Inspection on 14/09/05 for Willow Grange

This inspection was carried out on 14th September 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 but made no statutory requirements on the home.

Other inspections for this house

Willow Grange 28/05/08

Willow Grange 30/04/07

Willow Grange 09/01/07

Willow Grange 26/04/05

Willow Grange 13/01/05

Willow Grange 28/07/04

Willow Grange 14/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Willow Grange 118 St Bernards Road Olton Solihull B92 7DH Lead Inspector Amanda Lyndon Announced 14 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Willow Grange Address 119 St Bernards Road Olton Solihull B92 7DH 0121 708 0804 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Alpha Health Care Ltd Mrs Nicola Pudney Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number of places Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Mrs Pudney obtains the required management qualification, i.e Registered Managers award / NVQ 4 in Care Management by 2005 Date of last inspection 26 April 2005 Brief Description of the Service: Willow Grange is a residential care home registered for fourty six older people, located in the Olton area of Solihull. Following assessment, the home are able to accommodate older people for both long stay and respite care. The home is located near to a bus route and places of worship. Willow Grange is a large Edwardian house which has a purpose built single storey extension to the rear of the property. An adjoining coach house is also incorporated into the property. All bedrooms with the exception of six of the single rooms have ensuite facilities (shower, wash hand basin and toilet). The home has five double bedrooms, thirty six single bedrooms, kitchen, dining and seating areas, laundry and hairdressing salon. The home has a passenger lift. There are car parking facilities to the front of Willow Grange and gardens to the side and rear of the property and an inner courtyard. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was undertaken over two visits and this included an inspection undertaken by the Pharmacist Inspector when there were forty one residents living there. Information was gathered by speaking with residents and staff, observing staff perform their duties and examining care, medication and health and safety records. This is the second inspection of this service in the 2005/2006 inspection year and linked to the Commission’s focus on outcomes for residents and proportionate inspection, we would recommend that you read this report in conjunction with the last inspection of this service on 26 April 2005. The Commission received four completed comment cards in respect of the service provided at Willow Grange and these were all positive in nature. What the service does well: Residents are well supported by the care staff to meet their ongoing health, welfare and personal care needs and their personal preferences are taken into account in respect of this wherever possible. One resident said “ If I need the Doctor the staff arrange this for me”. In addition to this, good systems have been installed to ensure that medicines are administered as prescribed and the staff are keen to further enhance good practice. Residents are cared for in a respectful manner by staff working at the Home. One resident said, “ The staff always knock before they enter my room”. There is a wide variety of activities on offer for residents to participate in should they choose both inside the Home and in the local community. One resident said, “ We choose which activities we want to take part in, I really enjoy the pub lunches”. Residents are supported by the staff to maintain contact with their families and friends and visitors are made to feel welcome at the Home. One resident said “My visitors are always offered a cup of tea when they visit me here”. Residents are able to exercise choice over their daily lives and routines which promotes their independence and individuality. One resident said “ I have my breakfast in my room and then choose to go back to bed for a bit, it’s up to me”. Residents receive a choice of wholesome and nutritionally balanced meals, which meets any dietary needs. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 6 Bedrooms contain many personal items to reflect residents’ individual tastes and preferences to ensure that they feel comfortable in their surroundings. One resident said, “ I have a beautiful room with a beautiful view”. The Home does not use agency staff and have a loyal work force and this ensures continuity of care. Staff moral is good. One resident said, “ All of the staff are very nice. I haven’t got one single grumble”. Group meetings are arranged in order for those living at the Home to put forward their comments and suggestions about the service provided at Willow Grange. There is a robust system for the management of residents’ personal allowances should the resident choose for the Home to hold this on their behalf. What has improved since the last inspection? What they could do better: Residents do not have the option of serving their own food portions at mealtimes and this does not promote their independence. The garden must be made accessible to those people with limited mobility or wheelchair users. The Home does not have an assisted bathing facility and the showering facilities are inaccessible for a number of residents to use and this limits residents’ choice and does not promote their independence. One resident said, “My bathroom is very small and the staff have to help me get into the shower”. Remedial action on a number of health and safety and refurbishment issues in respect of the premises must be addressed in order to ensure that residents have a safe and comfortable environment in which to live. The approved staffing level of four members of staff on duty during night time hours must be maintained to afford full supervision to residents during that time. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 7 Not all staff had received training in health and safety and care practice issues and this may pose a risk to both resident and staff safety. 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 Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 The assessment and admission processes are comprehensive which ensures that prospective residents have all relevant information about Willow Grange and are aware that their individual care needs can be met. Contracts detailing terms and conditions are available for all residents. Residents’ changing care needs are assessed by the staff working at the Home to ensure that their needs are being met. EVIDENCE: The Organisation had produced a comprehensive statement of purpose and this included one factual inaccuracy which must be rectified as it states that Willow Grange has one assisted bathroom equipped with bathing aids and hoists and this is not the case. The service user guide is available in a large print format and this must be amended to include all current information. Since the previous inspection the pre admission assessment document had been further developed and included all information required. Prospective residents are encouraged to spend a day at the Home prior to admission and Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 10 at this time senior staff will undertake a comprehensive assessment of their individual care needs. Residents are issued with a letter identifying that their care needs will be met at the Home and on admission are issued with a comprehensive statement of terms and conditions of residency. Residents come to live at Willow Grange for a trial period of one month and after this time care reviews are held to ensure that the resident is happy to continue to live there and that the staff can meet their individual care needs. Residents are reassessed should their care needs change in order to ensure that the Home can continue to meet their needs. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Residents’ ongoing health and personal care needs are well met by the care staff who use comprehensive care plans to ensure residents’ continuity of care. The home demonstrates some good practice for medicine management and the Registered Manager is keen to improve this further. Residents are supported in a respectful manner by the staff and this ensures that their dignity and selfesteem are maintained. EVIDENCE: On admission to the Home comprehensive assessments are undertaken of residents’ holistic care needs and individual care plans are derived from these that include the personal preferences and routines of residents. The actual action required by the care staff to support residents was included in good detail within their care plans. Although much improved, care plans were not always reviewed and updated monthly to reflect the resident’s changing needs and were not always written and reviewed with the involvement of the resident and/or their representative. A care plan had not been written in respect of a resident who was exhibiting mental health care needs. Residents’ risk assessments had been undertaken including the risk of falls, pressure area care and nutrition and residents are weighed each month. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 12 Moving and handling risk assessments had been undertaken, however, these did not include the action to be taken by staff should a resident fall. Life histories were documented and activity care plans identified residents’ interests and abilities in respect of how their social stimulation needs would be met. The comprehensive daily reports included detail of the activities that the resident had engaged in that day. Residents have the option of retaining their own General Practitioner on admission to the Home (if the GP is in agreement) and residents have access to other visiting Health and Social Care Professionals including Social Workers, District Nurses and Chiropodists and a comprehensive record in respect of these visits was maintained. There was, however, no written evidence available to reflect that the care staff had monitored the effectiveness of treatment prescribed by a resident’s General Practitioner. One resident said “ If I need the Doctor the staff arrange this for me”. All of the medication audits undertaken to demonstrate that the medicines had been administered as prescribed were accurate and the care staff interviewed had a thorough understanding of the service users clinical needs. All staff had successfully undertaken accredited training in the safe handling of medicines and are currently completing a refresher course. Recommendations discussed during the inspection to improve standards further in respect of the management of medication were well received. Lockable storage facilities were available in some residents’ bedrooms and appropriate privacy locks were fitted to bedroom doors, which could be overridden in the event of an emergency. Risk assessments had not been undertaken to identify the reasons why a number of residents did not hold the key to their bedroom doors. The preferred term of address was recorded in each residents’ care plan and staff were observed greeting residents by their preferred name. One resident said, “ The staff always knock before they enter my room”. Residents were supported by staff to choose clothing appropriate for the time of year as required and have the option of a private telephone line installed in their bedroom. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The activities on offer meet the needs and expectations of residents living at the Home. Residents are able to maintain contact with family, friends and the local community with support from the Home’s staff. Residents receive a wholesome and varied diet, which meets any special dietary needs, but they must be encouraged to serve their own portions at mealtimes in order to maintain their independence and freedom of choice over the sizes of food portions served. EVIDENCE: The Home employs a dedicated activities organiser and the activities on offer and the management of the recording of the outcomes of these events is to be commended. Residents could choose to participate in a variety of activities including tea dances, pub lunches, quiz games, fish and chip suppers, indoor bowls and chess. A hairdresser visits twice a week, Holy Communion is available, residents’ birthdays are celebrated and plans are in place for a winter fund raising fete. Newspapers are delivered daily, there is a trolley shop and the management of this is good. A number of residents attend a day centre each week. An activity timetable of events is distributed to each resident in their bedrooms. One resident said, “ We choose which activities we want to take part in, I really enjoy the pub lunches”. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 14 There is an open visiting policy and a communication document between relatives and staff had been introduced to aid communications. One resident said “My visitors are always offered a cup of tea when they visit me here”. Residents can go outside of the Home with their relatives as they wish and can choose where they are served their meals. One resident said “ I have my breakfast in my room and then choose to go back to bed for a bit, it’s up to me”. The main meals of the day were wholesome and well presented. The menus identified a variety of nutritionally balanced meals and a choice was always available. The menus, however did not identify breakfast and supper time snack meals on offer and these must be amended to include this. Special diets are catered for including soft and pureed diets, low fat and diabetic options. Dining tables were laid attractively, cold drinks were served and the mealtime was relaxed and unhurried with good social interactions amongst residents. Residents are not given the opportunity to serve their own food portions at the dining tables and this must be reviewed in keeping with good practice. Daily menus were not accessible to residents. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The complaints procedure is comprehensive and is accessible to residents and their visitors. EVIDENCE: The Organisation had produced a comprehensive complaints procedure and this was accessible to residents and their relatives. Since the previous inspection the Commission and Willow Grange had received one complaint and the outcome of this was found to be not upheld. Comprehensive and well maintained records were held at the Home in respect of this. One resident said “ I wouldn’t hesitate to speak to any of the staff if I had a complaint”. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24, 25 & 26 Residents are provided with a homely, clean and comfortable environment to live in, with the exception of the communal shower room which is need of an urgent refurbishment as it is not fit for purpose in it’s current state. In addition, the Home does not have an assisted bathing facility and the showering facilities are inaccessible for a number of residents to use and this limits the residents’ choice and does not promote their independence. The garden is not accessible to all residents and remedial action must be taken in respect of this to ensure freedom and choice for all people living there. EVIDENCE: The internal environment of the Home was mainly homely in style and comfortable with some attractive original features in keeping with the age of the building. The Home had two patio areas and a large well maintained garden with a feature fish pond, however this was not accessible to wheelchair users or those people with limited mobility as they would have to negotiate a step. In addition to this, the external side entrance allowed unrestricted access to the front Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 17 entrance and main road posing a risk to some residents’ safety. New carpets had been fitted in a number of communal areas and bedrooms in the Home, however it was noted that the carpet was worn in one bedroom in particular and this was brought to the attention of the Registered Manager. A rolling programme of the replacement of carpets was in place. Furniture and decoration throughout the Home were generally of a good standard and a rolling programme of replacing furniture was in place. Since the last inspection a number of bedrooms contained attractive new furniture. One bedroom, however contained a commode instead of a comfortable chair despite the resident living in this room having no use for the commode, a chair in another bedroom was found to be old and stained. Bedrooms contained residents’ personal items. One resident said, “ I have a beautiful room with a beautiful view”. The dining area did not provide adequate seating for all residents who chose to be served their meals in there and despite a second small dining area having been created elsewhere in the Home, extra seating is still required. Plans were in place to replace the existing dining chairs as these were worn. The majority of residents had an en suite toilet and shower facility, however most residents were not able to use their shower independently as they had to negotiate a step up into them. One resident said, “ My bathroom is very small and the staff have to help me get into the shower ”. The Organisation is currently seeking advice from an architect in respect of creating an assisted bathing facility at the Home. There was one communal shower facility available, located on the first floor and in it’s current state would not be deemed fit for purpose. Space within this room is very limited and there is no space between the clinical waste bin and toilet. There was a stale smell within this room, the floor covering was uneven and torn and the light pull cord was deeply soiled. Remedial action was taken in respect of these issues directly following the inspection. The treatment room was full of surplus equipment and used for storage. An alternative location should be sought for these items. Since the previous inspection, radiator guards had been fitted to the majority of radiators in residents’ bedrooms. Lighting throughout was domestic in style and window restrictors were fitted. Checks on hot water outlet temperatures were undertaken regularly and water chlorination servicing had been undertaken. With the exception of the communal shower room and one bedroom, the Home was found to be clean and fresh on the day of the inspection. Residents and staff met expressed their satisfaction at the level of cleanliness at the Home. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 18 One resident said “ The staff clean my room every day”. Hygienic hand washing facilities were appropriately located. An effective and hygienic laundry service for residents’ clothing and bed linen was in place. One resident chooses to use a commode and the Home does not have a mechanical commode pot disinfector in order to clean this. A sink had been designated for the sole use of cleaning of the commode pots and an infection control procedure must be written in respect of this. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Adequate staffing levels are maintained during day time hours to meet the needs of residents, but during the night minimum staffing levels are not always maintained which does not afford full protection and safety for residents. The robust recruitment practice and staff induction ensures that residents are supported and protected by competent staff. EVIDENCE: The staffing rotas identified that the approved staffing level of four members of staff on duty during the night was not always maintained and due to the care needs of the residents and layout of the Home the approved staffing levels must be provided. The management team provide on call support for the person in charge of the shift. Kitchen, laundry, domestic and maintenance staff provide ancillary support and agency staff had not been used recently. A comment was made by a staff member that staff moral was very good. One resident said, “ All of the staff are very nice. I haven’t got one single grumble”. Staff files examined included all relevant information and pre employment health declarations were undertaken. Contracts of terms and conditions of employment are issued to all new staff members. Evidence of satisfactory criminal records clearance were held at the Organisation’s Head Office. The revised staff induction programme had not been implemented, however all new staff undertake an induction and this includes health and safety issues. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 20 Staff had undertaken training specific to the role that they perform including customer care, communication in care, bereavement care and NVQ Levels 2 and 3 in care. The uptake of dementia care training had been poor and adult protection training had not been provided this year. A training needs analysis had not been undertaken for each staff member. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 This is a well managed Home, run for the benefit of the residents and there are systems in place to monitor the quality of service on offer to residents. The systems for resident consultation are good and there is evidence that residents’ views sought are acted upon. Residents’ financial matters are safe guarded through robust accounting of personal allowances. The health, safety and welfare of residents are protected through some staff training and maintenance checks of equipment. Some health and safety issues outstanding in respect of the premises do afford full protection to residents. EVIDENCE: The Registered Manager is experienced in working within a managerial role, caring for older people and is due to complete the Registered Managers’ Award. Positive comments were made by the residents and staff in respect of both the Registered Manager and Deputy Managers’ positive and open management styles, and these included, “ The Manager and Deputy Manager would listen to anyone at any time”. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 22 Staff and residents meetings are held regularly and service satisfaction questionnaires are distributed regularly to residents and their relatives and a comprehensive report based on the findings of these is produced and accessible to all relevant people. In addition to this, quality monitoring visits are undertaken regularly by external Managers and reports of the outcomes of these are sent to CSCI. Staff do not manage the personal finances of residents and they are supported by their families in this area as required. There is a safe facility for the storage of residents’ personal allowances and the system for the management of this was found to be robust, including separate well maintained transaction records. Receipts of all personal items purchased from residents money were not numbered and although audits of this system was undertaken regularly, a written record in respect of this was not kept. All account balances examined during the inspection were found to be correct. The system for formal staff supervision and appraisal had been implemented but was not up to date, however staff stated that they were well supported by senior staff within their job roles on a daily basis. Health and safety checks of equipment used including fire fighting equipment and emergency lighting were maintained as required. Some staff had undertaken training in safe working practices including moving and handling, fire safety, food hygiene and health and safety. A number of staff had a first aid certificate and a fire drill had been held recently. There were still a small number of requirements outstanding following the most recent Fire Officer’s visit and suitable magnetic closing devices were not fitted to bedroom doors however risk assessments had been written in respect of this. Staff inform the Commission of most accidents and incidents involving residents and through this it had been identified that some residents were deemed to be at risk of leaving the building unsupervised by means of the front door as this had not got an appropriate lock fitted to it. Accident records were generally well maintained and accident audits were undertaken regularly, however a record of any action taken following an accident was not always available. A positive Environmental Health inspection had been undertaken recently. Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 2 2 x x 2 3 2 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 3 3 x 3 2 x 2 Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 24 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. 2. Standard OP1 OP1 Regulation 4 5 Requirement The statement of purpose must reflect the service provided. The service user guide must be amended as follows: The complaints procedure must include the information that the complainant can notify the Commission at any stage in the complaint process. (It is noted that the complaints procedure in the reception area of the Home does include this information). 3. OP7 15 The staff list must be updated. Care plans must be reviewed and 01/11/05 updated monthly to reflect the residents changing needs and must be written and reviewed with the involvement of the resident and/or their representative. (Previous two timescales of 26 August 2004 and 31 March 2005 not met.) Moving and handling risk assessments must include the action to be taken should a Timescale for action 14/12/05 14/12/05 4. OP7 13(5) 01/11/05 Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 25 resident fall. (Timescale of 01 July 2005 not met) Residents care plans must include detail of any mental health care needs. Residents acute health care needs must be monitored by the care staff. (Timescale of 01 June 2005 not met) Risk assessments must be undertaken to identify the reasons why a number of residents do not hold the key to their bedroom doors and a written record of this must be available. (Timescale of 30 June 2005 not met) A lockable storage facility must be available in each residents bedroom. Menus must identify the breakfast and supper time snack meal options available and the menus must be accessible to residents. The Registered Manager must undertake a review of the serving of the food at mealtimes. (Timescale of 01 July 2005 not met) The garden must be made accessible to all residents, including wheelchair users and those people with limited mobility The Registered Manager received this in the form of an immediate requirement Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 26 5. 6. OP7 OP8 15 12(1)(a) 01/11/05 15/10/05 7. OP10 12(4)(a) 30/11/05 8. 9. OP10 OP15 12(2)(m) 16(2)(i) 12(2) 01/12/05 31/10/05 10. OP19 23(2)(o) 14/12/05 11. OP19 13(4) A risk assessment must be written and remedial action undertaken in respect of residents unrestricted access to the front driveway via the external side entrance of the building 21/09/05 12. OP21 16(2)(k) The Registered Manager received this in the form of an immediate requirement An alternative location for the 14/10/05 clinical waste bin away from directly touching the toilet must be found within this room. The Registered Manager received this in the form of an immediate requirement. An alternative storage area for 31/10/05 surplus equipment must be sought. Comfortable seating must be 21/09/05 provided in all bedrooms and this must be fit for purpose. The Registered Manager received this in the form of an immediate requirement. An infection control procedure 21/09/05 must be written about the manual cleansing of commode pots. The Registered Manager received this in the form of an immediate requirement. The approved staffing level of 14/09/05 four members of staff on duty during night time hours must be maintained. The Registered Manager received this in the form of an immediate requirement. Staff must receive training about 30/11/05 adult protection issues. Version 1.40 Page 27 13. 14. OP22 OP24 23(2)(l) 16(2)(c ) 15. OP26 13(3) 23(2)(k) 16. OP27 18(1) 17. OP30 13(6) Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc 18. OP30 18(1) The Registered Manager must undertake a training needs analysis for each staff member to identify their individual training needs. (Timescale of 30 June 2005 not met) The system for formal staff supervision and appraisal must be up to date. The Registered Manager must ensure that all staff have undertaken training in moving and handling and fire safety. 31/10/05 19. 20. OP36 OP38 18(2) 13(5) 18(1) 23(4) 30/11/05 01/12/05 21. OP38 13(6) 37 22. 23. OP38 OP38 13(4) 13(4) The Registered Manager received this in the form of an immediate requirement. Health and Social Care 14/09/05 Professionals must be informed of all unexplained bruising involving residents. The Registered Manager received this in the form of an immediate requirement. A written record of action taken 15/10/05 following accidents involving residents must be kept. Ways to prevent residents from 21/09/05 leaving the Home unsupervised (for those residents deemed to be at risk) must be sought following consultation with the Fire Service. The Registered Manager received this in the form of an immediate requirement. Remedial action must be 14/10/05 undertaken to address the few requirements outstanding following the most recent Fire Safety inspection. (Timescale of 01 June 2005 not met) 24. OP38 13(4) 23(4) Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 28 The Registered Manager received this in the form of an immediate requirement. 25. 26. 27. 28. 29. 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 OP9 Good Practice Recommendations The medicines of all new residents admitted into the Home should be administered from the pharmacist labelled container and a system should be established to check these medicines with the prescriber at the earliest opportunity It is recommended that the receipts of all personal items purchased out of residents money are numbered for ease of auditing and a written record of audits undertaken are kept. It is recommended that a programme of fitting suitable magnetic closures to bedroom doors that are linked into the fire alarm system is considered, after consultation with the Fire Service 2. OP35 3. OP38 Willow Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Grange E54 S44889 Willow Grange V243387 140905 Stage 4.doc Version 1.40 Page 30 - 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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