Inspection on 11/09/06 for Willow Court

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 29/09/08

Willow Court 29/01/08

Willow Court 07/02/06

Willow Court 08/08/05

Willow Court 08/11/04

Willow Court 25/05/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOMES FOR OLDER PEOPLE Willow Court Osborne Gardens North Shields Tyne & Wear NE29 8AT Lead Inspector Ian Armstrong Key Unannounced Inspection 09:45 11 September 2006 th 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 DS0000028826.V289515.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. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow Court Address Osborne Gardens North Shields Tyne & Wear NE29 8AT 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) 0191 296 5411 0191 2964568 willow.court@fshc.co.uk Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Mr Ian Hindhaugh Care Home 48 Category(ies) of Dementia - over 65 years of age (45), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3) Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named resident is under the age of 65 years. Should this resident leave the home the Commission for Social Care Inspection must be notified. One service user is category DE. No further admissions to take place in this category without prior agreement of CSCI. 7th February 2006 Date of last inspection Brief Description of the Service: Willow Court is a 48 bed care home with nursing. Providing care for older people with enduring mental health problems. Care in the home is provided by Registered Mental Nurses supported by care staff. The home is owned and managed by Four Seasons Healthcare Ltd a large national provider of services for vulnerable client groups. The home is situated in North Shields close to local shops and good public transport links. The building is of two floors with 48 bedrooms on both floors, all of which have en-suite facilities. There are a number of lounge and dining rooms. On each floor there is also toilet and bathroom facilities. The home has its own kitchen and laundry room. The philosophy of care is to support the residents in their activities of daily living and to provide for their physical and mental health needs. On the day of the visit there was 37 residents in the home 25 females and 12 males with 11 vacant beds. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection which took place over one day. Time was spent with residents, relatives and staff. A number of home records were inspected, assessments and care plans, medication records, policies and procedures, residents financial records, staff training and recruitment files. A tour of the premises was carried out. Relatives, residents and staff were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Social assessments and care plans must be more detailed to meet individual residents needs. Activities for the residents need to show a greater range of events occuring than those currently. Activities need to be displayed on both floors of the home. Sleep profiles must be completed for newly admitted residents. More needs to be done to make mealtimes a more pleasant experience for the residents. Dining table settings are not satisfactory. Menus in current use in the home are not satisfactory. Cooked breakfasts must be stated, sandwich ingredients must be stated. An alternative to fish at lunchtime must be offered, alternative sweets at mealtimes must be offered. Suppertime meals need to show a greater variety of food than that currently offered. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 6 Weekly checks of the homes aspirator need to be carried out to ensure it is working satisfactorily these checks to be recorded. Staff recruitment, two written references must be obtained for all new employees. Supervision of staff must be carried out at least every two months. Staff meetings should take place at least every two months. 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 DS0000028826.V289515.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 Willow Court DS0000028826.V289515.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): 3 & 6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home does not provide intermediate care. EVIDENCE: Four residents pre-admission assessment records were inspected. The records showed good levels of information for each resident was documented. A relative spoken to said they had the opportunity to look around the home prior to admission and that they had received good information about the homes services. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is generally satisfactory. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Four residents care records were inspected. A good range of care plans was recorded in each residents file, there was evidence of regular evaluations of these taking place. However social care plans are too generalised and need to be more detailed and individualised. Social assessments also need to include more detail on residents previous lifestyles, interests and hobbies. Records carried out by other health care professionals were well completed. Sleep profiles for newly admitted residents need to be carried out. Risk assessment documentation was satisfactory. The systems for the management of medications were checked and were satisfactory. Two residents controlled medication stock balances were checked and were correct. The aspirator needs to be checked weekly to ensure it is working satisfactorily a record of these checks must be kept. The treatment room was clean and tidy a waste bin here needs to be replaced as it had no lid. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 10 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 not satisfactory. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A weekly activities programme for residents was inspected. This needs to be more comprehensive than at present, to provide a greater choice and variety of events for the residents. Activities programmes should be displayed on both floors of the home. Social assessments need to include more detail about residents previous lifestyles, interests and hobbies and these must be incorporated into a social care plan. A recent trip out to the seaside for some of the residents has taken place. Some residents have been out for pub lunches. Gender of staff for personal care tasks has been identified and is met. The home has an open visiting policy and a number of visitors were observed to come and go throughout the inspection. Two relatives were spoken to who said they could visit at any time and were made welcome by the staff. The lunch time meal was observed the meal was beef pie or baked potatoes with fillings, with peas, carrots, turnip and mashed potatoes. Sweet was Manchester tart. Staff were assisting with feeding where required and were attentive to the residents needs. Tablecloths to tables, however no cutlery in Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 11 place, no condiments to tables and no napkins. Lemon juice was provided to take with the meal no alternative drinks were provided. Menus were examined and are unsatisfactory for example, cooked breakfast by request is not acceptable, breakfasts must state what is offered cooked for breakfast each day. Sandwiches the ingredients for these must be specified, fish or fish on a Friday no alternative offered. Suppertime meals show little in the way of variety of food offered. Alternative sweets are not stated in the menus. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is generally good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The homes complaints policy was examined and is of a good standard. Two recent complaints had been received and these have been successfully resolved to the satisfaction of the complainants. The Protection of Vulnerable Adults policy is well written as is the whistle-blowing policy, staff spoken to were aware of procedure to follow. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26. Quality in this outcome area was generally satisfactory. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A tour of the premises was carried out. The downstairs lounge has recently been decorated, with new chairs purchased and a new carpet fitted to a good standard. Consideration should be given to purchasing a larger screen television for this room. A number of residents bedrooms were seen and these were in the main nicely personalised with personal effects and were clean and tidy. However the floor to the ensuite in room 37 is badly stained and deteriorated and needs to be renewed. A window in an upstairs lounge has condensation damage and needs to be renewed. The kitchen was seen there were good stocks of food present and it was generally clean and tidy. However kitchen cleaning records when checked these are not being adhered to. The laundry facility was clean and tidy COSHH information was on display. Generally the home was clean and tidy and odour free. Two relatives were spoken to who said they were generally satisfied with the services provided. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 14 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 generally satisfactory. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Duty rosters for staff were inspected these showed the following levels of staff being employed in the home each day: Am - 2 Qualified and 5 care staff Pm - 2 Qualified and 5 care staff Nights -2 Qualified and 2 care staff Rosters show that these staffing levels are being maintained and are based on the assessed needs of the residents and are in keeping with the reduced number of residents in occupation. Two staff recruitment records were inspected in both of these only one written reference was seen, all other checks were satisfactory. Staff training records were examined. Good levels of induction and statutory training were in place. Client centred training the manager intends to pursue this with North Tyneside College for Dementia Awareness. One of the relatives expressed some concerns about the numbers of staff on duty each day as being not enough in their view to meet residents needs Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 15 Two members of staff also felt at times there was not enough staff available to carry out the work needed to be done on the first floor. Discussed the issues with the manager. He said the arrangement in the home was that the third member of care staff on the ground floor was available to work on the first floor at busy times but he agreed this had not been happening and he would rectify this. Recommended that the manager carried out a dependency study in relation to ensuring residents needs are being met. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 16 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 generally satisfactory. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A new manager has been appointed and has been in post just over 4 weeks. Prior to his appointment he has managed another elderly care home. He has worked with older people with enduring mental health problems for almost 10 years. Commenced the Regional Managers Award training in March 06. Relatives meeting minutes were read and these are satisfactory. Staff meetings only one has been held this year. Staff supervision which must take place 2 monthly has not been taking place. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 17 Residents money records were checked there was evidence of regular expenditures with two signatures for all transactions. The fire log book and accident book records were checked and were being well maintained. Utility certificates were examined all of which were satisfactory. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 18 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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16.2(n) Requirement Timescale for action 31/10/06 2. OP7 15.1. The activities programme for residents must be reviewed to provide a better range of leisure events. Programmes of these must be displayed on both floors of the home. All residents in the home must 30/11/06 have detailed social assessments completed from which social care plans can be written to address each individuals needs. Menus in the home need to show an alternative choice of food for the main meals each day. Sandwich ingredients must be specified. Cooked breakfasts must be stated each day. Suppertime meals must show a greater variety of food being offered. Dining table settings must be improved. Weekly checks of the homes aspirator must be carried out to ensure it is working satisfactorily, these checks must be recorded. 30/11/06 3. OP15 16.2(i) 3. OP9 13.4© 17/09/06 Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 20 4. 5. 6. 7. 8. OP29 OP36 OP19 OP19 OP26 19.1© 18.2 23.2(b) 23.2(b) 16.2(j) Staff recruitment, two written references must be received for all staff employed in the home. Supervision of staff must take place every two months. Bedroom 37 the en-suite floor must be renewed. The window in the upstairs lounge condensation damaged must be renewed. Kitchen cleaning schedules must be adhered to. 31/10/06 30/11/06 30/11/06 30/11/06 17/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP24 OP15 OP27 Good Practice Recommendations Consideration should be given to providing a larger screen television for the downstairs lounge. Alternative drinks could be offered with the main meals each day. That the manager carry out a dependency study to ensure staffing levels are in line with residents needs. Willow Court DS0000028826.V289515.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000028826.V289515.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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