Inspection on 10/07/06 for Willow Court

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willow Court 03/10/07

Willow Court 28/11/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Willow Court Willow Court Charlton Road Andover Hampshire SP10 3JY Lead Inspector Sue Maynard Unannounced Inspection 10th July 2006 09:00 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 Willow Court DS0000063341.V298545.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. Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Court Address Willow Court Charlton Road Andover Hampshire SP10 3JY 0126 4325620 0126 4326623 mary.critcher@hants.gov.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) Hampshire County Council Mrs Mary Critcher Care Home 66 Category(ies) of Dementia - over 65 years of age (66), Old age, registration, with number not falling within any other category (66) of places Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: Willow Court is a purpose built residential home offering support and nursing care for up to 66 persons in the categories OP (old age not falling in any other category) and DE(E) (dementia over 65 years of age). All residents are accommodated in single rooms equipped with en-suite facilities on two floors in six separate living units with their own lounge, kitchen and dining facilities. The home, which was first registered in June 2005, is under the management of Hampshire County Council who are responsible for a number of similar homes throughout Hampshire. Sited adjacent to Andover War Memorial Hospital the home is on a main bus route within five minutes of Andover town centre and community facilities. The weekly fees for care in the home are based on Hampshire Social Service rate of £430. Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection for 2006/2007. The inspection was conducted by one inspector and took place over two days and lasted a total of eleven hours. During the visit the inspector toured the building and spoke to residents, members of staff and visitors to the home. Evidence was obtained from reading resident’s records and care plans. Staff recruitment records were examined. The inspector observed staff interactions and responses with the residents. Discussions were held with the Registered Manager who was present on both days of the visit. Additional information was made available prior to the visit in a pre-inspection questionnaire completed by the manager. Hampshire County Council also gave information in the Regulation 26 notices supplied to the Commission. What the service does well: What has improved since the last inspection? Since the last inspection the pre-admission assessment format has been reviewed to ensure that the psychological needs of the prospective residents are now fully assessed. The final draft of this document is being submitted to Hampshire County Council (HCC) as an assessment tool to be used to assess Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 6 all prospective residents requiring nursing care in a HCC nursing home throughout the county. The home has provided a mobile phone that now enables residents to make and receive telephone calls in the privacy of their own rooms. Written consent and risk assessments are now in place for all residents who may have restrictions placed on them by the use of bedrails and wheel chair lap belts. The manager has implemented a quality assurance system in the form of questionnaires that seeks the views of the residents, their families and staff working in the home. The home is actively seeking to recruit more permanent staff to work in the home to enable them to reduce the number of staff from outside agencies. 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. Willow Court DS0000063341.V298545.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 Willow Court DS0000063341.V298545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A system of assessment and identifying the residents’ needs is in place that ensures that the residents needs are be met. Standard 6 is not relevant to this service. EVIDENCE: Residents’ records demonstrated that they had been admitted to the home following a full assessment by the manager or a senior nurse. Assessments and information from the residents care manager and other health care professionals, including doctors; occupational therapists, physiotherapists and districts nurses are included in the assessment. At the last visit to the home the inspector noted that the assessment did not fully address the psychological needs of the resident. The assessment format has been reviewed and now addresses both the physical and psychological needs of the resident and forms the basis for the care plans that are written to meet their needs on admission to the home. Risk assessments are undertaken and the residents’ records Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 9 showed that these are reviewed regularly. Residents spoken to confirmed that they had been included in the assessment process. Full needs assessments are also undertaken for all residents who are admitted to the home for short stay respite care. Willow Court DS0000063341.V298545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The arrangements for planning care are clear and ensure that the health, personal care and medication needs of residents are met and their privacy and rights are respected EVIDENCE: The records for five residents were examined. These were all found to be comprehensive and documented information of the contact details for the residents’ next of kin and doctor. Care plans were detailed and addressed the individual needs of the resident. During the last visit to the home the inspector identified that the care plans did not reflect when restrictions had been agreed with the resident or their representative for the use of bed rails and wheel chair belts. This has been addressed and signed consents were included in the resident’s records. The care plans and daily records reflected the changes in the physical and psychological conditions of the residents. The inspector noted that none of the care plans had been signed by the resident or their representative to provide evidence that they had been involved in the care planning process. Staff had also not signed the care plans on completion. This was discussed with the manager and senior nurse who said they would bring Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 11 this to the attention of the staff responsible for the compiling of the care plans and ensure that all the plans were signed in future. All the care plans had been reviewed and updated regularly. The records also provided evidence that nutritional assessments had been undertaken and the dietary needs of the residents addressed especially for those residents whose nutritional needs were being supported by enteral (PEG) feeds. Risk assessments were in place for the safe moving and handling of the residents. Records seen and comments made by staff and residents confirmed that other health care professionals e.g. doctors, district nurses, community psychiatric nurses, physiotherapists and occupational therapists are consulted and visit the residents when required. Medication records were examined and found to be in order. MAR sheets had been completed and signatures for all medications given had been signed for. The medication procedure for the home ensures that all medications received into the home and those that are sent for disposal are documented and the signature of two nurses is recorded. All the medications are stored in secure cupboards and medication trolleys. Currently, tablet packages, that are not included in the medication blister packs, do not identify when the pack was opened. The inspector advised the manager and senior nurse that the opening date should be written on the pack to provide an audit trail in the event that any problems arose with a resident’s medication. They have agreed to ensure that this is done. Residents confirmed that the staff are always polite and respectful towards them. Members of staff were observed knocking and identifying themselves before entering a resident’s room and waiting for a response before entering. Since the last inspection residents now have access to a mobile phone that enables them to receive calls in the privacy of their rooms. Willow Court DS0000063341.V298545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management of the social and recreational programme is creating a positive, varied and interesting life for the residents, which meets their expectations for living in the home. The residents are supported and encouraged to make choices about how they live their lives, including choosing from a daily menu, that provides them with a well balanced and varied diet. EVIDENCE: A full programme of social and recreational activities is available to all the residents. On admission to the home the person responsible for the activities meets with the resident and/or their family to identify any special interests that the resident may have had during their lives before admission to the home. Together with information obtained from their life history, the home endeavours to maintain or revive these interests. A wide range of activities is available including music therapy, arts and crafts and therapeutic hand massages and a programme of chair exercises. Residents spoken to said how much they enjoyed the various activities especially the arrangements to mark special occasions and events. One resident spoken to said that she chose not Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 13 to join any of the activities but was always asked. She said she was never put under any pressure to join in or made to feel uncomfortable when she refused. Family and friends are able to visit at any time and residents can meet with them in the privacy of their own room, the visitors’ room or out in the garden. Visitors spoken to during the inspection said that they were always made to feel very welcome and were always offered tea and coffee. They told the inspector that they were very satisfied with the standard of care provided for their relative and that the staff and manager were always available to discuss the well being of their relative. They also confirmed that in the event of any change in their relative’s condition a senior member of staff had notified them and had kept them up to date with any further changes. The home is supported by voluntary organisations including the League of Friends who visit the home with a shopping trolley enabling the residents to purchase small items such as sweets and toiletries. Clergy from both the local Anglican and Roman Catholic churches visit the home regularly and hold a service for the residents. One resident spoken to said that her religion had always been important to her and how pleased she was that she was able to maintain this part of her life after her admission to the home. Residents spoken to praised the choice and quality of the meals provided in the home. The residents are offered a varied choice of food at each meal and special dietary needs are catered for. The food for the home is supplied by the catering department in the main hospital and brought to the home in individual heated trolleys. The meals are served to the residents in one of the four separate dining areas in the home. Staff support those residents who need assistance with eating their meals. Residents spoken to confirmed that they are able to eat their meals in their room if they wish to. Reports made to CSCI prior to the last inspection identified an issue with the quantity of food being supplied at some meals as being insufficient. The manager confirmed that this has been addressed and she is now satisfied with the current quantities being supplied. Willow Court DS0000063341.V298545.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The complaints procedure for the home ensures that residents and their families will have their complaints listened to, taken seriously and acted upon appropriately. Policies and procedures are in place that ensures the residents will be safe and protected from abuse at all times. EVIDENCE: The home maintains a record of any complaints that are received. The records demonstrate that the complaints are investigated according to the home’s complaints procedure and the outcome of any investigation into the complaint is documented. Residents and visitors spoken to told the inspector that if they had any concerns they would speak to the manager or a member of staff and were confident that any issues would be dealt with appropriately. Staff spoken to, confirmed that they had received training during their induction training on how to respond if they became aware of an incident of abuse towards a resident and would know how to report this. No additional training has been provided since this original training. This was discussed with the manager who has agreed that additional training updates will be arranged for the staff and that staff awareness will also be part of the staff supervision process. Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Systems are in place that ensures that the residents live in a clean, safe and well-maintained environment. EVIDENCE: A tour of the building demonstrated that the home is well maintained and kept clean. Specialist equipment including ceiling hoists and nursing beds are provided. All rooms are single occupancy and have an en-suite bathroom. The home employs a General Manager who has responsibility for the maintenance of the building and supervision of the team of housekeeping staff. A member of the housekeeping staff spoken to confirmed that they are provided with all the equipment and materials necessary to do their job. They also stated that they were supported in their role within the home by both the nursing staff and the managers. Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff who are trained and competent to do their jobs are employed in sufficient numbers in the home meet the residents’ needs. The robust recruitment policy and procedure ensures that the residents are supported and protected at all times. EVIDENCE: Since the last inspection the home is now at full occupancy, 66 residents. The home is employing staff from an agency to ensure that the numbers of staff on duty over a twenty-four hour period are sufficient to meet the needs of the residents. To maintain continuity of care, where possible, the same agency staff are requested for all shifts that have to be covered. The manager confirmed that she is seeking to recruit permanent staff and is due to interview applicants later in the week. One resident spoken to said that the staff always seemed to be very busy and that she sometimes had to wait for a nurse to answer her call alarm but that this did not happen very often. Care staff working in the home are undertaking training for NVQ at level 2 and 3. At this time 40 of the staff have achieved level 2 or 3. All staff are recruited in accordance with the Hampshire County Council recruitment and selection policy. Staff records seen confirmed that prior to the Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 17 commencement of employment, an application form had been completed, references had been obtained and checks had been undertaken with the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults register (POVA). All applicants are interviewed and gaps in employment history are looked at. On the commencement of employment all new staff are subject a probationary period and undertake induction training. In addition to their induction training the staff are provided with training updates covering manual handling, dementia, medication, food hygiene and infection control. Records of all training undertaken by the staff are documented in their personal files. Further training needs are identified during staff supervision and their annual appraisal. Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 18 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager is able to demonstrate that she is suitably qualified to ensure that the home is well run and that the needs of the residents are met. A quality assurance system is now in place that ensures that home is run in the best interests of the service users. Systems are in place that ensure that the service users financial interests are safeguarded Monitoring of fire safety procedures and systems have not been maintained and may be putting the residents at risk. EVIDENCE: Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 19 The registered manager who is a registered nurse has had management experience in the National Health Service and has a Diploma qualification in management studies. Since the last inspection the manager has undertaken quality assurance surveys with staff, the residents and their families. A sample of the surveys was seen during this visit and the feedback from these was very positive. Speaking to residents and visitors to the home it was clear that their opinions are regularly sought on an informal basis. The manager operates an “open door” policy and members of staff spoken to told the inspector that they were able to discuss any issues that they had quite freely with the manager or a senior nurse at any time and were confident that their opinions were always listened to. Procedures are in place that ensures that residents’ money is secure and is stored individually. Records of all money received and spent were available for examination by the inspector. Fire safety records examined by the inspector were found to be incomplete. The records showed that staff had not received a fire training update since June 2005. There were no records to demonstrate that fire safety equipment and alarm systems were being tested regularly. The fire safety procedure did not clearly outline how all the staff were expected to react in the event of a fire. This was discussed with the registered manager and the general manager who agreed that fire safety training for all the staff would be provided. On the second day of the inspection the training sessions had been arranged and notices informing all members of staff that they had to attend had been posted in the staff rooms. The registered manager informed the inspector that the fire safety procedure was to be reviewed and that advice was being taken from Hampshire County Council. The general manager confirmed that he would be undertaking regular checks of the fire alarm system and equipment. Records demonstrated that the staff have undertaken training for the safe moving and handling of residents. Infection control instruction is given to all staff during their induction training. A record of all accidents to staff and residents is maintained and the manager or a senior nurse audits these records. Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 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 2 Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 23 Requirement The Registered Manger must take adequate precautions against the risk of fire. Staff must be provided with regular fire safety training and drills. All fire safety equipment and alarm systems must be tested and maintained regularly. The fire safety procedure, including evacuation, for the home must be available and displayed for all those entering and working in the home. Timescale for action 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Willow Court DS0000063341.V298545.R01.S.doc Version 5.2 Page 23 - 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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