Inspection on 23/09/08 for Willow Garth Care Home

This inspection was carried out on 23rd September 2008.

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

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 Garth Care Home 25/09/07

Willow Garth Care Home 26/09/06

Willow Garth Care Home 12/12/05

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 30/01/2009.

CARE HOME ADULTS 18-65 Willow Garth Care Home Rolston Road Hornsea East Yorkshire HU18 1XP Lead Inspector Janet Lamb Key Unannounced Inspection 23rd September & 8th October 2008 10:15 Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 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.V373072.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 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.V373072.R01.S.doc Version 5.2 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) hatzfeldcareltd@btconnect.com Hatzfeld Care Limited Position Vacant – R Willis is Acting Manager Care Home 28 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (40), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Category MD(E) is restricted to three individuals named to CSCI on 19.5.06. This condition will cease when those named no longer live in the home. From the date of this certificate the service may provide care and accommodation for a maximum of 40 (forty) persons in the permitted registration categories. 25th September 2007 Date of last inspection 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 now registered for 40 people of either gender who have mental health needs. Personal support is provided for people along with all meals and a laundry service. People have access to the home’s minibus for outings and shopping, since access to local facilities in the nearby town is via the local bus service. Many people choose to walk to town along a road that is without pavement and lighting at certain places. The home is now well into its programme of upgrading with the development of additional bedrooms in phases that are within new build properties within the grounds. Therefore an increase in registered places to 40 has taken place. Accommodation in the original house is in 19 single and 2-shared rooms, which are situated on two floors. There is no passenger lift available. The main house has a large conservatory lounge, a kitchen, two dining rooms, a meeting room, laundry and a medication room. There are 10 additional places provided in single storey ground floor rooms, equipped with en-suite toilet and shower, within converted outbuildings. Since the last inspection another 7 single rooms with en-suite toilet and shower have been created in a new build quadrangle also in the grounds. There is also conservatory within the quadrangle which just houses a snooker table for recreation. The standard fees charged by the home range from £350.00 to £750.00 per week with additional charges made for hairdressing, toiletries and other amenities. This information was provided on the day of the site visit. Willow Garth provides general information about the home in its Statement of Purpose and Service User Guide, both available on request from the provider. Willow Garth Care Home DS0000062723.V373072.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 2-star. This means the people who use the service experience good quality outcomes. The Key Inspection of Willow Garth has taken place over a period of time. It involved electronically requesting an ‘annual quality assurance assessment’ (AQAA) document in July 2008 supplying information about people and their family members, and the health care professionals that attend them. It also asked for numerical data held in the home. The home sent us their AQAA in August 2008 and surveys were sent to people living in the home and to staff working there. Information taken from the previous key inspection report, from returned surveys and from notifications sent to us by the home, as well as from details sent to us of the alterations made to the home, was used to determine what it must be like living there. On 23rd September and 8th October 2008 Janet Lamb carried out site visits to interview people living in the home, staff and the manager, and to observe some of the daily routine, as well as to inspect records and documentation. This was to assess all of the information already received and to determine what it must be like to live at Willow Garth. All of the key inspection standards were assessed in sections and the following report provides a judgement on each section. Where a shortfall is identified a requirement or recommendation has been made. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People who propose to use the service are well assessed before they move into the home, and they are provided with good information about the support on offer, the staff and the routines in order to decide whether or not their needs can be met there. People have their needs and changing needs recorded in a plan of care, which takes into consideration their individual differences and specialist health requirements. They are encouraged to make their own decisions about daily life, which may involve taking risks in order to achieve independence or Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 6 rehabilitation. These risks are reduced where possible with the use of risk management documents, behaviour programmes and contracts of behaviour. People take part in appropriate community based activities and pastimes within the home or in the community, they enjoy relationships of their choosing with good advice coming from staff, and have their rights and responsibilities as citizens upheld wherever possible. People enjoy a variety of meals, usually of their choosing, and assist in the provision and preparation of food, as part of the occupational and recreational programmes within the home. People are well protected by the home’s systems for controlling and administering medication and for encouraging self-medication. They have their views listened to and feel confident they can make representations or concerns and complaints known to staff or the manager. People live in a comfortable environment that is clean and suits their preferences, and which is developing all the time. Competent and qualified staff support people in their daily lives and in sufficient numbers to meet their needs. Staff are well recruited and trained so people are confident they are safe. People benefit from the experience and competence of a respected management team that runs the home well and in people’s best interests. There is a good quality assurance system in place, which self-monitors the service provided. The health, safety and welfare of people and staff are well promoted and protected. What has improved since the last inspection? The service has reviewed and revised its Statement of Purpose and Service User Guide to make sure information is up to date and relevant regarding the service it now provides. It has also improved its systems for assessing people’s needs and for producing plans of care to make sure people’s needs are properly and accurately recorded and met. Included in this is the development and maintaining of risk assessments and the reviewing of people’s medications, as well as revising of medication policies and practices. The service has supplied street lighting to its driveway and repaired one of the toilets that was out of action at the last inspection. It has built new extension rooms to increase the number of registered places. The service has reviewed and increased the care and domestic staffing levels in the home, provided staff with relevant training in mental health issues and especially Korsakoff’s syndrome, improved the number of staff with the Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 7 relevant qualifications, and it has improved its performance in maintaining a safe environment. The service has reviewed the systems for making complaints representations and enabled people to do so in a less formal way. and 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. The summary of this inspection report can be made available in other formats on request. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 8 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.V373072.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have satisfactory information about the home, so they or their relative are able to make an informed decision about whether the service is right for them. The use of individual needs assessments means that people’s diverse needs can be identified and planned for before they move to the home, so they are confident their needs will be met. The contract of residence provides people with protection that the service on offer meets their needs. EVIDENCE: Discussion with the provider/acting manager reveals there is a new Statement Of Purpose and a new Service User Guide in place, since the last key inspection, which take into consideration the changes in staffing, and the changes in the service on offer to provide support to people with WernickeKorsakoff Syndrome. Discussion with three people and viewing of files reveals people have a full assessment of their needs before they are offered a place in the home, and are provided with a contract of residence. Assessments may be general or specific Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 10 to individual conditions of mental health, or both. Evidence is held in files and people spoken to recall the process they went through to obtain a placement. All documents are signed and most are dated. Staff must be vigilant in making sure everything recorded or composed is dated for authenticity. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People enjoy making many of their own decisions in life, with risk assessments being in place where necessary to enable them to lead lives of reduced risk. Care plans are now improved for everyone to meet needs better and these are reviewed as requested, necessary or in line with the requirements of the providing authority. EVIDENCE: Viewing of care plans and interviewing people and staff show there are clear and relevant plans of care put in place for everyone admitted or sectioned to the home. Three person centred plans of care were seen and they are written in a format that shows people’s profiles, assessed needs, the action plans to meet the needs and the goals people want to achieve. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 12 They also contain eight sections in which different information is recorded; personal information with an inventory, guidelines with set goals, health needs with set goals, finances, activities, personal plans, risks and behaviour records. Generally the files seem to cover needs well, personal and physical, cultural and racial, health, financial, emotional support, spiritual support etc. In one file there was a Humber Mental Health Support Intervention Plan, a disclaimer about finances and an agreement declaring wishes on death. There was also a relapse and risk management plan. Clearly plans of care are very individual. People are encouraged to make decisions and given a lot of guidance from the provider/acting manager and senior staff. Several people have advocates that work for social services departments or the NHS. People were observed coming and going as they please, carrying out tasks and jobs within the home, such as cooking and keeping kitchen, doing gardening or building work. There is always plenty of physical activity to engage in as the seasons are followed and celebrated well. Evidence of this is available in files and in picture albums. People handle their own finances where possible and always need extensive support and sorting of money issues on first being admitted. The provider/acting manager spends a lot of time liaising with the Benefits Agency, banks etc. on behalf of people. Risk taking is part of everyday life at Willow Garth due to peoples’ illnesses and their understanding of the world when they are ill. Risk assessment documents are in place and there may also be behaviour management programmes in place, both to reduce risks as much as possible. Sometimes people are obliged to sign behaviour contracts or agreements in order to help them modify their behaviour in their own best interests. These are clearly recorded, signed and dated and only implemented with their full cooperation. There is a written procedure for people going absent without explanation, which staff are fully aware of. All movement activity is now monitored and recorded much better. A requirement made at last key inspection has been met, as risk assessment documents are kept up to date and reviewed with care plans. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. When people are experiencing good mental health they enjoy a good level of satisfaction in their lifestyles that are mostly of their choosing, with good support from staff where necessary. So most of the time they are confident their needs are met. When people are experiencing poor mental health they receive greater encouragement and support from staff to achieve the best possible or optimum lifestyle until such time as people’s mental states improve. Proof that improved lifestyles happen takes time, but the judgement is that many benefit from the individual lifestyle regimes set for them. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 14 EVIDENCE: Discussion with management and staff, interviewing of people and observation of activities within the home, as well as viewing of some documents, show that jobs for people are mainly supplied or found within the setting of the complex. The vision and idea for the home is for the site to become a ‘village’ complex offering care, support, advice, occupation and activity, the latter two being based on agricultural and labouring roles. In the meantime people are encouraged to take up occupation or pastimes that suit their ability or current trade etc. in order to remain useful and valued. Not everyone has a role, especially if they do not wish it, but everyone is expected to help themselves to drinks by choice and to maintain their own personal hygiene to an acceptable level dictated by the group of people and staff as a whole. People are also asked to keep their room clean and tidy, though support is provided where it is needed. The home now produces a quarterly newsletter for people and relatives called ‘The Willow Garth Warbler.’ It is a source of information, provides entertainment and contains pictures as a memento or evidence of people on outings, doing activities, showing interest in hobbies etc. Here are lots of community links and social inclusion on offer to people. They use the town and resort of Hornsea well and transport is available for outings and trips. Plenty happens on site too, which is seasonal and fun. Evidence of activities in last 12 months is available in photograph albums, diary notes and records and individual activity plans and records. Events have included bonfire night, Halloween, Christmas and birthday parties, Karaoke nights, fancy dress, etc. One staff has encouraged people to design a Christmas card this week as part of a competition. The winning design will be published and sent out as the greeting from Willow Garth this year. Specialist rehabilitation programmes for those with Korsakoff syndrome includes extensive activity programmes and contracts for personal care and routines. People also complete a food hygiene course and certificate if they choose to help in the kitchen. The idea is to keep people as busy as possible, though not all want to join in. People are offered opportunities to do college courses, charity work, etc, but not everyone is willing. People exercise their right to vote. There are people of different cultures and backgrounds living in the home and their religions and other diversities are encouraged and accepted. Family and friend contact is fully encouraged and facilitated in respect of providing transport, funding etc. The provider/acting manager and other staff Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 15 offer lifts in the home’s minibus, taxis are sometimes used, but local buses and walking are the most frequent modes of transport. People write, telephone and visit family members and even stay-over if able and assessed as being risk free. There is a married couple living in the home, and others people are encouraged to develop relationships but only if appropriate, healthy and in their best interests. Routines are of people’s own making though meals are set and some tasks to be completed each day are also set. Everyone is aware of the need to have stability and routine in order to maintain reasonably good mental health. Rules on smoking are clearly defined and everyone has taken on board the need to cut down and to take smoking outside, where a new three-sided gazebo has been built in the grounds to house smokers. Almost everyone is trying hard to cut down on smoking in an effort to achieve improved physical health and they have agreed to contain it in one location. People having built the gazebo are proud of their achievements and of their ambitions to reform on smoking. Meals are all prepared and cooked on site using a mixture of fresh products grown on the land or purchased locally. People do the shopping, preparing, cooking and serving of food. Mealtimes are relaxed though have an industrious feel to them, as everyone has to be nourished and people have to ‘muck in’ to get the jobs done. Two hot courses are provided at lunchtime and people eat staggered according to their choice or to the tasks they perform. Those involved with cooking tend to eat last. There are two dining rooms and those people requiring encouragement receive it sensitively and with a sense of ‘fellowship’ – ‘we are all here together, we need to eat well to maintain our health, it’s good, let’s enjoy it.’ Menus are set from ideas put forward in house meetings, that are held every month and one visiting health professional confirmed these take place, as he has observed them on several occasions. Menus are according to healthy options and change with the seasons or people’s suggestions. No one had any complaint or issue with food provision at all. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People enjoy a much improved and good level of support and protection with their health care and personal care, and with administration of their medicines, so they know their care and health care needs are met. EVIDENCE: Few people actually need assistance with personal care. Everyone needs high levels of support on occasion depending on their state of wellbeing. People are always assisted in the privacy of a bedroom or bathroom and choose their own belongings and clothes on daily basis etc. There is no necessity for specialist aids and adaptations at the moment, though one person has a specialist bed to aid mobility, increase independence and ease pain. They spoke about how it has improved their quality of life. Receiving of specialist support and treatment from healthcare professionals is very important to everyone and they all receive services from Community Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 17 Psychiatric Nurses and Consultant Psychiatrists, through attending appointments at the hospital or in-house during house calls. People’s plans of care contain a good element of ‘Health Care Plan’ needs within them written under the section labelled ‘health needs with set goals.’ Records show how such needs are met. These were seen for three people with their permission. Health care plans include five sections to them; ‘the particular current profile,’ ‘support needs identified,’ ‘management of any needs,’ ‘action plans/goals’ and ‘supporting records.’ There is also a health sheet that records daily issues experienced by people or where any assistance/support is given. The home also holds copies of people’s NHS Service Plan and their NHS Care Plan. Plans of care and health care plans are or may be different for each person as they are very individual to their personal needs. Health care needs are well assessed, planned for and met. Some people have personal hygiene agreement plans, as sometimes their personal choices do impact on others in the home. Medication handling systems appear to be good. There is a dedicated medication and treatment room, where two new dispensing trolleys are available, and where a Boots Chemist ‘Medisure’ monitored dosage system in the form of weekly dispensing cards are stored. The cards show the person’s name, date, dose to be taken and name of drug. There is an anomaly with the supply of one particular drug, supplied by Lloyds Pharmacy, which is prescribed by the hospital. Therefore the drug is administered from the manufacturers boxes. There are also separate administration record sheets maintained for this. The drug is also stock-checked after every single administration, but it is not a controlled drug. There is a controlled drug record book available, but none are used at the moment. Any changes in or extra medicines prescribed are recorded on separate record sheets, but staff have only ever written and signed this singularly before. A recommendation therefore will be made for two staff signatures to be obtained when details on a record sheet are changed or added as new. Returns are recorded on the record sheets and in a separate returns book. Systems are robust. Plans of care now show any medication changes and prompt staff to check the record sheets when any changes have been made. People requiring medication are asked to make it their responsibility to come to the medication room each time they are due a dose. That way people take their medication discreetly and learn to be responsible on a regular basis. All requirements and recommendations made at the last inspection regarding medication have now been met. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 18 The staff are medication administration trained via induction, in-house instruction and then an external course with Castle College in Bridlington. Staff complete a work-based assessment, which is then sent off to the company for verification. Staff confirm their training in interview. An opportunity arose to speak to a visiting Community Psychiatric Nurse who backed up what had already been determined. He explains the home has improved greatly in the last year, as people are much happier and are enjoying the improvements in the environment. He says the care provided is now more focused on the individual plan of care that people have. He says communication between the home and health care professionals has improved, as he now receives a weekly update on the people he visits. Also that working relationships are better and everyone is now working together for the benefit of the people. He can also see people in private now in the consultation room that has been created. He says people are listened to more and have ‘a voice.’ Finally he says the medication handling systems have improved, as there is now a picture of everyone with their medication administration record sheet, and the home is using a monitored dosage system. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People and their relatives have access to satisfactory complaint and protection systems within the home, which have been improved. They are confident their concerns are dealt with appropriately and that they are protected from harm or neglect, as the general culture of the home is good and nurtures a self-determining lifestyle. EVIDENCE: Discussion with people and management and viewing of records show certain people make continuous complaints, but all are properly recorded and people are updated about the progress of their complaint. The home’s quality management review now looks at performance in dealing with complaints. A complaint record is maintained and had 21 recorded since August 2007, with 9 compliments. All of them are appropriately recorded and dealt with seriously. The home now has an appointed person to whom complaints and compliments are given to remove the fear of complaining to staff or management and having an adverse response. People are clear about whom they would tell. There have been no safeguarding referrals since the last key inspection, as procedures have been improved and staff are fully aware of their responsibilities. Staff are well trained in safeguarding on yearly basis if Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 20 possible, four new staff are booked to do course with Hull & East Riding Safeguarding Adults Board in November 2008. All seniors do the manager’s training. Staff files were not checked, but interviews with people show staff have good understanding of their responsibilities and of the procedure to follow. People spoken to also know they have a right to be protected and the community being as it is, someone would always bring to light any injustice or abuse. There were no concerns raised about finances. The provider/acting manager spends a lot of time helping people sort money issues, claim benefits and so on. He makes sure people are accommodated, fed and clothed, even though money may take weeks to sort. People are quite satisfied with the arrangements for receiving personal allowance and for handling finances, except for one, raised in interview with him. Discussion with the provider/acting manager reveals there are legitimate and recorded reasons why restrictions are placed on this person. No financial documents or records were viewed on the site visit. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People live in a satisfactorily furnished and equipped home, that is clean, safe and comfortable. The home offers sufficient space and facilities so people are able to lead independent lives. EVIDENCE: The environment is improving all the time. There is now a policy of bi-annual refurbishment to all bedrooms and the programme is almost complete this time around. There is also a phased development of the site, taking place. A new quadrangle has been added with 7 en-suite rooms since the last key inspection. This has increased the number of registered places to 40 and registration been approved. There is a final phase still to come. At the moment people are seeing gradual improvements in the general decoration of rooms and bedrooms, with the replacement of old furniture, and Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 22 with the overall building and extension work going on. One room has its own conservatory. Requirements made at the last inspection have been met. The driveway has been supplied with lighting and the out of use toilet has been repaired. The overall impression of Willow Garth has greatly improved over the years. It is cleaner, more modern and has improved in comfort. There is a permanent office block in place now and the grounds are to be developed further still, to include a resource centre and workplace not only for people in the home but also for people living in the community to access on a daily basis. The laundry was not inspected on this site visit, but it is understood equipment meets the requirements of the Water Supply (Water Fittings) Regulations 1999. Staff understand the need to maintain good hygiene and have done infection control training. A housekeeper was appointed in December 2007 as recommended at the last inspection, so the home is better maintained. Cleaners on duty were observed during the site visits. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. Well-recruited and selected staff that are qualified and trained are caring for and supporting people. There are staff in sufficient numbers and with sufficient contracted allocated hours to meet people’s needs. EVIDENCE: Discussion with the provider/acting manager and staff and viewing of records reveals all new staff complete ‘Skills For Care’ induction and training and undertake training courses with ‘Train To Gain.’ 59 of care staff have achieved NVQ level 2 and one of the deputies is completing NVQ level 4 Registered Manager’s Award (RMA). Staffing levels have been reviewed since the last key inspection and now there are three carers on both the morning and afternoon shifts, with the deputy and manager also available, and still two waking night staff. There is now a Rosters and staff housekeeper employed throughout part of the day. interviews evidence this. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 24 Recruitment policies, procedures and practice remain the same as at the last key inspection, so systems were not assessed, but brief discussion with management informs us there is now a three month probationary period for all new staff recruits and the increase in minimum pay has attracted people with greater competence and skill to do the job. Staff are now fully involved in the programme of care planning, and the home also undertakes Criminal Records Bureau (CRB) security checks with an umbrella organisation, and is no longer a CRB signatory itself. Finally all recruitment files are now held on site and not at Hatzfeld headquarters. Evidence in staff files and from interviews with staff and management show there is annual mandatory training to complete, as well as specialist training now provided on such as mental health conditions. All requirements and recommendations made in this section have been met since the last key inspection. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People enjoy the benefits of a well run home. The quality assurance systems are suitable for determining the quality of the service provided and show the service to be good. There are very good policies, procedures and safe working practices available, that staff use effectively. People are confident the conduct and management of the home is good, which means care needs are well met and people lead fulfilling lives. EVIDENCE: The home provider is now managing the service on a full-time basis, but he has been approved as the registered manager some years ago, before the last manager was registered and left her position. The Regional Registration Team has approved this, as it is Hatzfeld’s intention to register one of the deputies as Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 26 manager once she has completed her RMA. The current provider/acting manager, who has more responsibility to maintain the financial side of the service, will continue in this role and currently supports the deputies to carry out care management, until one of them does become the registered manager. Both people are experienced and complement each other well in the sharing of the overall management of the service. The home is being well run and in the best interests of the people living there. The quality assurance systems remain the same as at the last key inspection and were not assessed on this inspection, but brief discussion with management and staff reveals the East Riding of Yorkshire Council Quality Development Scheme, parts 1 and 2 have now been achieved. The home also follows the QMS ISO 9001 system of quality assuring, as well as receiving full audits from the health and safety company Stallard and Kane Associates. Several areas of health and safety were sampled during the site visit and a whole array of safety checks, maintenance and recording practices carried out within the home have been assessed. Some examples include fie safety systems, moving and handling, storage and handling of the hot water, control of substances hazardous to health, and waste management. The only minor shortfall is in the recording of fire safety training drills. Staff attending a drill need to sign to say they have been present as evidence, and to enable the management to determine that all staff receive a minimum of two staff training drills in every twelve-month period. Evidence seen to support how the home promotes and protects peoples’ health, safety and welfare through safe working practices was in the form of safety certificates, maintenance monitoring and recording and internal safety checks carried out. Standards 37, 39 and 42 are satisfactorily met. Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 27 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 Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 28 No 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations The registered provider should make sure all staff administering medications sign and ensure a second staff signature as witness to any changes or additions they make on the medication administration record sheets, so people are confident their drugs are administered safely. The registered provider should make sure all staff attending a fire safety training drill sign to evidence they have attended, enabling the management to determine that all staff receive a minimum of two fire safety drills in every twelve month period, so people are confident they are being protected from the risk of harm from fire. 2 YA42 Willow Garth Care Home DS0000062723.V373072.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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