended a dementia study day to gain a better understanding of dementia but this had not provided any suggestions for relevant activities. It is recommended that relevant organisations or training be accessed in order for relevant actives to be provided. In terms of equality Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 13 the home is registered to provide a service to both older people and people who have a dementia. Currently the activities provide more opportunities for the older people in terms of activities. Residents said that their religious and faith needs were met. Visitors spoken to said that they were able to visit the home when they chose to. Residents gave examples of how they were able to chose how they spent their days, such as choosing when to get up and go to bed, where they sat in shared areas and what meals they had. Residents made positive comments regarding the food provided. Menus were varied and in addition to the 2 main meals provided at lunchtime there were also 10 other dishes, which were available at all mealtimes such as omelettes and snack items. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 14 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of information regarding the management of complaints does not give confidence to residents and their relatives that their concerns will be investigated or taken seriously. Lack of training in Safeguarding Adults issues places residents at potential risk. EVIDENCE: Since the last inspection 3 allegations have been referred to social services in accordance with Safeguarding Adults Procedures. These issues have now been concluded and action needing to be taken has been discussed with the home. One of the requirements was that all staff received training in safeguarding adults issues. One of the 5 staff spoken with confirmed that they had “Seen a video on adult abuse”. When the inspector gave the 5 staff a scenario of adult abuse to respond to all staff said they would speak with the manager or report to the nurse in charge. It was evidenced that this was not what had happened in respect of the previous issues. Training records did not demonstrate what training had been given in this area. Resident said if they had any concerns regarding how they were being treated they would either speak to their relative or the manager. Residents were not aware of the complaints procedure or where to locate this. 2 relatives spoken to said they had made a complaint and were not satisfied with how this had been dealt with. The issues within the complaint were referred to the area manager following the inspection by the inspector. In the past 4 months 3 complaints had been made to CSCI regarding the home. Complainants have been satisfied with how the registered provider has dealt with these issues. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 15 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): 19,20,22,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes environment is generally comfortable and residents feel safe. An ongoing review is needed to ensure all areas of the home are of a satisfactory standard. EVIDENCE: A tour of the premises was undertaken. The home was clean and tidy and no obvious hazards were noted. An adverse odour was noted on entering the home and in one of the bedrooms. One bedroom had a soiled carpet which is in need of replacing with a more suitable flooring. Residents said they were satisfied with their bedrooms. No evidence was located in care files to evidence that residents had been consulted regarding bedroom door locks. This was a requirement from the last inspection. It was also recommended that hospital beds be purchased to assist with moving and handling of residents. New beds have been ordered; these were of the divan kind. The main home is welldecorated and new furniture and carpets have been fitted. The dementia unit lounge and dining room would benefit from some minor decorative work. Toilets and bathrooms are colour coded on the dementia unit to assist Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 16 residents with locating the bathrooms. Bedroom doors had been personalised with a name and in some cases a picture to also assist residents in identifying their room. An ongoing issue, which was made a recommendation following the last inspection, is the limited amount of space for residents to use on the dementia unit. There is a lounge and a dining room which together meet the minimum requirement for communal space. No action has been taken to resolve this issue. It is advised that this issue be reviewed and a solution sought. The kitchen was briefly inspected and this was found to be clean and tidy with all work surfaces clean. A cleaning rota is in place. In one bedroom viewed it was noted that an unclean jug and glass had been placed in the bedroom an adverse odour was coming from the heavily strained carpet, 2 used continence wipes were found by the bed and one of the pillowcases on the made bed was heavily soiled. These issues were raised with a care staff who took action to rectify those issues that could be dealt with. Fresh flowers were noted at various points around the home and cleaning staff were working throughout the home during the inspection. Residents spoken with said they felt safe living at the home and that the physical environment was comfortable. One resident stated that on some mornings the lounge was not very warm but this had been addressed with the manager and was “hopefully going to be sorted out”. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory to meet resident’s needs. Lack of robust recruitment procedures places residents at potential risk. Lack of training and induction records do not always demonstrate the skills and knowledge of the care team. EVIDENCE: During the inspection 5 staff were spoken with and 3 staff files were inspected. It was evidenced that one file did not have any references, one file contained one reference and the other file contained one reference from the carers relative. Details such as proof of identity and a recent photograph were missing. Residents made very positive comments about staff and how they were “always willing to help no matter how busy they are” One resident stated that they had had to wait for up to 10 minutes after the bell had been answered to be given assistance. Care staff spoken with said that mornings were very busy in the home and sometimes residents did have to wait a little while but this would only be because other residents were being attended to. Staff gave examples of recent training they had attended. One carer had attended a first aid course, a dementia care study day and a care plan study day. 2 staff have been enrolled on a (National vocational qualification) NVQ 2 course. Induction records for one staff member were not clear and it could not Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 18 be established what induction had been given to the member of staff. The member of staff had not worked as a carer before. Moving and Handling training and fire training is delivered by the maintainace person. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 19 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home would benefit from a review of the management structure, to one, which affords support for the manager. The manager’s approach to dealing with concerns should be reviewed. Health and safety systems protect residents. EVIDENCE: The homes manger is registered and works full time in the home. Residents spoken with said that the manager was approachable and they would often see her when she was working. Two relatives commented that they felt that the manager was not always approachable when they raised concerns. There is no deputy manager in the home and it is advised that a review take place of the management structure as the manager may benefit form support. The regional director who produces a report regarding the conduct of the home visits the home monthly. This is sent to the CSCI. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 20 It was not clear if a quality assurance programme was in place for residents to feedback their views on the home, however it was evidenced that resident meetings take place and that residents felt they could raise any issues they may have. It was a requirement from the last inspection that formal supervision take place for staff. Those staff spoken to were not clear if they had received supervision, one staff said they had received an appraisal. Health and safety arrangements in the home are satisfactory. The maintainace person maintains records for fire safety training and moving and handling. Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 21 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 1 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 17 x 18 2 3 3 3 x x x 3 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 3 3 2 3 2 Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 15 Requirement The registered person must ensure that all care plans are reviewed regularly with the involvement of the service user or their representative, and accurately reflect residents current care needs. (Original timescale of 31/12/05 not met). The registered person must ensure that the Statement of Purpose is updated to reflect management and staff changes in the home. The registered person must ensure that a record is maintained of all medication received into the home. The registered person must ensure that all staff have references and evidence of identification before commencing employment. The registered person must ensure that all residents and DS0000002575.V293509.R01.S.doc Timescale for action 31/08/06 2. OP1 4 31/08/06 3. OP9 13(2) 30/06/06 4. OP29 19 30/06/06 5 OP16 22 31/07/06 Willoughby Grange Version 5.1 Page 23 6 OP18 13(6) 7 OP30 19 persons visiting the home have access to the complaints procedure and a record is maintained of all action taken when a concern is raised. The registered person must 31/08/06 ensure all staff receive training in safeguarding adults, in sufficient depth for staff to be able to identify practices which may constitute abuse and how to report these. The registered person must 31/08/06 ensure a record is maintained of all training provided and attended by staff. 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 OP20 Good Practice Recommendations It is recommended that ways of increasing communal space in the dementia unit be explored. It is recommended that the use of hospital style beds for nursing residents be considered. 2. OP22 Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Lincoln Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Willoughby Grange DS0000002575.V293509.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!