Inspection on 28/08/08 for Willow Gardens Care Home

This inspection was carried out on 28th August 2008.

CSCI found this care home to be providing an Adequate service.

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 Gardens Care Home 30/11/07

Willow Gardens Care Home 30/08/06

Willow Gardens Care Home 15/02/06

Willow Gardens Care Home 21/04/05

Willow Gardens Care Home 29/11/04

Willow Gardens Care Home 02/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Willow Gardens Care Home St Edmonds Road Bootle Liverpool Merseyside L20 7AJ Lead Inspector Ms Lorraine Farrar Key Unannounced Inspection 28 August 2008 1.40pm 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 Gardens Care Home DS0000059852.V365660.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 Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Gardens Care Home Address St Edmonds Road Bootle Liverpool Merseyside L20 7AJ 0151 922 4324 0151 922 7437 willow@europeanwellcare.com 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) European Wellcare Homes Ltd Manager post vacant Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (22), Physical disability (24) of places Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 2 named female out of category service users, under pensionable age. The variation applies to the named service users only, should they leave the home then the variation will cease to apply. Not accommodated in Willow View Unit. The age range between service users in the Willow View Unit should be no more than 25 years. Service users to include up to 22 OP(N) Service users to include up to 24 PD to be accommodated within the unit known as Willow View. Bedroom number 24 to accommodate one named PD service user to be reviewed on the 01/06/06 One named service user accommodated on the unit known as Willow View. To be reviewed on 01/06/06 2 3 4 5 6 Date of last inspection Brief Description of the Service: Willow Gardens is situated in the Bootle area of Liverpool. It provides care with nursing for up to twenty two older people and twenty four younger adults who have disabilities. The building is purpose built and provides accommodation over two floors. The unit for younger adults is on the top floor with accommodation for older people provided on the ground floor. The younger adults unit is referred to as Willow View and has separate facilities and staff to the older persons service. All bedrooms are single rooms with many providing en-suite facilities and all having sinks. There are gardens to the rear and sides of the home that provide space for people to sit outside in good weather. These are easily accessible from the large ground floor lounge. The home is privately owned and the company have a variety of other homes within the UK, providing care for people with a wide range of differing needs. Willow Gardens is near to local amenities including a local shopping centre. There are bus and train stops nearby and car parking facilities within the grounds. It currently cost between £322 and £650.49 each week to live at Willow Gardens. Fees are based on the persons assessed support needs. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We gathered information for this inspection in a number of different ways. We carried out an unannounced visit on the 28 August 2008. This took place over 6.20 hours and included reading records and looking at the building. . We spent time looking at the support the people living at Willow Gardens receive. This included looking at the support they get with their daily lives, care plans, medication, money, activities and environment. We talked with eight of the people living there and with eleven members of staff including the supporting manager. We also attended a residents meeting that was taking place during our visit. Any information the Commission for Social Care Inspection (CSCI) has received since the last big inspection of Willow Gardens in November 2007 is also taken into account in writing this report. Before our visit we sent out survey forms to the home. Ten of the people living there and ten members of staff completed these and their replies helped us with planning our site visit and in writing this report. The previous manager completed a self assessment form we sent him before our visit. Information from this was again used by us to plan this inspection and in writing this report. What the service does well: The people living at Willow Gardens receive good support to meet their health care needs. This includes supporting them with making and attending appointments and monitoring their health for any complications that may arise. The home organises a range of activities each week that people can take part in. This includes the opportunity for people to get out and about in their local community as well as joining in with activities at home. The views of the people living at Willow Gardens are obtained regularly, via meetings and surveys. This gives people the opportunity to comment on how the home operates and make suggestions for the future. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 6 The people living there told us that they like the staff team and during our visit we observed that staff have a good knowledge of the people living there and their support needs. We also observed that staff are respectful towards the people living there and take time to talk with them as well as meet their basic health and personal care needs. Clear information is made available to people about how they can raise any concerns they may have about the home. The people living there told us that they knew who they could talk to if they were unhappy and that they are confident they would be listened to and their concerns acted upon. What has improved since the last inspection? What they could do better: The assessment and planning processes in the home should include detailed sections on people’s diverse needs and choices. This should include assessing and planning to meet any needs or choices people have based on their culture or disability. This would help to ensure that the home can provide an equal service to everyone that lives or stays there. Clear records of how peoples money is managed and reasons why they may have a company appointee should be available in the home. This would help to ensure that a clear audit trail is in place and that peoples are being supported to be as independent as possible. The menus offered to people need to be reviewed to ensure that they offer the opportunity to people to eat a healthy meal. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 8 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 Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 People who use this service experience adequate outcomes in this area. We have made this judgment using available evidence including a visit to this service. A range of information is provided to and obtained about people moving into Willow Gardens. However this does not always fully take into account their individual needs and choices. EVIDENCE: The people who live at Willow Gardens told us in their comment cards that before they decided to move in they were given enough information about the home to help them decide if it was right for them. This was further confirmed in discussion with one person who had recently moved in who told us that they were able to visit and look around first and were given ‘paperwork’ to tell them about the home. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 10 In addition to this copies of a guide to the services available at Willow Gardens are freely available in the foyer. Before anyone moves into Willow Gardens a member of staff meets with them to carry out an assessment of their needs and choices. The information provided to and obtained about peoples support needs, helps staff to plan how to support the person and helps the person to decide if Willow Gardens is the right place for them to live. The assessment form used provides information about the person’s health and wellbeing and some information about their social preferences. However it does not fully provide all the information about people’s individual choices that may affect the support they receive. For example, the mini bus at the home is not currently adapted for use by people who have an electric wheelchair. Information such as this should be fully covered before someone decides to move in so that they can make their decisions based on all of the support available to them. Willow Gardens does not provide an intermediate care service. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. The health and personal care needs of the people living at Willow Gardens are generally recognized and met by the service. EVIDENCE: The people living at Willow Gardens told us in their comment cards that they get the care and support they need with their personal care and that they always get medical attention when they need it. During our discussions with some of the people living there they confirmed this, with one person telling us, “They are looking after me well. I feel a lot better”. Another person told us that staff ensure she gets frequent support with her personal care and also, “they turn me every two hours” to help her with her pressure areas. People told us that they get support to have a bath or a shower whenever they want and also that staff respond quickly if they use their call bell for help. One lady told us, “They are here within two minutes”. We observed this during our visit when call bells were always responded to quickly. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 12 Another person explained that they are unable to use their call bell and therefore have no way of calling for help. This was discussed with a senior member of staff, who explained that they were aware of this and arrange to check if she needs assistance frequently. However a thorough assessment and planning process may have enabled staff to arrange for a system for this lady to be set up quickly that would meet her particular needs. Individual care plans are in place for the people living at Willow Gardens. We looked at several of these and found all to be up to date and regularly reviewed. These care plans provide clear information for staff about the support needs people have, particularly around their health and personal care. Plans were up to date and had been discussed with the person. This helps to ensure that any changes to the person’s support needs or any issues with their health can be quickly noted and acted upon. In discussions with the staff team they were knowledgeable about the support people need and prefer with their personal care and were also able to explain the support people need with their healthcare. This includes being aware of any forthcoming appointments people have and the support they need to attend them. For example, they have requested an interpreter for one lady and her family, when she attends an important healthcare meeting. This is good practice, as it would enable her to get the best out of the appointment, with support from relatives. One of the people living at Willow Gardens explained that staff “mind” her privacy and we observed during our visit that they responded appropriately to requests for support, spoke in a friendly and respectful manner to people and ensured they knocked on doors before entering. Each unit at Willow Gardens has a separate room to store people’s medication in. Medication, including controlled drugs, was seen to be stored correctly. A photograph of the person is stored with their medication sheet. This helps to ensure unfamiliar staff can double check before dispensing medication to anyone. Records of medication were completed correctly, with a clear recording of when it had not been given or had been refused. However although some records are kept of medication received into the home there is no clear stock check system in place. Therefore it is not possible to accurately audit or sample medications to ensure they are being managed safely. For example on looking at records we found that some medications tallied with the amount held and the records of the amount given; however others were not totally accurate. A clear stock check system would help to quickly establish any inaccuracies or issues with medication and therefore quickly address these. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use this service experience adequate outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people living at Willow Gardens are generally supported to live a lifestyle of their choosing. However more consideration needs to be given to meeting people’s individual and diverse needs. EVIDENCE: During our visit we attended a residents meeting that had already been arranged. The people living there had the opportunity to discuss the meals provided, recent staff and management changes and activities they had taken part in. They also contributed ideas for future activities they would like to see organised. These meetings are good practice as they enable people to stay up to date about any changes within the home as well as contribute their ideas. A full time activity co-ordinator is employed to work with the younger adults living on Willow View and a part time activity co-ordinator to work with the older people. However in practice many activities are open to all. For example a regular Friday pub meal is arranged and a trip to a local cinema takes place weekly. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 14 As well as going out and about and being offered the option of going on an annual holiday people can also take part in in-house activities if they wish to do so. These include, quizzes, crafts and entertainers. A monthly catholic service is held in the home for anyone who wishes to attend. Some of the people living at the home told us that they are always asked if they want to join in activities and records showed that as well as organising group events, activity staff sit 1-1 with people and chat etc. One person told us that they get to go out on activities and also “can come and go as I please” with no fixed routines within the home. However where people have individual needs these are not always fully catered for. One lady told us that she would like to go out but had not yet done so. The supporting manager later explained that the current mini-bus at Willow Gardens is not suitable to take people who use an electric wheelchair. She advised that they are now looking into changing this. It was identified at our last inspection that English was not the first language of one of the people living there and that her family did not speak English either. Since then some attempts to obtain an interpreter have been made; however there was no clear plan or record of this, which could lead to the issue not being resolved as quickly as possible. Nor was a clear plan in place to meet this person’s cultural needs. For example, staff had obtained music in her first language but there was no record of when this was played or how they ensured that different music was played for her. This lack of planning around individual’s diverse needs may lead to some people not receiving as good a service or level of support as others receive. During our visit we observed that people’s visitors are welcomed at any reasonable time and able to meet with the person in their own room or in the lounge as the persons preferred. The people living at Willow Gardens are supported to make everyday choices in their lives around how they want to spend their day, whether they want to join activities etc and also through attending residents meetings if they wish. However there are no records on file that indicate whether people are offered support to manage their own finances or how it is/was decided why the organisation should act as appointee for some people’s money. A clear assessment and on-going review would ensure that wherever possible people are supported to be independent in this area. We received mixed comments from the people living at Willow Gardens with regards to their meals. Most people told us that they like them with comments including, “very nice, you get different things” and “excellent” whilst another explained, “it’s not what I like”. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 15 Menus showed that people are offered a choice of meals and that they can have a cooked breakfast if they prefer. We identified during our last inspection of Willow Gardens that menus recorded only one choice of fruit or vegetables on some days. During this visit we again reviewed menus and found that this situation remained the same. As the government guidance is that people should eat at least five portions daily, this means people may not be getting the opportunity to choose to eat a healthy diet, which could impact on their health and wellbeing. We also identified at our last inspection that the practice of drinks being served to the people upstairs via a drinks trolley from the main kitchen should be reviewed. This is not only routine based and possibly disruptive it is also not in keeping with supporting, people, particularly younger adults, to live as ordinary a lifestyle as possible. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people who live at Willow Gardens are confident that any concerns they have will be listened to and acted upon. EVIDENCE: The people living at Willow Gardens told us in their comment cards that they know who to talk to if they are unhappy or have any concerns about the service. This was further confirmed when we talked to some of the people living there during our site visit. People told us that they would raise any concerns with a member of staff and they were confident staff would listen to them and act on their concerns. Information about how to raise concerns is made available to people via their guide to the home and also through leaflets available in the foyer. A clear log is kept at Willow Gardens of any complaints raised and the actions taken to address them. This helps to ensure complaints are dealt with quickly and that any recurring issues can be quickly noted and acted upon. Copies of local authority adult protection procedures are available to guide staff if needed. In discussions with staff they were aware of these procedures and able to explain the actions they would take if any issues arose. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 17 This open approach to concerns and complaints helps to ensure that the people living at Willow Gardens can feel safe and supported. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. Willow Gardens provides an environment which meets the needs of the people living there. However parts of the home would benefit from redecoration and repair in order to provide a more pleasant environment for the people living there. EVIDENCE: The people living at Willow Gardens said in their comment cards that the home is fresh and clean and this was observed during our visit. Willow Gardens is a purpose built home over two floors, with a lift providing access to the first floor. Everyone living there has their own bedroom which they can personalise if the wish. Fifteen of these have en-suite facilities; other bedrooms provide a hand basin. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 19 Some areas of the home would benefit from re-decoration. For example one bedroom we visited had peeling wallpaper and the bedside cabinet door was hanging off. In the toilet and shower room on Willow View toilet cubicles had been boxed in from floor to ceiling to provide more privacy, however the boxing in remained unpainted. In another bathroom the bath was marked and chipped and there was no blind at the window. Although this did not affect privacy in the room it added to the overall clinical feel. An audit of the environment carried out by the organisation in June 08 identified some of these issues. However work to address them, and therefore improve the environment for the people living there, had not yet commenced. There are two small lounges and a kitchen on Willow View. The kitchen has been adapted for use by people with a physical disability. One of the lounges is furnished in a homely manner and looks welcoming and inviting. The other lounge has internal windows and straight-backed chairs so it does not appear as homely or as domestic. The ground floor has a nice dining room for use by the people living there and a very large lounge with patio doors leading outside. This has been recently re-carpeted and decorated and the people living there explained that they were waiting for new chairs to be delivered to complete the room. Several aids and adaptations are provided to support people with their mobility and personal care. These include, hoists, grab rails, a lift, adapted baths and a walk in shower. Outside there are gardens around the home which are nicely maintained and provide places to sit as well as areas for people to take part in caring for plants and vegetables if they wish. Policies are in place for the control of infection in the home and appropriate disposable equipment is provided. Our visit to the laundry room showed that infection control polices are carried out and staff are provided with the equipment they need to help prevent an outbreak of infection. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people living at Willow Gardens are supported by an experienced staff team who they have confidence in. Planned training will further enhance staff skills and knowledge. EVIDENCE: The people living at Willow Gardens consistently told us that they like the staff team and that there are enough of them to provide support when needed. They described staff as, “smashing, very helpful” and “couldn’t fault them, very nice”. During our visit staff we spoke with also told us that they feel there are sufficient staff to spend time with the people living there as well as supporting them. We observed that requests for support were answered quickly and that staff had a good understanding of people’s individual needs and how to support them. Staff told us in their comment cards that before they started work at Willow Gardens a series of checks were carried out on them. This was confirmed by looking at a sample of staff files. These showed that the home obtains written references and carries out a check of the Protection of Vulnerable Adults register and Criminal Records Bureau. These checks help to ensure that staff are suitable to work with the people living at Willow Gardens, who may be vulnerable. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 21 Approximately 80 of the staff team hold a nationally recognised qualification in care (NVQ). This helps to ensure that they are aware of current good practice in care. The previous manager told us in the pre-inspection questionnaire he completed that they were aware some staff training was out of date and planned to complete an assessment of training needed so this could be planned. During our site visit the supporting manager acknowledged that training for staff had not been kept up to date; however she was able to provide a list of training planned within the following two months. This included training around health and safety, such as moving and handling and infection control and training in supporting people with their health care such as diabetes and pressure area care. Discussions with staff and records showed that staff had received some up to date training in the past year in areas such as fire and the protection of vulnerable adults. Once completed the training planned will help to ensure staff are up to date with current good practices in supporting people safely and well. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 People who use this service experience adequate outcomes in this area. We have made this judgment using available evidence including a visit to this service. Willow Gardens is generally safely managed. Once systems are fully implemented this will improve the service offered to the people living there. EVIDENCE: Shortly before our visit we were advised by the organisation that the home manager had left. They explained that the deputy manager would be managing the home for a while. She is a registered nurse with many years experience in management within a care home setting. During our visit we met with Yvonne Robinson. She explained that she is a manager for another home within the organisation and is spending time at Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 23 Willow Gardens supporting the deputy manager three days a week. She also explained that the post of manager has been advertised with a closing date of 2 September 2008. Staff we spoke with told us that although there have been several changes in management of the home in the past couple of years they do not feel this has affected staff morale or the support offered to people living there. There has been no manager for Willow Gardens registered with ourselves for over a year. The process of a manager applying to and being registered by ourselves helps to ensure that that they meet national standards for managing a care home safely and well. There are several systems in place at Willow Gardens for monitoring the quality of the service they provide and planning further improvements. During our visit a senior manager from the organisation was present carrying out a monthly visit to the home. This was detailed and included looking at areas such as the support provided to the people living there, health and safety and staffing. Once completed he explained he would draw up an action plan for any issues raised. The people living at Willow Gardens are given a survey to complete twice a year asking for their views of the home. The results of the last survey were put together and a copy made available to the people living there. This gives people the opportunity to have a say in the running of their home and in planning future improvements. Several audits of different areas in the home have been carried out. These included the kitchen, maintenance needed, health and safety and the laundry. The maintenance audit was carried out in June 08 and identified areas such as wardrobe trims needing replacement. The supporting manager was aware that these had not been addressed and explained that she intended to draw up an action plan for this and a more recent health and safety audit. This will help to ensure Willow Gardens provides a comfortable and pleasant home for people to live in. A sample of records and monies held in the home for people were checked during our visit; these were clear and tallied. However the organisation acts as appointee for some people’s benefit money and little information is available within the service regarding this. Without clear information that is readily available to people about how their money is managed it is not possible to easily establish how their money is managed by the organisation or why, in some instances, they act as appointee for people’s benefits. Certificates in the home showed that the organisation arranges for regular contractors checks to be carried out to ensure equipment and appliances are safe to use. This includes check on gas, electrics and the lift. However records showed that the fire alarm, water temperatures and the nurse call system had Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 24 not been tested for over a month. These are usually checked weekly to ensure they are working safely. Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 25 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 26 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 Standard OP14 Regulation Requirement Timescale for action 30/11/08 14(1)(a)(c The assessment process must ) include information on any different needs people have due to their culture and must ensure the service can meet those needs. This requirement was given at a previous inspection in November 2007 2 OP35 17(2) schedule 4(9) Information about how people’s money is managed by the organisation must be documented and available within the home. This must include information on how the person can access their financial records quickly if they wish to do so. This will help to ensure people’s money is managed safely and in their best interests. This requirement was given at a previous inspection in November 2007 30/11/08 Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 27 3 OP38 13(4)(c) A system must be set up for ensuring all regular health and safety checks are carried out. This will help to ensure that Willow Gardens is a safe place for people to live. 14/10/08 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 OP15 Good Practice Recommendations The diet available to people should be reviewed to ensure people can choose a healthy diet at all times. The practice of drinks being serving via the main kitchen to the younger adult unit should be reviewed. This will help to ensure people are supported to be as independent as possible. 2 OP12 Care plans should contain a clear section on equality and diversity. This will help to ensure that through clear planning everyone receives a service that meets their individual needs and choices. The organisation should draw up a clear plan to action the findings of the assessment they carried out on the environment. This will help to ensure that Willow Gardens provides a comfortable, well maintained home for people to live in. Once a manager is appointed for Willow Gardens the organisation should support them to apply to register with the Commission for Social Care Inspection as soon as possible. This will help to ensure that there is a suitable manager in place within the home. 3 OP19 4 OP31 Willow Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North West Region Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Gardens Care Home DS0000059852.V365660.R01.S.doc Version 5.2 Page 29 - 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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