Inspection on 08/08/05 for Willow Court

This inspection was carried out on 8th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11/09/06

Willow Court 07/02/06

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 Announced 8 August 2005 09:30 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 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 B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willow Court Address Osborne Gardens North Shields Tyne & Wear NE29 8AT 0191 296 5411 0192 296 4568 willow.court@fshc.co.uk Cotswold Spa Retirement Hotels Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) vacant CRH 48 Category(ies) of DE(E) Dementia - over 65 (45) registration, with number MD(E) Mental Disorder - over 65 (3) of places Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 8/11/04. 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. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection of the home and took place over six hours. The inspector looked around some parts of the building and a number of records were inspected. Six residents and two relatives were spoken to and also six members of staff. 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 B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 standard(s) 2,3. Each service user has not got 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. EVIDENCE: None of the residents whose files were seen had a written contract/statement of terms and conditions with the home. Four residents pre-admission assessment records were inspected. These showed a satisfactory standard of resident information had been recorded. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10. The service user’s health, personal and social care needs are not fully set out in an individual plan of care. Service user’s health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Four of the residents care plans were inspected. Three record files showed a good range and variety of plans with evidence of regular evaluations of these taking place. However in the other file there was no mental health care plan written. A number of records in all four files had not been dated and signed. Records for GP, Dental, Optical and Chiropody were all satisfactory. The systems for the storage, management, administration and disposal of medications were checked and were satisfactory. Records showed that residents see visiting professionals in the privacy of their own bedrooms. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15. Service users find the lifestyle experienced in the home does not fully match their expectations and preferences, or fully satisfy their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/friends/representatives and to a lesser degree the local community as they wish. Service users are helped to exercise choice and control over their lives. Whilst menus need to be improved, service users do receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: Records inspected showed lots of good social history information for residents. However this was not reflected in individual residents social care plans. Little evidence was seen of residents accessing local community facilities. Records showed that residents chose what clothes to wear each day. Menus in the home were inspected, work is required in the following areas to improve these. Breakfast meals need to state what is offered each day. Some main meals do not offer choice ie, fish or fish. Sandwiches fillings must be stated. Some suppertime meals should offer hot food. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 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: Four complaints have been received by the home since the last inspection all of these being successfully resolved. The homes Complaint policy was read and is satisfactory. One POVA incident had been reported and had been satisfactorily concluded. The homes POVA policy is of a satisfactory standard. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 standard(s) 19,24,26. Service users generally live in a safe, well-maintained environment. However some work identified in this report requires to be carried out. Service users live in safe, comfortable bedrooms with their own possessions around them. The home is generally clean and hygienic. EVIDENCE: The grounds and gardens of the home are generally well maintained. However a border to the side of the home is overgrown with weeds and needs attention. Since the last inspection new lounge chairs and furniture have been purchased for upstairs and new furniture has been ordered for the downstairs lounge. Bathroom and toilet areas could be made more homely. A number of resident bedrooms were visited and were in the main reasonably furnished decorated and personalised. A new floor covering is required for bedroom number 27. Three glass windows in the upstairs lounge need to be renewed due to condensation damage. Coshh information must be kept in the homes laundry at all times. The toilet outside of the homes kitchen is to be designated only for use by kitchen staff, a new flush cover is required to be fitted here. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30. Service users needs are met by the numbers and skill mix of staff. Service users are supported and protected by the homes recruitment policy and practises. Staff are trained and competent to do their jobs. EVIDENCE: The duty rosters for staff were seen these showed the following levels 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, 1 Qualified and 4 care staff. This level of staffing is in line with the assessed needs of the residents. Two staff files were inspected and these had 2 written references that were appropriate, and proof of identity checks were completed. One file had a necessary work permit satisfactorily completed. Staff training files were checked and these showed that 68 of support staff were trained to NVQ level 2 or above. Statutory and client centred training levels were found to be satisfactory. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38. The home is run in the best interests of service users. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Relatives meeting minutes were read there have been 2 of these meetings in the last 2 months, agendas are appropriate for the client group. Evidence was seen of the homes manager acting on issues of relatives concerns. Residents financial records were checked, these showed evidence of regular expenditures. Financial records for residents need 2 staff signatures for all transactions, which is not happening at the present time. Health and safety records in the home were checked and were all satisfactory. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION 2 x 2 x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 2 x x 2 Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 Page 15 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. 2. Standard 7. 12. Regulation 15.1. Requirement Timescale for action 31/10/05. 30/9/05. 3. 15. 4. 5. 6. 19. 24. 19. 7. 8. 2. 19 All residents in the home must have written, individual mental health and social care plans. 16.2(m)(n A comprehensive activities ) programme for residents, over a 4 week cycle to be submitted to the CSCI. 16.2(i) Menus should state what is cooked each day for breakfast. Some main meals need to show an alternative choice. Sandwiches need to specify fillings. Some suppertime meals should provide hot food. 23.2(b) The garden border to the side of the home to be weeded. 16.2© The floor covering in bedroom 27 needs to be replaced. 23.2(j) The toilet outside of the homes kitchen to be designated for use by kitchen staff only. The flush cover here needs to be renewed. 5.1(b) All residents must have an individual written contract with the home. 23.2(b) The glass windows in the upstairs lounge with condensation damage need to be renewed. 30/9/05. 21/8/05. 30/9/05. 31/8/05. 30/9/05. 31/10/05. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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. 2. 3. Refer to Standard 35. 21 38. Good Practice Recommendations Two staff signatories should be recorded for all residents financial transactions. Bathrooms and toilet areas could be made more homely. COSHH information should be kept in the homes laundry at all times. Willow Court B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection 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 B53-B03 S28826 Willow Court V231435 080805 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!