Inspection on 12/12/05 for Willow Garth Care Home

This inspection was carried out on 12th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow Garth Care Home 23/09/08

Willow Garth Care Home 25/09/07

Willow Garth Care Home 26/09/06

Willow Garth Care Home 04/05/05

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Willow Garth Care Home Rolston Road Hornsea East Yorkshire HU18 1XP Lead Inspector Lynne Busby Unannounced Inspection 12th December 2005 09:30 Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 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 Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willow Garth Care Home Address Rolston Road Hornsea East Yorkshire HU18 1XP 01964 534651 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) Hatzfeld Care Limited Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (23) Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Willow Garth is located in a rural setting close to the town of Hornsea on the East Riding of Yorkshire coast. The home is registered for 23 service users (male and female) who have mental health needs. Personal care is provided for all service users along with all meals and a laundry service. Local facilities are only accessible via a bus journey. The home has a mini bus to transport service users; some service users choose to walk to town and this is on a badly lit road. Accommodation is provided in 17 single rooms and 3 shared rooms; communal space is available in two lounges, a dining room and a smoking area, which is in a walkway/conservatory. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was completed as part of the programme of inspections for the year. It was an unannounced inspection undertaken by one inspector. The inspection day lasted from 9.30 am until 3.00 pm. The inspection could not be completed due to an appointment the manager had and the inspection was continued on the 16th December from 9.00am to 11.00 am. During the inspection a number of service users were spoken with, and three were engaged in longer conversations with the inspector. The inspection process included a review of the documentation, a tour of the premises and discussions with the manager, staff on duty, the cook and a relative. What the service does well: What has improved since the last inspection? What they could do better: Whilst some improvements have been made in the home there are some areas, which require redecoration and repair, in particular the bathroom and Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 6 shower areas. There is building work in progress and a risk assessment must be in place to ensure the safety of the service users. Recording on the recruitment of staff must be robust to ensure that service users are protected. The manager of the home is in the process of being registered with CSCI. 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 Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Service users can make an informed choice before being accommodated at the home from the information provided. Service users are assessed prior to moving into the home so the home can ensure their needs can be met. EVIDENCE: The home has developed a statement of purpose and service user guide. This is available for all prospective service users. This enables service users to make an informed decision before being accommodated in the home. The service users are all referred through Care Management. The service users files indicated that a person who is competent to do so undertakes assessments and the files tracked had care management plans in place. The home has an individual service user plan based on the Care Management plan. The home does not place any restrictions on the service users’ choice and freedom. There were risk assessments on service users files. There is a copy of the statement of terms and conditions in the service users guide. The manager advised that each service user has a copy that is signed by the manager and the service user. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Service users are consulted about their changing needs and participate in all aspects of life in the home and are supported to take risks as part of an independent lifestyle. EVIDENCE: The service users files include a plan of care and this is drawn up with the involvement of the service user. Each service user has a key worker who reviews the care plan on a monthly basis. The plan is reviewed fully every six months and updated to reflect changing needs. There was evidence recorded on individual files that staff respect service users’ right to make decisions. Choice is only limited through a process of negotiation and consultation and this was observed during the inspection. The manager advised that the staff provide service users with the information, assistance and communication support to make decisions. This was confirmed in discussions with the service users. The manager said that all service users manage their own personal allowances. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 10 There were risk assessments on service users files based on the service users’ individual plan. The home has identified risks regarding outside activities and risk assessments were in place for service users who go for walks on their own, specifically for walking into the local town. To assist in minimising risks a mini bus is provided to take service users into the local town. The staff were aware of risks and service users are encouraged and supported to take responsible risks as part of their individual lifestyle. The manager advised that a health and safety consultancy had been appointed by the home to look at risk and develop assessments. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15,16 17 Service users can choose to take part in appropriate leisure activities in the local community. Service users are supported to have personal relationships and their rights are respected in their daily lives. Service users are offered a healthy diet that meets their individual needs. EVIDENCE: Service users are encouraged to take part in activities in the community and the manager advised that the home have links with the Hornsea Education Centre and staff bring information on courses available. Service users are encouraged to continue with activities they were engaged in prior to entering the home. One staff member said that they intended to take two service users swimming who had chosen to do this activity. The service users are supported to maintain family links and on the day of the inspection it was observed that family and friends are welcomed into the home. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 12 The day-to-day routines of the home and house rules promote independence. Service users have unrestricted access to the home and grounds. The inspector observed staff with service users. Communication was relaxed and staff used the preferred form of address of service users. There was evidence of staff knocking on service users doors’ before entering. Service users can choose when to be alone or in the company of others. Staff said that service users are encouraged to take responsibility for housekeeping tasks. Service users are aware of the rules on smoking, drugs and alcohol. One service user said “ the staff told me the rules when I came into the home”. This needs to be clearly stated in the contract. Service users are offered a choice of menus. The cook keeps a record of when a service user has an alternative to the main meal. The cook has been in post 6 months and has introduced fresh vegetables and fruit to the menu. One service user said “its nice tasty food”. Mealtimes are relaxed and flexible to suit the service users. Service users nutritional needs are monitored and this was observed on service users files. On the day of the inspection a number of service users were going to a local restaurant for Christmas lunch. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20 Service users can retain, administer and control their own medication where appropriate. Service users receive personal support as they prefer and require. EVIDENCE: Staff provide individual support for service users, which is sensitive and respects privacy and dignity. During the inspection one of the older service users was being reassessed, as the home could no longer meet their needs. In the short term the staff had sought specialist support and equipment to assist the service user whilst the assessment was completed. Service users are given guidance on personal hygiene and can choose their own clothes and hairstyles. The home is flexible on times of getting up and going to bed. This was confirmed in discussion with the service users. The medication system has recently been changed to a NOMAD system. The records checked indicated that the records for medication received, administered and leaving the home are appropriately completed. There is only one controlled drug currently prescribed to service users and this is kept in separate lockable storage and a controlled drugs register is available. The staff had not all had accredited medication training but this is on the training plan for the New Year. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users’ views are listened to and acted upon. EVIDENCE: The service users advised the inspector that they know how to make a complaint. The complaint procedure is displayed on the notice board and is also available in the service user guide. The procedure needs to be updated to include timescales within which complaints will be responded to. There have been two complaints made to the home by service users. These were dealt with by the manager and recorded. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26,27, 30 Service users live in a comfortable environment. Service user’s bedrooms suit their lifestyle and promote independence. The bathrooms and toilets provide sufficient privacy. EVIDENCE: The home has three communal areas including a dining room, a lounge and a small room which is used as a quiet room. On the day of the inspection some service users were using this room to make invitations to the Christmas party. There is also a conservatory, which is used as the smoking room. The downstairs lounge window had a large crack in it. This requires attention. The service user’s rooms are decorated in individual colours and in those newly decorated the service users had chosen their own colour scheme. These reflect the different styles and tastes of the service users. There is a range of furniture available in individual rooms and service users can personalise their rooms. The decisions regarding the provision of furnishings and fittings to each room must be agreed and documented in each service users care plan. Service users rooms are fitted with locks that are accessible to staff in emergencies and service users are given a key, unless a risk assessment suggests otherwise. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 16 The toilet and bathroom facilities include two bathrooms and a shower room. In addition, there are two separate toilets and two service users’ rooms have ensuite facilities. The bathroom near room 17 has a rusted radiator that needs attention and the separate toilet needs the taps replacing. The bathroom at the rear of the building on the first floor requires redecoration. The downstairs shower room has a strong malodour that permeates into the downstairs corridor; this requires urgent attention. The manager said that the odour was due to the drainage system and the on site builders were going to try to solve the problem. The home has a laundry that some service users access to do their own washing. The staff advised that service users are supervised. The home is set in extensive grounds and access is via a long drive from the main road. The driveway has a number of potholes. There is a car park at the top of the driveway. The driveway and car park are unlit. This was identified at the last inspection and could constitute a safety risk to service users, staff and visitors. There is presently building work in progress and the manager advised that the drive and lighting would be completed as part of this work. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 The home’s recording of recruitment practices does not fully protect service users. Staff are supervised and trained to meet the individual and joint needs of service users. EVIDENCE: Staff who spoke to the inspector said that they are aware of the main aims and values of the home and said that they have the opportunity to discuss ideas and opinions at the staff meetings. Some staff meeting minutes were available for inspection. Staff have a contract of employment. Discussion with the manager indicated that the home has an ongoing NVQ training programme. One member of staff has completed NVQ Level 2 and one staff member has an NVQ Level 3. All other staff are working towards the qualification. The home has a staff rota available and this indicates that there are two care staff working throughout the day and two waking night staff. In addition, the home has a cook, a domestic and a maintenance person. The present care hours are 325 a week. Given the number of service users now accommodated and their dependency levels the Department of Health recommends that this should be reviewed. The manager advised that they were recruiting new staff. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 18 The home has recruitment and selection procedures available including an equal opportunities policy. Three files were inspected and one had no evidence that a CRB had been completed. In one instance there were two references but one was verbal. One file had no references. The manager advised that the references and CRB had been completed but these should have been available at the inspection. Staff have a statement of terms and conditions. There was no evidence that gaps in employment are explored. The home has a training and development plan and each staff member has an individual training plan. This is in the early stages of development. The manager advised that a staff member has been given the responsibility of coordinating training. Staff supervision has been implemented and an appraisal system is in place. This has just begun and the inspector will have a clearer view of this working in practice at the next inspection. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The management of the home is improving. The home offers service users a safe environment where their health and welfare is promoted. Service users’ views are listened to. EVIDENCE: The manager is in the process of being registered with the CSCI. Service users and staff felt supported by the manager and gave positive comments. The manager has worked hard to improve the service for the service users since she has been appointed. The manager has completed NVQ Level 4 in care and management. The manager advised that further improvements would be made regarding recording systems as an administrator is to be appointed. The responsible individual visits the home regularly but Regulation 26 visits are not recorded. The home has recently been awarded the local authority quality development scheme Part 1. The manager advised they are now working towards Part 2. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 20 There was evidence that staff had completed mandatory training. However, there is not always a qualified first aider on duty at all times. The manager advised that this had been arranged but due to unforeseen circumstances had had to be rearranged. There were maintenance certificates for emergency lighting and fire extinguishers but not for the fire alarm system. The electrical installations identified a number of outstanding areas that required work. An immediate requirement was issued for this to be completed. The fire alarm and evacuation records were available for inspection. The maintenance person had the Portable Appliance Test records but these were not on the premises. There is a fire risk assessment in place. The manager advised that a health and safety company had been appointed to complete risk assessments on safe working practices. This must include a risk assessment for the building work to ensure service users are safe. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X 3 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 3 2 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willow Garth Care Home Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 3 X DS0000062723.V260159.R01.S.doc Version 5.0 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 18 Requirement The registered provider must ensure that care staff (responsible for the administration of medication), receive accredited medication training. (Previous requirement timescale 01/02/05 - not met). The registered provide must ensure that the complaints procedure includes a timescale. The registered provider must ensure access to and from the home is safe and consider how the driveway to the car park can be adequately lit. (Previous requirement - timescale 1/02/05 - not met). The home requires redecoration, especially the bathrooms and shower room. The window in the lounge requires replacing. A maintenance plan must be in place. The registered provider must ensure that recruitment procedures are followed and staff files contain all the information and necessary checks in regulations 18, 19 and schedule 2 of the Care Homes Regulations DS0000062723.V260159.R01.S.doc Timescale for action 31/03/06 2. 3. YA22 YA24 17 13,23,39 31/01/06 31/03/06 4. YA24 23 31/03/06 5. YA34 18,19 31/01/06 Willow Garth Care Home Version 5.0 Page 23 6. YA39 12,15,24 7. 8. YA39 YA42 26 (2) (3)(4)(5) 17, 23 2001. (Previous requirement timescale 1/02/05 - not met). The registered provider must 31/03/06 ensure that effective quality assurance and quality monitoring systems (based on seeking the views of the service users) are in place to measure the success in achieving aims, objectives and the statement of purpose of the home. (Previous requirement timescale 01/06/05). The home must be visited in 28/02/06 accordance with the regulation and a report produced. A copy of the electrical 11/01/06 installations certificate must be forwarded to CSCI. (Immediate requirement issued). Evidence that the fire system has been serviced and the portable appliance test has taken place should be forwarded to CSCI. The registered provider must 31/01/06 ensure that a risk assessment is place for the building work to ensure service users are safe. There must be window restrictors in place, based on assessment of vulnerability of and risk to service users. 10. YA42 23 Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 24 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. Refer to Standard YA16 YA32 Good Practice Recommendations The registered provider should ensure that rules on smoking, alcohol and drugs are clearly stated in the contract. 50 of the care staff should have achieved NVQ level 2 in care by the end of 2005. Willow Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Garth Care Home DS0000062723.V260159.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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