Inspection on 30/08/06 for Willow Gardens Care Home

This inspection was carried out on 30th August 2006.

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 Gardens Care Home 28/08/08

Willow Gardens Care Home 30/11/07

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 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Willow Gardens Care Home St Edmonds Road Bootle Liverpool Merseyside L20 7AJ Lead Inspector Ms Lorraine Farrar Unannounced Inspection 30th August 2006 02.00 X10029.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.V298655.R02.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 and Care Homes for Adults 18 – 65*. 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.V298655.R02.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 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 Mrs Elizabeth Mumford 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.V298655.R02.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 15th February 2006 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, to 22 older people and 24 younger adults with disabilities. The building is purpose built and provides accommodation over 2 floors. The unit for younger adults is on the top floor with accommodation for older people mainly 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 Residents to sit outside in good weather. These are easily accessible from the large ground floor lounge. The home is privately owned and the company has a variety of other homes within the UK. They provide care for a number of residents with a wide range of differing needs. There is a shopping centre near to the home and public transport system nearby. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this inspection was gathered in a number of different ways. This included an unannounced site visit where time was spent reading records, talking with Residents and Staff, observing life in the home and looking at the building. ‘Case tracking’ was used as part of the visit. This involves looking at the support a person gets from the home including their care plans, medication, money and bedroom, time is also spent meeting with the Residents and with Staff about how they meet the persons needs. Case tracking was used to look at life in the home for four of the people living there. Discussion also took place with 9 Residents, 1 Visitors 6 members of staff. In addition comment cards were sent out before the visit, 6 Residents, 3 Relatives and a GP returned these and their views are incorporated within this report. The Manager was given the opportunity to provide information about the service prior to the inspection. This information and any other relevant information the CSCI has received about the home, since the last full inspection in February 2006, is included within this report. The home is registered to provide care for more younger adults than older people. However there were more older people living there at the time of the site visit. Therefore scores at the end of this report relate to how the home met national standards for caring for older people. The summary, judgements and evidence sections of the report, relate to the overall care provided. Fees to live in the home range from £360.50 to £ 772.13 What the service does well: There is a good system in place for assessing Residents needs before they move in, this helps staff to plan their care and make sure they can support the person effectively. Residents or their Relatives are able to visit the home and look around before deciding if they want to live there. Residents’ healthcare needs are identified and plans written and followed to meet these. Staff talk to Residents about their care plans and get their agreement to the contents. One Resident explained “I please myself” and all Residents spoken with confirmed that they make basic choices such as what to choose from the menu and when to get up. The staff team have a clear understanding of Residents needs and have built good relationships. One Resident said, “99 of the staff are very good”. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 6 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 Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP – 3 & 6 YA - 2 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Sufficient information is obtained about and given to, potential Residents to help everyone decide whether the home can meet the persons needs and choices. EVIDENCE: A care plan for a new Resident showed that Staff from the home had carried out an assessment of his needs before he moved in. This covered all areas of the support he needed and his choices. This assessment had been recently updated, for a Resident who had lived in the home longer. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 9 Records showed that one new Resident’s son had visited the home to look at its suitability. In their comment cards, Residents all said that they received enough information about the home before they moved in. The assessment helps staff to make sure they can meet the person’s needs before they move in and the visits and information help the Resident and their family to choose a home that meets their needs and choices. Willow Gardens does not provide an intermediate care service. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): OP – 7,8,9 & 10 YA – 6,9,16,18,19 & 20 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents healthcare needs are met by Staff, however their personal care needs are not always met within an appropriate time. EVIDENCE: Individual care plans were in place for all Residents. These covered all areas of the person’s personal and health support needs and had been regularly updated. Plans had been signed by the Resident to say that they agreed with Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 11 the contents. A Resident explained her Keyworker had discussed what was in her plan with her and asked her if she wanted a copy to keep. Records showed that Staff monitor Residents health regularly and get advice from other health professionals when needed. In their comment cards most Residents said that they always or usually receive the care and support they need, Staff are available to help them and they get the medical care they need. However one Resident commented, “I often have to wait long periods for my bell to be answered”. Several other Residents made similar comments during the site visit. One Resident explained she had pressed her bell; a member of staff had popped in and said she would get a second member of staff to help her. The Resident said this was 30 minutes ago and the Inspector observed her waiting another 10 minutes before 2 members of Staff arrived to help. By this time the Resident required additional support, as during her wait she had been incontinent. Residents are able to register with their own GP wherever possible and a GP comment card stated that, Staff have a clear understanding of Residents needs and take appropriate action when they cannot meet the person’s needs. Medication in the home was stored correctly and records well maintained. Staff who deal with Residents medication have had recent training in this area. Some of the policies and procedures in the medication room were out of date, these should be removed and new policies obtained. Staff will then have access to the right information and lessen the risk of medication errors being made. A Resident explained that staff always knock on her door before entering her room and this was seen to happen during the visit. Residents confirmed that they decided when to get up and go to bed, they are aware of how their money is managed and get their mail on time and unopened. During the visit Staff were seen to talk appropriately to Residents. However the length of time it takes for some call bells to be answered does impact on Residents dignity. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP – 12,13,14 & 15 YA – 12, 13, 15 & 17 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents are offered basic choices about their daily lives, however these need to be further developed. EVIDENCE: The home employs a part time Activity Coordinator to work with the younger Residents. She explained that she also includes older Residents in outings and organised events. The Manager explained that there is a vacancy for another part time Activity Coordinator to work with other older Residents and this has been advertised. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 13 Residents and Relatives views on the activities arranged by the home were mixed. One Relative commented, “could do with more activities, e.g. vocational courses, talks etc”. The Manager explained some of the younger Residents had recently been on holiday and that the cost of an annual holiday is covered by their fees. Four of the younger Residents said they had never been asked about the activities they like and would like to go out more, especially at night. One would like to do voluntary work and another would like to help the Chef make cakes. These opportunities had not been made available to them. Older Residents and their Relatives had a different view of the activities arranged with one Relative explaining Staff actively encouraged her Mum to do activities including taking up knitting again. A Resident explained staff tried to encourage her to participate but she was happy listening to her radio. No printed information about activities was on display in the home and records of individuals’ leisure opportunities were limited. These records should be expanded so that each Residents preference are recorded and the Manager can monitor them to make sure reasonable opportunities are offered. A Relative explained that “you can visit at any time” and several visitors were seen popping in during the visit. Several of the older Residents spoken with said that they make their own choices in the home, with one explaining, “I please myself what time I get up and go to bed”. Residents were able to explain how their money was managed and the home records the Residents choices as to who they discuss their money with. All Residents agreed they have a choice of food from the menu, one Resident explained, “Chef comes around every day, if you don’t like the choices, he’s very good he produces something”. However another Resident was of the opinion that “you get the same thing.” Residents generally stated that they enjoyed the food. Younger Residents said they would like to be consulted about the menu and that their meal was often cold. The Inspector observed a meal being served on Willow View. The food was on an unheated trolley and was uncovered, despite the fact that both courses were hot dishes. The meal was chips, pizza or fishcake, apple pie and custard, and a lot of convenience food was noted in the freezer. Menus should be reviewed to take into account Residents preferences and also to provide a healthy option. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP – 16 & 18 YA – 22 & 23 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There are appropriate polices and procedures in place for dealing with concerns and allegations, however Residents are not always aware of how to report these. EVIDENCE: In their comment cards all Residents said that they know how to make a complaint and most said that staff listen and act on what they say. A Relative of an older Resident explained that they discuss any concerns with the Manager and “she always addresses them straight away”. However four of the younger Residents spoken with said that they were unsure of how to make a complaint. The home has a policy in place for dealing with complaints, however records of actual complaints are sent to the head office. A copy of these must be held on the premises so that the Manager can check for any trends. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 15 Information provided by the Manager stated that the home had had two formal complaints in the past year, all had been responded to within 28 days and neither had been upheld. There are policies and procedures in the home for dealing with any allegations of abuse and records showed that staff had received training in this area. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP – 19 & 26 YA – 24 & 30 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home is clean and comfortable, however risks to safety are not always acted upon and further adaptations would benefit Residents. EVIDENCE: Willow Gardens is purpose built and provides all Residents with single bedrooms 15 of which are en-suite, the remainder having sinks. Bedrooms are clean, tidy, and individually decorated. All rooms on the top floor have been Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 17 recently redecorated, four bedrooms downstairs have also been decorated and the Manager advised there are plans to decorate others. There are sufficient baths, toilet and living areas throughout the home, although clean and tidy, there was a smell of urine present in some of the downstairs areas visited. The floor covering in the main kitchen was ripped and could cause an accident. The Manager explained this was due to be repaired shortly and agreed to make it safe. Several aids and adaptations are in place to support Residents. These include, hoists, grab rail, a lift and walk in shower. Younger Residents felt that additional adaptations would help them to be more independent. They explained that doors were too heavy for them to open easily; therefore their movements within the home were restricted. One was unable to use the call system due to visual difficulties and felt a different system would help. Another was unable to use the phone due to hearing difficulties and felt an adapted phone would be of use. A radiator in a downstairs bedroom was uncovered and was hot to touch, similarly the radiator in the upstairs dining room was only partly covered and hot to touch at the side. This leaves Residents at risk of burning should they fall. The temperature of the downstairs bath was taken. After several minutes this recorded as 20 degrees and would be too cold for most people to comfortably use. Policies are in place for the control of infection in the home and appropriate, disposable equipment is provided. Staff were seen to wear disposable gloves to provide personal care. They then left the bedroom and entered a bathroom, touching doors along the way. This practice could lead to a spread of infection. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,29 & 30 YA – 32,34 & 35 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents are protected by good recruitment policies. Staff have received a variety of training to enable them to do their jobs competently, however they do not always meet Residents personal care needs within an acceptable timescale. EVIDENCE: Residents were generally positive about the staff team, one Resident stated, “I enjoy living here. Staff are great. They really looked after me”. A group of younger Residents all said that the like the staff team. The Manager explained that basic staffing levels are set and these are added to for any Residents who are funded for additional care. Whilst Staff felt that there were sufficient staff working in the home, Residents had a different view. Several explained that sometimes, they waited a long time for their bell to be answered and that Staff were very busy. During the site visit a Resident was Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 19 observed to wait an unacceptable length of time for staff to provide her with personal care. Records in the home showed that good recruitment practices are followed, which make sure that staff are suitable to work with Residents. They also showed that Staff receive appropriate training. For example staff working with younger adults have completed training in disability awareness whilst a member of staff working with older Residents has had recent training in Parkinson’s disease. As well as attending formal courses the home is a member of a number of organisations that provide information on specific medical conditions and accesses expertise from within their own company. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP – 31,33, 35 & 38 YA 37, 39, 42 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There are clear management and quality assurance systems within the home, to ensure Residents health and welfare. However these need to be further developed to ensure issues are identified and acted upon. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 21 EVIDENCE: Mrs Elizabeth Mumford is the Registered Manager of the home; she is an experienced manager and holds care and management qualifications. Residents were complimentary about the Manager, explaining that they had confidence in her and could talk to her. During dealings with the CSCI the Manager demonstrates she is motivated and keen to continually improve the service offered. There is a clear management structure within the home. Good systems are in place for assessing the quality of the service provided. These include surveys of Residents opinions, an external quality assessment once a year and regular visits by the organisation. Following the visit the organisation produce a clear report with actions for improvement and dates these should be met by. These systems note Residents views and identified an issue with the length of time it takes to answer call bells on occasion. However some Residents feel their views are not always obtained and the issue with calls bells was unresolved. The home provides a safe for Residents to keep some of their money in and a policy is on place covering how Residents’ money is managed. Where possible Residents manage their own money, those spoken with knew how their money was handled and were confident they could access it when they wanted. Records of monies were checked and were in order. Records showed that regular health and safety checks are carried out, including regular fire and gas checks. Training is provided for staff in health and safety issues. Some issues around health and safety were noted during the visit, including, hot radiators and ripped floor covering in the kitchen area. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 22 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 X 2 X 3 3 4 X 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 1 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 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 1 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 12 Requirement The manager must carry out a review of response times to residents call bells. She must act on any findings that are detrimental to Residents. The Manager must ensure all meals served to Residents are of an acceptable temperature. The Manager must ensure all Residents are aware of the homes complaints procedure. The Manager must monitor bath temperatures in the home and take action if they are not of a suitable temperature for Residents safety and comfort. The Manager must carry out a risk assessment of all radiators in the home. Action must be taken if any risks are identified. DS0000059852.V298655.R02.S.doc Timescale for action 30/11/06 2. YA17 12(1)(a) 30/11/06 3. YA22 22(5) 30/11/06 4. YA24 13(2)(c) 15/11/06 5. YA24 13(2)(c) 15/11/06 Willow Gardens Care Home Version 5.2 Page 24 6. YA39 24 The Manager must carry out a formal consultation with the people living on Willow View. This must include Meals Activities Aids and adaptations A plan for addressing the outcomes of the consultation must be drawn up. A copy of the report must be forwarded to the CSCI 30/12/06 7. OP27 18(1)(a) The Manager must regularly review and record staffing levels in the home to ensure Residents needs are met. 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. OP12 YA14 OP26 Refer to Standard OP9 YA17 OP15 Good Practice Recommendations The Manager should remove out of date policies from the medication room. The Manager should review menus, including the use of convenience food. The manager should establish a system for monitoring records of Residents leisure choices and opportunities. The Manager should discuss good infection control practices with the Staff team. Willow Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Gardens Care Home DS0000059852.V298655.R02.S.doc Version 5.2 Page 26 - 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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