Inspection on 28/05/08 for Willow Grange

This inspection was carried out on 28th May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willow Grange 30/04/07

Willow Grange 09/01/07

Willow Grange 14/09/05

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Willow Grange 119 St Bernard`s Road Olton Solihull West Midlands B92 7DH Lead Inspector Martin Brown Unannounced Inspection 28th May 2008 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Grange Address 119 St Bernard`s Road Olton Solihull West Midlands B92 7DH 0121 708 0804 0121 708 0804 willowmanager@alphacarehomes.com www.alphacarehomes.com Alpha Health Care Limited 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) Mrs Nicola Jayne Pudney Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named service user under the age of 65 by reason of OP not PD. 30th April 2007 Date of last inspection Brief Description of the Service: Willow Grange is a residential care home registered for forty-six older people, located in the Olton area of Solihull. Following assessment, the home is 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 that has a purpose-built single storey extension to the rear of the property. An adjoining coach house is also incorporated in to the property. The home does not have any assisted bathing facilities. All bedrooms, with the exception of six of the single rooms, have en suite facilities (shower, wash hand basin and toilet). The showers are at a level raised from the floor and residents have to negotiate a step up; staff are available to provide assistance to residents when showering. The home has five double bedrooms, thirty-six single bedrooms, kitchen, dining and seating areas, and laundry and hairdressing salon. The home has a passenger lift. There are car-parking facilities to the front of Willow Grange. Wheelchair users can access the gardens to the side and rear of the property and an inner courtyard. The home has a varied activities programme on offer. The scale of charges range from £380-£415. Items not included in the charges: hairdressing, chiropody, newspapers, and private telephone. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This report has been made using evidence that has been accumulated by the Commission for Social Care Inspection. The inspection visit was unannounced and took place on 28th May 2008, between 8am and 3.30pm. During the inspection, people living at the home were seen and spoken with. Staff on duty, as well as the manager, were spoken with, and their interactions with residents were observed. Visiting friends and relatives of three residents were spoken with during the inspection, and another relative was contacted by phone for their views after the inspection. Surveys sent out by the home and returned by relatives were also examined during the inspection. The Annual Quality Assurance Assessment, completed and returned by the manager, also informed the inspection. This was hand written, and gave a summary and self assessment of the home’s achievements, how it benefited users of the service, and how it could improve in the future. Policies and procedures and care records were examined, and three service users were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. This was done by examining their care files, talking to staff involved in their care, talking to them or their relatives or friends, and observing interactions and care. Staff, management and users of the service were welcoming and helpful throughout the inspection. What the service does well: Residents at the home were appreciative of the warm friendly atmosphere in the home, and particular residents enjoy the character of the building, and are very pleased with their rooms and their outlook. “ I’m very happy here” said one resident, adding, “I’ve no problems whatsoever” (with the service). One resident, while acknowledging the lack of space in some of the communal areas, commented that “the most important thing is the people…and the staff are good” Another said “the staff are very nice here.” These were typical comments, with residents and relatives being full of praise for the staff. A relative of a lady with very high needs praised the care and attention she was given, feeling confident that she could ‘always trust’ the staff to do the right thing. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 6 Staff were observed being prompt in answering call bells and requests for help, and responding in a respectful, polite and patient manner to all needs. They showed a good awareness of individual needs and how to meet them. The home caters successfully for a wide variety of needs and wishes. There are a variety of activities, and a busy atmosphere in the lounge area with frequent visitors welcome and feeling at home. What has improved since the last inspection? What they could do better: Refurbishment is planned, and is needed in many areas, notably, the provision of a bathing facility that includes a bath, so that residents have this option, rather than just a shower. “I would love to have a bath here’ was a typical comment. The most frequently used communal toilets (most frequently used because they are nearest to the lounge) need improvement. They are institutional in appearance, and, by their small size, do not help residents’ dignity and privacy. Carpets, particularly stair carpets, are worn and in need of replacement. In some communal areas, the flooring is uneven. A sluice room would help staff maintain cleanliness and hygiene. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to have a comprehensive assessment process, so that prospective residents can be confident that the service is able to meet their needs. EVIDENCE: Two relatives of a prospective resident who were visiting during the inspection spoke very positively about the home, saying it was very welcoming and very informative about how it could meet individual needs. They said the home provided all the information needed to make an informed choice. The prospective resident stopped for lunch and all continued to be impressed. Assessments of needs are in individual files. These are undertaken by the service prior to admission, and detailed individual needs that were to be met by the service. The service continues to undertake its own full assessments of all private residents. Those funded by Social Services receive initial Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 10 assessments from Social Services. Residents spoken with concerning their admission said that they had a positive choice to come to the home and had not regretted it. Intermediate care is not provided at the home. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans reflect and guide individual care; these might be clearer if they were printed rather than hand written. Health needs are met effectively, with the support of outside professionals as necessary. The dignity and privacy of residents is well supported by staff, but is also compromised by environmental issues such as small toilets. Medication is administered and recorded more satisfactorily than at the time of the last inspection. Daily stock control of all ‘non-blistered’ medication would better evidence that all medicines are accurately dispensed. EVIDENCE: A sample of four individual files were looked at. All had individual plans of care. Initial details included the person’s preferred mode of address, and social history, family details and interests were included. Care plans are hand written Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 12 on individual pages showing specific areas of need and how they are met. The manager agreed that the use of a computer would enable care plans to be amended more clearly, and that it would also make care plans easier to read. Separate pages show regular, monthly ‘evaluation’ or review of these needs. Discussions with staff and individual residents, and observations showed that these plans guided and reflected care. The ‘key worker’ for one resident was able to discuss knowledgeably how current care concerns for this person, including tissue viability, were managed. Effective management of this person’s care needs was shown by the fact that a district nurse had been able to recently ‘sign off’ involvement in regards to a pressure sore that had now heeled. Other issues, such as weight, nutrition, and eye care, were recorded on the care plan and the staff showed a good awareness of these. Comments from a relative were very favourable concerning the care and attention provided. Risk assessments were seen to be in place to assist the management of individual risks. One activity not covered previously, involving the use of a wheelchair for one particular resident, now has an assessment. A discussion was had with the manager as to how a little more detail would more clearly demonstrate why this particular risk was justified. Care plans showed appropriate involvement of health professionals where required. Visits from health professionals took place privately, in residents’ rooms. Where residents had diabetes, appropriate care was identified, with professional support being evidenced as required. The kitchen staff were aware of who had diabetes, and adjusted individual diets accordingly. This was noted at mealtimes, with satisfactory alternatives being offered. Medication continues to be administered and recorded from lockable trolleys. Any medication not in the trolleys is stored in a locked cupboard area. This has now been moved to a far less obtrusive area than was the case at the previous inspection. Medication continues to be administered in a discrete, professional manner. A sample of Medication Administration Record Sheets were looked at, and recordings were seen to be accurate. Details of all medicines looked at were pre-printed. Where medications were not given or taken, and the reason was clearly recorded, and audits adjusted accordingly. The majority of medications are dispensed from ‘blister packs’. Where they are not, staff advised that a weekly audit is done, but agreed that a daily stock control for these relatively small amount of medicines would pick up any and enable any error to be rectified immediately. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 13 The controlled medication register was examined. There was only one such medication currently being administered, and this was properly recorded, stored, and accounted for. The manager and senior staff had addressed previously noted shortcomings regarding the recording and disposal of controlled medication. Staff were observed to be interacting with residents in a respectful, friendly way throughout, and being attentive to needs. Whenever residents were heard to ask staff for assistance, staff responded promptly. Residents’ comments concerning the staff were all very positive, remarks such as ‘the staff are lovely’ and ‘they are always helpful’ being typical. Observed and overheard interactions of staff with residents showed that staff were always polite, patient, and clear in the support and guidance they offered. Staff were seen to be responding to the call bell system effectively; this supported residents who wished to make choices about remaining in their rooms, were wanting assistance to come downstairs, or were wanting assistance upstairs. “Staff come when asked for” said one resident who was in bed. Call bells were not heard very often. Many residents spoken with were aware of them, but said they did not use them. Some preferred to call out if they wanted assistance, some felt they would only need them if there were a dire emergency, some did not appear aware of them. The manager agreed that while they were accessible in bed, if someone fell in their room, they were unlikely to be accessible, and she was exploring possible alternatives to meet particular needs. Residents have keys if they wish, and are able to lock their doors if they wish. Residents also have lockable spaces if they wish. Some residents used these, others did not. The manager advised that some residents still requested any valuables to be held centrally. Whilst staff were seen to be treating residents with respect and dignity, and supporting individuals to use the toilets in privacy, some residents were noted to be using toilets independently with the door open. This was discussed with staff and management, who agreed that the small size of some of the communal toilets did not encourage some residents to put a premium on their own privacy when using them. This issue is looked at further in the ‘environment’ section of this report. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can enjoy a variety of activities in a busy and stimulating environment, in which visitors are welcome, and frequent. Residents enjoy a balanced and varied selection of food, in a pleasant atmosphere, despite the rather cramped dining facilities. These facilities pose potential restrictions on, in particular, wheelchair users. EVIDENCE: The activities organiser was able to show records of a wide variety of activities, in and out the home, on a regular basis. Bingo, involving a dozen or so active participants, took place in the afternoon. A number of trips out were planned for the following month. Some residents showed a limited awareness of planned activities, with one person saying that animals weren’t allowed in the home, in spite of evidence of regular visits from a ‘pat the dog’ scheme. Noone spoken with complained of a lack of activities, with comments indicating that activities were there for those who wished them. “We get out and about” and “there’s no time to do anything more!” were two comments. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 15 The lounge areas continue to be busy places, with much stimulation from visitors, staff and residents passing through. Religious wishes continue to be catered for, with regular church services for those who wish it. Visitors were frequent, particularly in the afternoon. Those spoken with said that the home was always welcoming and friendly. “We are always made welcome” said to visiting friends of one resident. One fact commented on by several visitors was the lack of anywhere private to talk with residents, other than their bedrooms. Some visitors utilised the dining area, others the ‘green room’, which is in fact an area in a corridor. Residents and visitors commented that the courtyard area provides extra space in good weather. The home continues to support people who need a relatively high amount of support and help, through mental and physical frailties, as well as people who are relatively independent within the context of residential care. People spoken with felt that their choices and control over their lives were not compromised by this. People were observed to come and go as they pleased, requesting staff assistance as required, and spending time in the company of people with similar interests, or in their own company, as preferred. A meal was taken with residents who said that food was generally good and that there was always a choice. Choices were offered and portions were generous. Those requiring assistance were given it by staff, who showed a good awareness of what help was likely to be required. Menus showed a variety of healthy food available, and meals offered showed an awareness of who had special diets and how they were catered for. The dining room only comfortably sits 28 people. A number of residents prefer to eat either in their rooms or in easy chairs in the lounge, and a number were out. An increase in the number of people wishing to use the dining room, or needing to use a wheelchair in the dining room would, the manager agreed, pose a problem. She advised that space between the dining room and one lounge area could be more flexibly used if needed. Residents, when asked about the dining room, did not respond that they felt it cramped or restrictive. The most positive responses were from those who enjoyed the choice of sitting in the dining room, lounge or own room. One person did comment that she preferred eating in the lounge, ‘rather than amongst all that coughing’. Staff wore blue plastic disposable gloves whilst serving food in the dining room. The manager agreed to check out whether this was necessary or desirable. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 16 Bowls of fruit were available in the lounge. Drinks of squash were available, and tea and coffee was served in-between meals. No residents spoken with had concerns about the availability of food and drink. Breakfasts were now available earlier (ie; before 8am,supported by the night staff, for those wishing this). The manager advised that this helped prevent breakfast time carrying on until midmorning or later, and to ensure there was not an unnecessarily long gap between supper and breakfast. When I arrived at 8am, many residents had had breakfast. Morning tea and biscuits was served at 10.30am. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, relatives and friends can be confident that complaints will be listened to and acted upon, and that residents are protected from abuse by policies, procedures, and, above all, the positive attitudes evident amongst the staff team. EVIDENCE: The complaints log was seen. Two complaints were recorded from the previous twelve months, one of these the manager had already informed us about. discussion and recording showed that the complaints had been dealt with satisfactorily. Concerns and suggestions that were not raised as complaints but which were highlighted on surveys as part of the service’s quality assurance were being addressed as part of the action plan in that quality assurance. These included creased clothes, the need for a bath, and hand gel being available for visitors, and were in the context of many favourable responses such as ‘all staff appear to be kind and caring’. Relatives spoken with all said that they had no complaints, and that if they did they would raise them with staff or the manager. Details of the complaints procedure are available in the home, and feature in the service user’s guide. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 18 Residents continue to be complimentary about the home, and especially about the staff. Staff spoken with concerning abuse showed a good awareness of what constituted abuse and what to do if this were witnessed. All staff interactions with residents were observed and heard to take place in a respectful and friendly manner. There is a small number of male staff employed as carers. The manager was able to show the relevant part of the service’s policy detailing how male staff only provide personal care for females who have no problems with this, and that this is recorded on individual files. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents enjoy the positive aspects and ‘character’ of the building, but continue to be restricted by the lack of a bath. This continues to be a major restriction on choice. A lack of space can restrict access in communal areas such as the dining room, corridors, and particularly, the downstairs toilets. The mixed quality of the toilets detracted from the homeliness of the service, and their lack of space can limit privacy and dignity. In spite of evident hard work by cleaning staff, some individual rooms gave off faint, but detectable, unpleasant odours. Planned environmental improvements need to address all these issues. EVIDENCE: The building is a large Edwardian House that has been extended and adapted for use as a care home. Corridors are not wide, so that a wheelchair or someone walking with the help of a frame takes up the entire width and does Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 20 not allow for other passage. Communal toilets are small, with manoeuvring required for staff to assist residents. One toilet had a large, very institutional square yellow bin, further restricting space. This toilet also had paint peeling on the ceiling, and a ‘wet floor’ sign, marked ‘leave in bathroom’ on it. There was also a small cupboard high on the wall, with no door, and one pad in it. Several times, independent residents were observed using two of the toilets nearest the lounge with the door open, presumably because of the difficulty they found in manoeuvring to shut the door. This did not appear to be a problem with two toilets nearer the front of the building, which have more room. One of these is marked ‘visitors’ toilet. Another downstairs toilet, used by all, had a ‘men’s’ symbol on it. Some of the toilets had seat raisers, on the floor. The manager advised that some residents benefited from these, and had them in their en suite toilets, whilst others did not. A discussion was had about the feasibility of some communal toilets having raised seats permanently. The manager advised she would investigate this possibility. The home benefits from large windows and a pleasant courtyard, usable in fine weather. The ramp to one part of the courtyard was in need of repair to ensure it could be used safely; this would have featured as a requirement, but the manager was prompt in bringing this to the on-site handyman’s attention as requiring urgent attention. The courtyard and the garden areas are accessible for escorted wheelchair users. Several residents commented on the peaceful, pleasant nature of the garden at the rear of the home. The service strives to overcome space limitations. In the absence of a private space for team handovers, these now take place between shift leaders only, who pass on relevant information to individual staff. The medication cupboard has now been moved to where it is less likely to be an obstruction to residents. The central communal area consists of two lounge areas, and a dining room, with archways and glass partitions giving a degree of separation. This was a lively, busy area. The ‘busyness’ appeared a source of stimulation, rather than irritation, for residents. There is now a hair salon, making a much more attractive and comfortable setting for residents for this activity. There is no bath at all in the home. The manager advised that there were plans to have one installed. Several residents spoken to said they would like a bath. “It would be lovely to have a bath,” commented one resident. Several residents spoke positively of their rooms; those seen were pleasantly furnished and with individual possessions much in evidence. Many were Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 21 pleased with the outlook from their room. The size of rooms varies greatly. Some rooms would be unlikely to meet space standards if they were newly registered, others, some formerly double rooms, are spacious. The manager advised that there are currently only two double rooms. One is used by a couple, and the other is likely to become a room for single use. The stair carpet is worn on certain steps. The manager agreed that although it may not be a hazard at present, it will eventually become so, and should be replaced sooner than later. Flooring is uneven in some of the corridors and in part of the lounge. This is a potential hazard. There have been a number of falls in the home in the past year, although the manager advised, and records confirmed, these have occurred in individual rooms. Cleaning was seen to be in progress throughout the home during the inspection, and all areas seen were clean and tidy. There was a faint but noticeable odour of urine detectable in certain rooms. This was discussed with the manager who advised that renovation plans may involve replacing particularly affected floors. Staff also felt that the lack of a sluice room hampered the effective maintenance of hygiene and cleanliness, and were pleased that one was planned as part of the refurbishment. Renovation plans, including the building of a bathroom, and the replacement of carpets and the gradual refurbishment of individual rooms and communal areas, were seen. The manager was pleased to advise that the organisation was showing a commitment to improving the environment. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident of the attentions of a staff team they rate very highly, and who are properly recruited and deployed, and for whom training is enhancing the already high levels of care they are providing. EVIDENCE: Staff were observed providing care and support to residents in a relaxed and professional way throughout. Staff were spoken with regarding their roles and showed a good knowledge of the needs of the people they were helping, and a commitment to meeting those needs. Observation showed staff responding promptly to the needs of residents and always supporting and helping them in a patient, respectful manner. This fact was frequently commented on by residents and relatives. “Staff are very good” and “they always respond very quickly and use the proper equipment and methods.” The nearest to any criticism was the implication in a response to the home’s survey that noted “most staff are welcoming”. One resident noted that “people always respond, if I ring the bell, day or night”. When undertaking specific tasks, such as toileting, staff were heard to be informing residents what was happening and why. At times, as for example, when a resident was being pushed through a communal area, some staff appeared a little quiet, but the manager advised that the presence of the Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 23 inspector may have made some a little bit more reserved, and that more usually they would be chatting or even singing to residents. Rotas showed a sufficient number of staff on during the day and at night to meet residents’ immediate needs. The manager advised that additional staff were being recruited. One agency staff was working with the staff team that morning. Comments from relatives and residents showed satisfaction with the numbers and availability of staff, with no adverse comments concerning there not being staff available. Staff managed to always be busy, and attentive, without being rushed. Staff commented that they enjoyed the atmosphere in the home. Some commented on the lack of a staff room, as the only facility is a small locker room/toilet area. Staff felt that they could not relax during any break as there was no suitable private space. A sample of four staff files were examined, including two of the most recent recruits. These all had appropriate employment checks and references, including satisfactory Criminal Records Bureau checks. The manager said she was pleased with the organisation’s renewed commitment to training. This was further evidenced by the presence of the training officer during the inspection. A training matrix showed all mandatory training being undertaken, with additional training in specific areas, such as falls prevention, being undertaken. The manager advised that 50 of staff had achieved National Vocational Qualification level 2. Staff spoken with spoke of their satisfaction with the level of training. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a home being managed effectively and in which their views are taken account and in which their health, safety, and welfare are promoted and protected. EVIDENCE: The manager advised that she has now completed her NVQ4 in management. Staff, residents and relatives were positive concerning the running of the home. The manager has worked hard and successfully in addressing the majority of shortcomings noted in the previous inspection. Those that have not yet been resolved are primarily environmental, and should be addressed in refurbishment planned for late summer. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 25 Copies of surveys and the responses, and the consequent action plan by the home, showed that views of residents and significant others are helping to inform the running of the home. Regular visits and comments by the area manager were also in evidence. The home keeps small amounts of personal monies on behalf of residents where this is requested. A sample of these looked at and were seen to be kept and recorded accurately and safely. The pre-inspection questionnaire detailed all necessary health and safety checks as being up-to-date. There were no health and safety breaches apparent during the inspection, with items stored appropriately and safely, and the kitchen being clean and tidy. Where bedroom doors were kept open, this was now done by an alarm activated fireguard device. Staff spoken with were clear about the procedure in the event of the fire alarm sounding, although there was some lack of clarity with some care plans referring to the evacuation of a resident in the event of fire, which may involve two or more staff per individual – clearly impossible in the event of a large scale emergency. The manager advised that she would clarify this. Staff spoken with were clear on the importance of having a closed fire door between any fire and all other persons. Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 1 x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 12. Standard OP21 Regulation 23(2)(j) Requirement An assisted bathing facility must be made available to meet resident’s needs and choice. (This is an outstanding requirement from the previous inspection). Timescale for action 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The use of a computer system would enable care plans to printed, be more legible, updated more easily, and be more accessible and of more use to staff and residents. Daily stock control of medicines that are not ‘blister packed’ would ensure that any errors were rectified promptly, reducing potential harm to residents. Staff would benefit from a suitable private space to take their break during a shift. 2 OP9 3 OP19 Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 28 4 OP19 Handrails would enable residents to use the courtyards more independently. The stair carpet that is worn should be replaced before it becomes a safety risk. Where flooring is noticeably uneven, this should be rectified, to avoid it being a hazard. More effective use of ‘seat raisers’ on communal toilets would assist residents’ independence and well-being. Refurbishment should also include better communal toilet provision, so that residents’ dignity and well-being is not compromised by toilet facilities that are too small to properly meet their needs. The provision of a sluice room would greatly aid effective hygiene throughout the room. 5 6 7 8 OP19 OP19 OP21 OP21 9 OP21 Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Extracts may not be used or reproduced without the express permission of CSCI Willow Grange DS0000044889.V364958.R01.S.doc Version 5.2 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. 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