Inspection on 04/04/07 for Willoughby Grange

This inspection was carried out on 4th April 2007.

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 31/05/06

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 Mr Toby Payne Unannounced Inspection 4th April 2007 08:15 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.V332477.R01.S.doc Version 5.2 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.V332477.R01.S.doc Version 5.2 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 willoughby.grange@fshc.co.uk www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) vacant post 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.V332477.R01.S.doc Version 5.2 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. 31st May 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 accommodation on the first floor accessed by a shaft lift. The home has its own mini bus and is also situated close to a bus route and the centre of Boston. 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 nursing and personal care 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 £380 to £550 per week. Extras were hairdressing which ranged from £5 to £22, chiropody £8 and personal newspapers and magazines. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection started at 8.15 am. It was undertaken using a review of all the information available to the inspector regarding our service history about Willoughby Grange. It took place over 6 hours. The inspector spoke to 9 residents 6 staff and the acting manager. Four comment cards were received after the inspection visit. The main method was called “case tracking”. This involved selecting 2 residents and tracking the care they received. This was done through the checking of records, discussion with them, the care staff and observation of how care was delivered. As a result of concerns during the previous key inspection of the 31/5/2006 an unannounced random inspection took place on the 8/11/2006. 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. The summary of this inspection report can Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 6 be made available in other formats on request. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 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.V332477.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvement to the service user’s guide and statement of purpose, required from the previous inspections and so this information is now up to date and providing current information relating to the home. People coming into the home receive an assessment and know their needs can be met. EVIDENCE: Since the last random inspection the statement of purpose and service user’s guide had been reviewed and now had information about the current status of the home including the home manager and staffing structure. A copy of the service user’s guide was given to each new resident. The information was also available at the front entrance to the home. Each person coming into the home was assessed by the manager using a new comprehensive dependency assessment form, which was the base of the care plan and was introduced in October 2006. The manager was not aware of the Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 9 requirement to send written confirmation to all new people that based on assessment the home could meet their needs. However this was addressed during the inspection. Each person received terms and conditions and during the inspection a clearer fee structure was produced. The home does not provide intermediate care. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans had improved since the last inspection and there is now good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. Procedures relating to the delivery of personal care are sufficient. Medication has also improved and is safely given by staff who know what they are doing. EVIDENCE: Since the last random inspection a new care planning system had been introduced in October/November 2006 and staff had received training on the new system. Care records for 3 people were examined and were detailed with a resident identification sheet with photograph, dependency assessment tool including monthly evaluation, care plan index with care needs, care plan with details of assessed needs, expected outcomes, care and evaluation. Care records had greatly improved and existing residents care needs were being transferred to this new system. There was however little evidence to show that residents/relatives had been involved in identifying their needs. The manager acknowledged this and explained that reviews involving the resident/others would be introduced in the future. A comment card stated, Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 11 “basic care is good. Attention to detail is sometimes lacking. Clothes sometimes not ironed. Drinks, tissues and radio I not always within reach. The staff are generally caring and hard working”. Medication had also been addressed since the last random inspection. A member of staff was now responsible for medication. There were clear records of medication being received into the home and the monitored dosage system was introduced into the home in October 2006 and staff had been trained on the system by Boots. Medication was administered by nurses and senior care assistants who had been assessed as competent to administer medication by the manager. The manager also undertook a monthly audit of the medication. The inspector observed a medication round during lunch. There were no concerns. Residents felt there privacy was respected and this was shown by staff knocking on doors before entering rooms and talking to people in a calm and friendly manner Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s social and cultural needs are met at the home. The range of activities provided by the home have improved since the last inspection. There was a variety of nutritious food provided. EVIDENCE: Since the last random inspection activities had improved and been reviewed following discussions with residents at a residents meeting on the 28/2/2007. Residents expressed a wish for more arts and crafts and outings in the minibus. It had been decided that a weekly activities programme would be produced and the content reviewed each week. Residents who spoke to the inspector were quite satisfied about the new activities. The main improvement had taken place on the dementia unit. The activities person was now concentrating on activities for residents rather than other activities, which were identified at the previous random inspection. He had also joined national activities organisation NAPPA and was developing links. The overall environment was more stimulating and residents were more alert, drinking coffee, in conversation with one another or staff. There was no sign of distress, no calling out and a much more relaxed atmosphere. Residents commented, “there are things to do” and “the food is enjoyable”. A comment card stated, “ the standard of food is very good. Mum has pureed meals and Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 13 they are tasty and well cooked. We are pleased with the standard of care given”. Concerning catering, Boston Borough Council inspected the home on the 20/3/2007 and once again awarded a bronze award for catering which was the same as in 2006. Not all catering staff had received training. Two staff out of 6 had not had food hygiene training but this was to take place during April 2007. Another cook was to be recruited and the interview took place during the inspection. Picture menus were being introduced and the menu was to be displayed in the future to give information to the residents. The menu had 2 choices but an alternative could be provided. Residents had no complaints about the food. The manager also audited the catering every month. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have taken place in the way complaints are handled. People know how to make a complaint and feel that staff will listen to their views. Staff are aware of how to respond to a complaint or an adult protection allegation. EVIDENCE: Since the last inspection the complaints procedure had been reviewed and now made reference to the CSCI local office with phone number. A copy of this was in each service user’s guide and displayed on the wall at the entrance to the home. The complaints register was examined and showed one complaint was received by the home since the last random inspection. There was a clear audit trail and evidence to show the complaint had been thoroughly investigated. The commission had received no complaints since the last random inspection. A comment card stated, “I have always received a sympathetic response when I have brought issues to the manager’s attention”. Adult protection training was to be provided for all staff during April 2007. This would also be covered in the new comprehensive induction standards for all new care workers. Staff who spoke to the inspector confirmed this information and knew what abuse was and what they should do if abuse was suspected. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 15 None of residents, staff or visitors had any concerns about the home. A visitor commented “I can visit whenever I wish to do so and I have found the staff helpful and friendly”. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have taken place since the last inspection to the environment on the dementia unit and these people live in comfortable, clean and safe accommodation. However accommodation is let down by the poor standard of carpets in some parts of the home. EVIDENCE: A tour of the premises was undertaken. The home was clean and tidy and no obvious hazards were noted. Since the last random inspection a great deal has been done to improve the environment on the dementia unit. The lounge, dining room and corridor had been repainted in bright colours and the corridor had a gardening theme with bright flowers, wall hangings, watering cans on the wall and area providing a stimulating environment. The lounge was restful with fresh flowers, pictures, fish tank and television. There was no odour. New brighter lighting had also been installed. The company were exploring Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 17 ways to improve the amount of communal space available in the dementia unit. It had been brought to the inspector’s attention by Boston Borough Council’s Environmental Health Officer concerns about the suitability of the shower. This was followed up at this inspection. The manager confirmed that from February 2007 to April 2007 there were no bathing facilities available on the dementia unit. Residents had to use the bathing facilities on the first floor. This on account of the bathroom requiring a complete replacement. This had taken place and a new specialist bath had been provided and was able to be used on the 10/4/2007. The manager told the inspector that the company were addressing the shower issue and trying to find out the best way of addressing the problems. Following the inspection the inspector was told that a power pump would be installed in the future. The manager agreed that many of the carpets required replacement due to age or wear and tear. There were some bedroom carpets on the first floor, which were stained and heavily worn. She explained that there was a planned replacement for carpets one bedroom a month and the handyman who was in the home on the day of the inspection did most of the repainting. She also agreed with the inspector’s observation that some hand towels were frayed (on a linen trolley on the first floor) and some sheets were worn and needed replacement. She explained that an order for replacement would be sent in the future. Four Seasons had also introduced a planned replacement of beds in each home. Ten new profile beds were to be introduced in the very near future and eventually beds would be replaced with profiling beds. Also since the last inspection odour control and new cleaning procedures had been introduced. There was no noticeable odour during the inspection and all areas were clean. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment practices. Improvements have been made to the training of staff to meet the needs of the people living in the home. However formal training in care and support needs to be increased. EVIDENCE: Many staff had worked in the home for many years. The manager monitored dependency and was able to employ more staff where required. Staff commented that if all staff turned up for work especially at the weekends then they could manage. The manager acknowledged there had been a problem but explained that she monitored sickness and absence and an improvement had been seen and staff were more committed to their work. Staff confirmed this. The manager also explained that she had been addressing the need to have more full time staff rather than relying on part time and bank staff. Two Additional nurses had been recruited. In addition 2 full time care staff were also to be recruited in the very near future (interviews were taking place during the week). The post of deputy manager remained vacant and the manager intends to see how the new staff settle in before recruiting again. Training since November 2006 had included Dementia awareness, moving and handling and Protection of vulnerable adults. New comprehensive induction Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 19 standards for all new care workers had been introduced. The workbook/induction was to cover a period of 12 weeks and staff would work with a mentor. There were however only 8 of care staff who had a qualification in care (National Vocational Qualifications) (4 staff out of 25). The manager was aware this was below the 50 required. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to voice their views and opinions. Residents benefit from the positive leadership from the manager. EVIDENCE: In December 2006 a new home manager was appointed. She has wide experience as a nurse and manager and acknowledged that there was a lot to do to improve the home. It is to her credit that all the requirements from the random inspection had or were being addressed. She was applying to the commission to be the registered manager. She had introduced monthly residents meetings. She also intended to have monthly staff meetings. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 21 A customer survey was sent out to 30 residents/relatives in March 2007. A new care manual with updates was introduced in 2006. This included clinical procedures and comprehensive infection control. Since the last inspection Four Seasons have introduced Total Quality Audit Process in March 2007. This was a very comprehensive auditing system. Internal audits carried out by the manager included kitchens, care records, accidents and bed rails. The home received monthly monitoring visits by the regional manager (reports have not been sent to the commission) but the only report available were the visit on the 8/1/2007. Residents and relatives were satisfied with the care and approach of the staff. Comments were “I am very satisfied” and “whenever I need staff they are there”. Staff commented, “the manager is strict but fair, approachable and visible about the home”. They also noted that residents seemed happier and more settled. There were very comprehensive maintenance records, which were well maintained. Staff had gloves, aprons and alcohol hand washes. There were also detailed health and safety policies. The manager acknowledged that staff were not receiving regular formal supervision. There was an equality and diversity policy. The manager did not feel there were any communication issues and this was confirmed by the observation during the inspection. There were no issues regarding equality and diversity. Accurate records were kept of resident’s monies, which were computer records with receipts and tallies. The records were well maintained and managed by the receptionist. Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 22 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 3 2 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 x 18 3 2 x 2 X X X x 3 STAFFING Standard No Score 27 3 28 2 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 Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 23 No 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations The state of linen and towels should be monitored and a programme of replacement identified and frayed/worn linen replaced. To ensure that people living in the home have clean and acceptable linen. A minimum ratio of 50 of care staff should receive training in care to NVQ standards Staff receive support/supervision at least 6 times a year. Supervision should include all aspects of practice, philosophy of care in the home and career development needs. 2 3. OP28 OP36 Willoughby Grange DS0000002575.V332477.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincolnshire Area Office Unity House The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V332477.R01.S.doc Version 5.2 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!