Inspection on 07/02/06 for Willow Court

This inspection was carried out on 7th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willow Court 29/09/08

Willow Court 29/01/08

Willow Court 11/09/06

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 Unannounced Inspection 7th February 2006 12.30p 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.V276232.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.V276232.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.V276232.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. 8th August 2005 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 43 residents in the home 29 females and 14 males with 5 vacant beds. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours. The inspector looked around some parts of the building and a number of records were inspected. Four of the homes residents a visitor and four of the homes staff were spoken to. 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. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 6 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.V276232.R01.S.doc Version 5.1 Page 7 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. No service user moves into the home without having his/her needs assessed and been assured that these will be met. EVIDENCE: Four of the resident’s pre-admission assessment documents were inspected. These were all found to be completed to a reasonably good standard. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 8 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): 7,9. The service users health, personal and social care needs are generally set out in an individual plan of care. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Four residents care plans were read. These showed that in the main a good range of care plan had been written. With evidence of these care plans being regularly evaluated. Social care plans are gradually being developed. However in one resident care records there was no mental health care plan. The systems for medications in the home were checked and found to be satisfactory. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 9 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): 15. Service users generally receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The homes menus were seen. These were found to be the same as those used in the past. The companies promised new corporate menus had still not been received in the home. The menus currently used in the home are not entirely satisfactory in that they state cooked breakfasts by request, sandwich ingredients are not specified, the lunchtime meal on Fridays is fish or fish. Evidence was seen of mealtimes being taken flexibly according to individual needs. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 10 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. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The homes policies for Complaints and POVA were found to be satisfactory. Three complaints in the Complaints log book had all been successfully investigated and resolved. A recent POVA incident in the home had also been investigated and resolved to the satisfaction of all parties involved. Action taken by the home in this matter was appropriate and correct. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 11 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. Service users generally live in a safe, well-maintained environment. Service users live in safe, comfortable bedrooms with their own possessions around them. The home is clean, pleasant and hygienic. EVIDENCE: The majority of the homes environment was visited and was found to be being reasonably well maintained. However rubbish and debris to the front of the homes garden areas needs to be cleaned. A number of resident’s bedrooms were seen these were generally well decorated with evidence of personal possessions here. Four of the homes residents were spoken to all spoke well of services provided by the home. A relative of a resident was also spoken to who stated they were generally satisfied with the homes services. Most areas of the home seen were generally clean and hygienic, however the upstairs lounge carpet needed to be cleaned. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 12 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. The numbers and skill mix of staff meets Service user’s needs. EVIDENCE: Duty rosters for staff were inspected, these showed the following numbers of staff employed in the home on an average day; Am, 2 Qualified and 6 care staff, Pm, 2 Qualified and 6 care staff, Nights, 2 Qualified and 3 care staff. These levels of staffing are in line with the assessed needs of the client group. The duty rosters showed that these staffing levels were being maintained over the four weeks cycle studied. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 13 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): 35,38. Service users’ financial interests are generally safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Resident’s personal allowance money records were inspected. These were found to be in the main satisfactory, however some record transactions did not have two signatories. The homes Fire log book and Accident records were inspected both of these were found to be being satisfactorily maintained. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 14 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 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 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 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 3 Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 15 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP15 Regulation 15.1. 16.2(i) Requirement All residents in the home must have written, individual mental health plans. Menus in the home need to show an alternative choice of food for the main meals each day. Sandwich ingredients must be specified. The gardens to the front of the home the debris seen here to be cleaned away. Timescale for action 31/03/06 31/03/06 3. OP19 23.2(o) 08/02/06 Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 16 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 OP35 Good Practice Recommendations Two staff signatories should be recorded for all residents’ financial transactions. Willow Court DS0000028826.V276232.R01.S.doc Version 5.1 Page 17 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.V276232.R01.S.doc Version 5.1 Page 18 - 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. 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