Inspection on 28/11/05 for Willow Court

This inspection was carried out on 28th November 2005.

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

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

Other inspections for this house

Willow Court 03/10/07

Willow Court 10/07/06

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 Peter J McNeillie Unannounced Inspection 28th November 2005 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.V256252.R01.S.doc Version 5.0 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.V256252.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willow Court Address Willow Court Charlton Road Andover Hampshire SP10 3JY 0126 4325620 0126 4326623 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.V256252.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A 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 ensuite 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. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection since the home was registered on 27/06/05. During the inspection, which took place between 9:00am and 2:30pm, the inspector spoke with a number of resident’s, the registered manager and staff on duty. Evidence was also gathered from a tour of the building, reading records, care plans, comments by management/staff, observations and responses to comment cards distributed prior to the inspection by The Commission for Social Care Inspection (C.S.C.I.), reports to C.S.C.I. under regulation 26 and a pre inspection questionnaire provided by the homes Registered manager. What the service does well: What has improved since the last inspection? What they could do better: The home needs to 1) Improve the assessment documentation to include more information on potential residents with dementia. 2) Ensure that care plans include information on any restrictions placed on residents e.g. bed sides etc. 3) Provide a more detailed risk assessment re who has responsibility for the administration of resident’s medication. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 6 4) Provide more staff in the morning to ensure residents do not have to wait to get up and get dressed. 5) Provide facilities for residents to make and receive telephone calls in private. 6) Introduce a quality monitoring system that seeks the views of residents. 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.V256252.R01.S.doc Version 5.0 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.V256252.R01.S.doc Version 5.0 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 The home has a system of assessing and identifying residents needs which ensures residents safety and assessed needs can be met. EVIDENCE: Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 9 Residents and records viewed confirmed persons were only admitted on the basis of a multi disciplinary assessment of need and risk by the manager or another member of the senior staff( who visits the potential resident in their own home or in hospital )and a number of external health care professionals including GPs, geriatricians, continence advisors, physiotherapists, occupational therapists and care managers. Verbal confirmations by residents and records viewed confirmed residents or their representatives were consulted and contributed to the assessment process. Records viewed also confirmed assessments of need and risk for all current residents are reviewed on a regular basis again in consultation with external health care professionals. Since her appointment the manager is reviewing the assessment documentation to ensure all residents needs can be identified and plans produced to ensure these needs can be met, this is of particular importance when supporting/caring for persons with dementia about whom more information is required than is at present available. Progress will be reviewed at a future visit to the home. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 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 The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected EVIDENCE: Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 11 All of the residents spoken with expressed total satisfaction with the care they were receiving and the manner in which it was delivered. They also confirmed they were consulted about the contents of their individual care plan and the assessments on which the plan was based. All were aware they could view their plan at any time. Care plans which were reviewed monthly contained information on how identified needs including any special needs were to be met but did not reflect when restrictions e.g. use of bed sides and wheelchair restraining belts had been agreed. The manager gave a verbal undertaking on care plans where this information was not clear or missing plans would be updated as a matter of urgency and advises C.S.C.I. when complete. A new corporate care planning format is due to be implemented. Progress will be reviewed at a future visit to the home. Residents confirmed any personal care was given in private, staff always knocked and waited before entering their bedroom. Following discussion with the manager the inspector formed the view that despite the availability of telephone points in their rooms residents were not always to make and receive telephone calls in private. A number of residents had made arrangements to have their own phone installed. Files seen and comments made by staff confirmed consultation with a range of external health care professionals e.g. doctors, district nurses, community psychiatric nurses, geriatricians, and continence advisors take place. Other specialists would be consulted on a needs basis. All resident’s drugs and medicines which are securely stored are administered in accordance with the homes medication policy and procedure by trained staff and procedure including recording the administration and disposal of unwanted drugs records of which were viewed. No residents were self-medicating. Whilst risk evidence to confirm consultations as who is responsible for the administration of resident’s drugs and medication were available, the inspector commented that the existing records must include a more detailed medication risk assessment. This was discussed with the manager who gave a verbal undertaking this matter would be attended as part of the assessment and care planning review. Progress will be reviewed at a future visit to the home. Staff confirmed residents or their representatives were free to choose their own GP(Currently 22 doctors from at least 6 local practices visit) and the source of other personal services e.g. chiropodists, dentists optician etc and would receive assistance in accessing any service in the community. Any restriction on choice with regard to a GP was outside the control of the home. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 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 The social activities family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 13 Residents in praising the quality of their day-to-day lives were very complimentary about the homes staff, management and all other aspects of living in the home. From these comments and observations made by the inspector formed the view that routines were arranged to meet the needs of the residents and not the needs of the home/staff. All residents confirmed they were able to exercise choice in respect of all aspects of their day-to-day lives bedtime’s mealtimes, visiting or receiving relatives/friends including attending in house activities, which include music, holy communion and visiting special entertainers. A member of staff has been given special responsibility for activities, which it is anticipated, will expand and offer a greater choice. Service users spoken to praised the quality, quantity, choice and presentation of food, which is provided by the kitchens of the adjacent hospital. Recent reports sent to C.S.C.I. indicated that whilst the choice and quality of the food was satisfactory the quantity was a problem. The inspector was assured that residents were not aware of these concerns, as the homes management prior to food being served to residents had dealt them with. All matters relating to the supply choice and quality of food are monitored daily by the homes management to ensure the quality is maintained. Tea and coffee is available at all times. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 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): 16and 17 The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: A corporate Hampshire County Council policy/procedure designed to protect vulnerable residents from abuse was available. Staff spoken with confirmed they had had received training in recognising abuse and what to do should they witness or suspect the abuse of any resident. The complaints procedure, which was also included in the service users guide included information on how to contact The Commission for Social Care Inspection (C.S.C.I), was seen, as was record of complaints. Residents spoken to stated they felt comfortable in raising any concerns they had with the homes management and confident any matters raised would be dealt with fairly and promptly but made it clear to the inspector “They did not have concerns”. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 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): 19,26 A safe, well maintained, clean and suitably furnished home is provided for service users which meets their needs. EVIDENCE: A tour of the purpose built new building indicated that it was fit for its stated purpose, accessible, safe, well maintained and meeting resident’s individual and collective needs. Furniture was comfortable and homely and in keeping with the décor. Residents commented how satisfied they were with the accommodation. Following specialist assessments, a number of communal and personal aids have been provided. These include handrails, ramps, bath hoists, raised toilets ,raised chairs lifts and special beds . The home was clean, hygienic and free from adverse odours. An infection control policy and procedure was in place. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 16 Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 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 and 30 Residents needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all service users. EVIDENCE: Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 18 Due to the home opening in July 2005 and the number of residents (currently 42) and their dependency levels changing the staffing profile is subject to constant review and revision. At the time of the inspection staffing levels were based on two care assistants for every ten residents plus two qualified nurses on each floor level. Two catering staff, three cleaners, three laundry staff and a management team including the registered manager support the carers. The care needs of all residents are very high all requiring two carers to help them at times. As resident numbers increase to the maximum levels for which the home is registered (66), a review of staffing numbers, their deployment and skill mix must be undertaken to ensure all the assessed needs of residents can be met. Comments were made to the inspector by care staff that due to the high care needs of some residents that require two staff on occasions residents may be kept waiting in the morning when they wish to get up, wash, and dress. At the time of the inspection a large number of agency staff are employed. The inspector was assured by the manager the use of agency staff would decrease as permanent are employed to meet the increase in resident numbers. Staffing levels will be reviewed at a future visit to the home. All staff are recruited and selected in accordance with a the Hampshire County Council recruitment and selection policy and procedure which involves, the completion of an application form, an interview the signing of a rehabilitation of offenders declaration and satisfactory Criminal Bureau Records (C.R.B.), Protection of Vulnerable Adults (P.O.V.A), medical and reference checks prior to the commencement of employment. On commencement of employment all staff is subject to induction training, a period of probation before a final permanent position is offered. Following induction and a probationary period all staff are expected to participate in National Vocational Qualification (N.V.Q.) training programme. Currently 23.5 of care staff has been trained to N.V.Q level2. In addition to 34 care staff 17 first level nurses are also employed. Apart from the above training all staff are involved in additional training covering the administration of medication, food hygiene, moving and handling, first aid and the protection of vulnerable adults and any other subjects as determined and agreed during regular one to one supervision. Future arranged training includes, dementia as well as clinical updates for nurses. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 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 and 38. The management of the home ensures the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents whose views about living in the home are not formally sought due to the absence of a quality assurance monitoring system. EVIDENCE: The registered manager who is a qualified nurse has had many years experience working as a manager for the N.H.S. A formal written quality assurance and quality monitoring system that seeks the views of residents has yet to be introduced, however from talking with residents it was clear their opinions of the service are sought in an informal manner. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 20 A health and safety policy, control of substances hazardous to health (COSHH) assessments, equipment servicing and accident records were available, as were records to confirm all staff have receive training in the techniques of moving and handling first aid health and safety and the procedures to follow in the event of fire (including evacuation. A sample audit was taken of residents monies held for safekeeping .All cash held reconciled with the records that included receipts of all money spent. Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 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 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Willow Court DS0000063341.V256252.R01.S.doc Version 5.0 Page 22 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 OP10 Regulation 12(4)(a) Requirement Timescale for action 28/12/05 2 OP33 12(4)(a) The registered person is required to ensure all residents can make and receive telephone calls in private The registered person is required 02/02/06 to ensure an effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 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.V256252.R01.S.doc Version 5.0 Page 23 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.V256252.R01.S.doc Version 5.0 Page 24 - 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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