Inspection on 30/04/07 for Willow Grange

This inspection was carried out on 30th April 2007.

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Willow Grange 119 St Bernard`s Road Olton Solihull West Midlands B92 7DH Lead Inspector Martin Brown Key Unannounced Inspection 30th April 2007 08:10 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.V335074.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.V335074.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 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) www.alphacarehomes.com Alpha Health Care Limited 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.V335074.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That Mrs Pudney obtains the required management qualification, i.e. Registered Managers award / NVQ 4 in Care Management by 2005 To admit one named service user under the age of 65 by reason of OP not PD. 9th January 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.V335074.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 8.10am on a weekday and finished at 4.40pm. During that time, many of the residents were spoken with, as were a number of relatives visiting that day. The home had 41 residents at the time of the inspection. There is one current vacancy; the double rooms are all currently occupied as ‘enhanced single rooms’. The manager and deputy manager were present for most of the inspection, and staff from both shifts were also spoken with. The pre-inspection questionnaire returned by the manager also informed the inspection. Inspection questionnaires and surveys had been sent out to residents and relatives, but none of these had been received by the inspector prior to the inspection. One relative’s survey reply was received prior to the completion of the report. The manager advised that she had been told that at least some of these had been returned. Policies and procedures and care records were examined, and four residents were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. What the service does well: Residents at the home were appreciative of the warm friendly atmosphere in the home, and of the ‘character’ of the building, as one resident put it. One resident pointed out the stained glass windows as a feature she particularly appreciated. Residents and relatives were full of praise for the staff. “Willow Grange makes the residents feel as much as possible to being at home” was the comment from one relative. Several residents commented that they felt ‘much better’ since moving in, with comments such as “I couldn’t knock the place”, and “the staff are very good”, “the staff are wonderful” being typical. 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. Residents receive a good choice of well-presented food, and were appreciative of it. “I’ve put on weight-good!” and “portions are always generous” were typical comments. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The service needs to ensure that the recording, particularly regarding the disposal, of controlled medications is done satisfactorily, so that residents can be confident that such medicines are disposed of properly when no longer required. Several residents expressed the wish to have a bath. At present they cannot do so within the home, as the home has only showers. Dining room space is still limited, with comfortable room for 28 only at one time. At present, this means the service is reliant on at least twelve people choosing to eat other than in the dining room. Accessibility to the courtyard is limited, owing to the sloping ground, and the absence of handrails. Residents still do not have lockable facilities to store personal items of personal value. The service needs to speed up the provision of closure devices on bedroom doors, to ensure that unnecessary fire risks are not created by doors being propped open. Willow Grange DS0000044889.V335074.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.V335074.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.V335074.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): 3 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: Assessments of needs were seen to be in place in individual files. These are undertaken by the service prior to admission, and demonstrated that individual needs could be met by the home. One example discussed by the manager concerned a lady who had been admitted a number of years ago as a private resident, but whose abilities and needs had been misrepresented by relatives. The manager advised that now the service always undertook its own full assessments of all private residents. Those funded by Social Services receive initial assessments from Social Services. Residents spoken to regarding their admission said that they had made a positive choice to come to the home. “I looked at several, and this was the nicest,” and “I’m glad I chose this place,” were two typical comments. Intermediate care is not provided at the home. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are set out in individual care plans. The monthly evaluations of these needs do not always thoroughly reflect changes, leading to the potential for needs not to be met. The home meets identified health needs, and improves the well-being of residents, with the support of outside professionals as required. Residents can be reasonably confident that medication practices help ensure their personal well-being, but may be concerned by shortcomings in the recording and disposal of unused medication. Privacy and dignity for residents would be enhanced by the provision of secure storage for valued possessions. EVIDENCE: All the individual files had individual plans of care. Initial details included the person’s preferred mode of address, and social history, family details and interests were included. Individual care plans do not have a photograph of that person. Care plans are hand written and tend to consist of individual pages of specific areas of need and how they are met. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 11 Separate pages then show regular, monthly ‘evaluation’ or review of these needs. In cases, the handwriting was not easy to read. The manager acknowledged this. Many of these evaluations indicated ‘no change’. In one instance, part of a care plan showed that a catheter was in place, and guidance given in respect of this. Regular evaluations did not clearly show that the catheter was no longer in place, and the original part of this care plan had unchanged details concerning the care plan. The removal of the catheter was noted in another part of the care plan. 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. Risk assessments were seen to be in place, with the exception of one activity. One person has his own specific wheel chair, which he verbally confirmed he had requested without footpads, so that he can propel himself around the home. This was observed. At one point, a member of staff assisted by pushing him a short distance. There was no recorded risk assessment to ensure that this takes place with due regard to his safety. The manager agreed that a risk assessment must be must in place for this. Staff with the appropriate use of footrests assisted all other wheelchair users observed. Care plans showed appropriate involvement of health professionals where required. One lady said that the home was ‘helping her feel better’, and two residents said that they’d put on weight since moving to the home and had felt much better since moving here. Visits from health professionals took place privately, in residents’ rooms. Where a resident had diabetes, appropriate care was identified. The kitchen staff were aware of who had diabetes, and adjusted individual diets accordingly. The two staff responsible for medication on the morning shift explained the procedure. Medication is administered and recorded from lockable trolleys. Any medication not in the trolleys is stored in a locked cupboard area next to a toilet. Checking of this area was constantly interrupted by people going to the toilet. From their perspective, going to the toilet was hindered by people standing by the cupboard next to the toilet door. Medication was administered in a discrete, professional manner. Medication Administration Record Sheets now have photographs of residents, and recordings looked at were seen to be accurate. Details of all medicines looked at were pre-printed. The staff dispensing the wide variety of medications was aware of the reason and purpose of most, but not all, of them. Most medications were administered via a pre-packed medi-dose system. Other medications were seen to be stock-controlled satisfactorily. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 12 Where medications were not given or taken, and the reason was clearly recorded, and audits adjusted accordingly. The manager advised that night staff have now had appropriate training to enable them to dispense medication as necessary. The controlled medication register was examined. Some page headings of the controlled medication record did not name the medication, only the person’s name and a dosage. The manager agreed that this was unacceptable, and that the person’s name, the medication and its dosage, must be recorded at the top of every page. Two persons signed all medications administered in the register. One person is only signing off medication being signed out. One medication was recorded and signed as being returned to the pharmacist on a specific date. The returns book contained no detail of this medication, although other medications on that date were returned and signed for by the pharmacist. The person responsible for this was contacted, as was the pharmacy. Although, in this instance, no direct harm to residents would result, the manager agreed that it was unacceptable that any amount of controlled medication should not be accounted for. An action plan was produced by the deputy manager the following day to ensure such an event does not re-occur, detailing additional safeguards, changes in practice and procedure, additional training plans, and meeting with the pharmacist, and senior management. Staff were observed to be interacting with residents in a respectful, friendly way throughout, and in general being attentive to needs. One instance was noticed where a resident asked the inspector if she could be assisted to the toilet, saying that she had asked staff who said they would attend to her but had not returned. they responded when attention was drawn to this. Residents commented that the staff ‘were very good’ and also that ‘they are always kept busy’. 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. Records and agreements were seen identifying whether individual residents had keys or not, and if not, why, and agreed by the resident or their representative. Residents spoken to confirmed that they could lock doors if they wished to. Some preferred not to. Residents spoken to stated that they did not have any lockable storage for any valuables. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 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. 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 the stimulation of a large, busy, home, although some may appreciate the opportunity to get out and about more often. Residents’ benefit from group, and individual, activities. Residents enjoy a balanced and varied selection of food, but the limited space in the dining room means that only two thirds of the residents can be comfortably accommodated there. EVIDENCE: The pre inspection questionnaire returned by the manager listed a large number of activities, within and without the home. Residents and relatives spoken to expressed a general level of satisfaction with the activities provided. Some residents said that they enjoyed outings organised for local pub lunches. The most frequent comment in respect of activities was a wish to be accompanied to take small trips to the local shops more often. One resident commented that residents without relative to take them out, or money to pay for trips don’t get out so often. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 14 There is an activities organiser who organises activities in the home on a group or individual basis. She also researches life histories and activities with individual residents so that activities can be tailored to their needs. Residents spoken with were content with the level of activities within the home. A number of residents attended day services at various points of the day. Religious wishes continue to be catered for. One resident said, “there are weekly church services for those who wish it.” The location of the lounge area means that it is central to the home and therefore always seemed busy, with staff, visitors, and residents much in evidence throughout the day. This appeared, from observation, a source of stimulation, rather than irritation, to residents. A number of relatives visited during the inspection. One couple said they been regularly visiting for years and knew many of the residents. Other visitors were able to use the courtyard as a more private area, as the weather was good. One relative felt there was a lack of private areas, other than bedrooms, for visitors, commenting that ‘it would be useful to have room for visitors.’ There is a small seating area, off the courtyard corridor, where residents can sit away from the main lounge area, but this is not separate from other areas. One resident, whilst showing me her room, showed me the chairs she had purchased, both for inside and outside use. She, like other residents spoken to, felt she had freedom and choice to do as she wished within the home, and that there were activities she could take part in if she wished, or she could spent time with people she wished. One lady was visited by her husband, who resided at a dementia home. The manager advised that they could not admit him as they could not meet his needs, but that regular visits were arranged. The couple spent much of the afternoon sitting together. A meal was taken with residents, and was tasty and well presented. Residents on the same table said that it was a typical meal and that the food was generally good and in generous portions. One said, jokingly, that her only complaint was that she had put on weight. 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, with a choice being offered at the table. Kitchen staff were able to show me 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. One resident was quite adamant, when asked, that she preferred her meal in the lounge. The manager acknowledged that if everyone wished to eat in the dining room at the same time, this could not be currently accommodated, and could limit people’s choice. She advised that she had requested some fold Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 15 down tables and the lamination of part of one of the lounge areas joining the dining area for use as an extended dining area. Bowls of fruit were available in the lounge by mid-morning, along with some savoury snacks. The manager advised that the fruit and vegetable delivery is now more regular than previously, and had arrived that morning. Drinks of squash were available in the lounge throughout the day. The evening meal is at five o’clock. The manager advised that residents were happy with this time, that supper was available at eight, and that an additional ‘drinks slot’ had been arranged at 6 o’clock to meet requests from residents. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents, relatives and friends can be confident that complaints will be acted upon, they may benefit from being encouraged to raise any concerns they may have at an earlier stage. Protection from abuse would be enhanced by ensuring that current practice in the care of residents by staff of a different gender is clearly confirmed by relevant policies and procedures. EVIDENCE: The complaints log was seen. All the complaints recorded dated from before the previous inspection. Records show that previous complaints had been acted upon. 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 were pinned on a wall, but the manager acknowledged it was not as eye-catching as some other notices. Residents were complimentary about the home. One compared it very favourably with a previous home, and said ‘they are far more professional here’. Another person added, “You are looked after very well here.” One person added that ‘it would be useful to have a room for visits’. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 17 One resident spoken with said that her French windows did not lock and that she had raised this with staff but that nothing had been done. When I raised this with the manager neither she nor the ‘handyman’ said they had been aware of the problem, which was swiftly rectified. The manager advised that this person may have raised her concern with a relative, but agreed that the fact that this concern did not reach the right person indicated that the system for residents or relatives raising concerns needed to be revised. Staff spoken with concerning abuse showed a good awareness of what constituted abuse and what to do if this were witnessed. Staff interactions with residents were observed to take place in a respectful and friendly manner. There is a small number of male staff employed as carers. One advised that he only provides personal care for females who have no problems with this, and that this is recorded on individual files. There are two male staff employed at night. The manager advised that these two staff are always deployed separately, so that female staff are always available to give personal care to female residents who wish for carers of the same gender. The manager could not locate a cross–gender care policy to confirm current practice. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 18 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): 19,21,24,26 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 is a major restriction on choice. A lack of space can restrict access in communal areas such as the dining room, corridors, as well as downstairs toilets. The mixed quality of the toilets detracted from the homeliness of the service. Good hygiene practices are compromised if all staff do not adhere to them at all times. 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 takes up the entire width and dose not allow for other passage. Communal toilets are small, with manoeuvring required for staff to assist residents. Two residents remarked that the building had ‘character’, and stated that they much preferred this to a bland, characterless building, even if facilities, such as wider corridors and larger toilets, might be better in such a building. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 19 They said they particularly appreciated the windows and the garden. The courtyard is a pleasant area, used by residents and relatives in the fine weather. It is split into two by a linking corridor; one side of the courtyard has a fishpond. All those spoken to were pleased with this outdoor area, although several commented that it was difficult to use without help, owing to the slope from the doors. Several residents and relatives thought that handrails would help make it more accessible for residents to use independently. The courtyard and the garden areas are accessible for escorted wheelchair users. Several residents also commented on the peaceful, pleasant nature of the garden at the rear of the home. Communal space is at a premium. There is a medication cupboard, but medication trolleys have to stored elsewhere. Staff handovers take place in a section of the dining room. The discussion could not be readily overheard on this occasion from the lounge area, and there were no other persons at that time in the dining area, but the manager agreed that the only way for confidentiality to be fully guaranteed was for meetings to take place in a proper room. The central communal area consists of two lounge areas, and a dining room, with archways and glass partitions giving a degree of separation. There is also a small area with seating at the end of the courtyard corridor, where residents and relatives who wish for a quieter area can sit. One resident asked me what the time was, being unable to see a clock. She thought that having a large clock that she could see would be useful. Most rooms have en suite showers. There are additional showers for residents without en suite facilities. The communal toilets on the ground floor are well-used as many residents spend a lot of time down. Some toilets had nothing on the door to indicate they were toilets. One resident was seen to ask a staff member ‘Is this the toilet?’ Toilets looked in were cramped, with institutional-looking large yellow bins and a notice pinned to an otherwise bare wall reminding staff to attach a code number to yellow bags. Soap and hand towel dispensers were working, although one had no hand towels at 9am. It was filled by mid-morning. later, one toilet had a number of paper towels on the floor. En suite toilets seen were much ‘homelier’. A ‘visitors’ toilet appeared in better condition than others on the ground floor. The manager advised that residents were not restricted from using this, but a staff member was overheard redirecting a resident away from this toilet, to one further away. The manager agreed that all toilets should be maintained to the same high standards, and that residents should not be restricted from using toilets in their own home. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 20 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. ‘I’d love to have soak in a bath’ commented one resident. Another thought she could no longer have baths, until the concept of an assisted bath was explained to her, and then she was very enthusiastic. Several residents spoke positively of their rooms; those seen were pleasantly furnished and with individual possessions much in evidence. Many were pleased with the outlook from their room. One exception noted was the ground floor room, which appeared gloomy and impersonal. The curtains were closed, as this room is directly overlooked by the front car park and all visitors entering the building. The laundry facilities are in a room sufficiently small not to have room to do the ironing in. Staff advised that ironing is done in the nearby hairdressing room when it is not in use. Staff were seen to struggle assisting residents in the lift as they had to stop the lift door shutting, whilst pushing a wheelchair into the lift. This was a difficult operation for one person to manage. The manager was advised to investigate ways of this system to be improved. 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. 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 odour of urine detectable in certain corridors, particularly in the morning. This was less noticeable as the day progressed. One relative’s comment was “Occasional urine smell on entering the home. Perhaps a little more bleach to be used in the toilets.” Staff were seen to be wearing gloves and aprons when providing personal care and removing them afterwards, with one exception of a staff member who took a coat downstairs whilst wearing gloves. The manager advised that she would remind staff of the need of adhering to proper hygiene procedures at all times. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 21 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. For that confidence to be enhanced, the service needs to ensure that all staff are appropriately trained for the tasks they undertake, particularly in respect of manual handling and infection control, and that staff always offer explanations of movements to wheelchair users. EVIDENCE: Staff were observed providing care and support to residents in a relaxed and professional way. Relatives and residents had nothing but praise for staff. “They are wonderful” was a typical comment. One resident singled out the Polish staff for particular praise. Another resident commented, “They are always there when I need help.” Staff who had worked at the home for a number of years spoke of the ‘pleasant atmosphere’ and added that they enjoyed working at the home. When undertaking specific tasks, such as toileting, staff were heard to be informing residents what was happening and why, but on other occasions, as for example, when a resident was being pushed through a room, but then reversed, or taken another way, this was sometimes done without direct explanation to the resident concerned. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 22 Rotas showed a sufficient number of staff on during the day and at night to meet residents’ immediate needs. The manager advised that nighttime staff have now had appropriate training to enable them to dispense medication as necessary. Recruitment procedures were seen to be sound on the previous inspection, and assurances were given by the manager that the same processes remain in place. The manager confirmed the information on the pre-inspection questionnaire that staff did all the mandatory training, although she advised that this was always an on-going process with new staff undertaking training, and staff having refresher training. The manager advised that ‘very nearly’ 50 of staff had achieved National Vocational Qualification level 2, and that, again, this fluid, with staff joining and leaving. The manager also advised that further training in infection control was scheduled. Staff were spoken with regarding their roles. One person, who was a relatively new recruit, said that they had had been shown how to use the hoist by other staff, and had helped with two person hoist. When asked, they said they would be confident and able to use the one person hoist by themselves. The manager later advised that this would not allowed and that training was currently underway with specific senior staff to enable them to become accredited trainers in the home on manual handling. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. The manager has worked well to make good many of the shortcomings identified at the previous inspection. Her suitability to run the home will be fully confirmed upon completion of the Registered Manager’s Award. The home’s quality assurance processes, whilst responsive in many areas, do not yet fully account for concerns felt by individuals. The health, safety and welfare of residents is compromised if doors breach fire safety standards by being propped open. EVIDENCE: The manager had just returned from maternity leave at the time of the last inspection, has completed her NVQ4 in management and advised that she now has two units to complete to obtain her Registered Manager’s Award. She is supported by a deputy manager who has worked at the home for many years. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 24 Staff, residents and relatives were positive concerning the running of the home. The manager advised that quality monitoring, meetings, and feedback continue to take place, and gave an example of where feedback from residents that they would like an early evening drink had resulted in a six o’clock tea and coffee time being introduced, in between tea and supper time. She acknowledged that, as detailed in the complaints and protection section of this report, some concerns still did not reach the appropriate person to action them, and agreed to look at improving this process. Financial records were not examined on this occasion, as these were seen to be satisfactory on the previous inspection, and involved relatively minor amounts, the majority being held by residents or relatives. The manager confirmed that the same system was in operation as before and advised that it worked satisfactorily. 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. One bedroom door was propped open by a bin. The manager advised that a program had been introduced to install fireguard devices on bedroom doors, with new ones being purchased monthly. A number of doors had these on them and were able to be safely left open. Other bedroom doors were shut. The manager agreed that priority to installing new fire door closures should be given to rooms where residents wished to keep their doors open. Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 25 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 2 3 2 2 x x 3 x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 26 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. 1 2 Standard OP7 OP7 Regulation 15 15 Requirement Evaluations of care plans must adequately reflect any changes in that care plan. A risk assessment must be in place for the resident who wishes to use a wheelchair without footrests. All medications in the Controlled Register must be properly detailed at the top of the page to ensure the right medication is being given. Any medications in the Controlled Register that are being returned to the pharmacist must be signed out that book by two staff. The action plan produced by the home to prevent future errors in returning controlled medication must be fully carried out. Staff handovers and meetings must be able to take place without compromising the confidentiality and privacy of residents. Suitable lockable storage for residents personal valuables must be available to them. (this DS0000044889.V335074.R01.S.doc Timescale for action 10/06/07 10/06/07 3 OP9 13(2) 10/05/07 4 OP9 13(2) 10/05/07 5 OP9 13(2) 10/06/07 6 OP10 12(4)(a) 10/07/07 7. OP10 16(2)(l) 10/08/07 Willow Grange Version 5.2 Page 27 8 OP18 12 9 10 OP20 OP21 23(2)(g) 23(2)(j) 11 12 OP21 OP26 23(2) 13(3) 13 OP30 18(c)(i) 14 OP31 9(2)(b)(i) 15 OP38 23(4)(c) is an outstanding requirement) There must be a cross gender care policy in place to ensure that care of residents by staff of a different gender takes place sensitively, safely, and with the consent of all concerned. Dining room facilities must be sufficient to meet the needs of residents. An assisted bathing facility must be made available to meet resident’s needs and choice. (This is an outstanding requirement from the previous inspection). All toilets must be clearly labelled as such, so that residents are aware of them. The Resident Manager must ensure that staff adhere to procedures for control of infection, to ensure the safety and well-being of residents. Staff must only operate hoists when they have been properly trained to do so, to minimise the risk of harm to residents. The Registered Manager must complete the Registered Manager’s Award, to ensure she is suitably qualified to run the home. Bedroom doors must not be propped open, so that fire safety is not compromised. 10/06/07 10/08/07 10/08/07 10/07/07 10/06/07 10/05/07 10/10/07 10/05/07 Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 28 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. Each care plan should include a photograph of the person concerned. Staff dispensing medication should be aware of the reasons for all medications dispensed. A dedicated medication storage area, sited away from toilet, would assist the administration of medication, and enhance residents’ privacy and dignity. Staff should always ensure that residents are aware of when and where they being moved, and why. The menu displayed should be updated regularly to accurately reflect the meals on offer. Residents and relatives would benefit if the process for raising concerns or making complaints was made clearer. The stair carpet that is worn should be replaced before it becomes a safety risk. Handrails would enable residents to use the courtyards more independently. Improvements should be sought to the lift door, so that staff do not have to struggle to hold it open, whilst also helping a resident into the lift. Residents may benefit from another, large, clock in the lounge area. There should be no restrictions on residents using ‘visitors’ toilets. DS0000044889.V335074.R01.S.doc Version 5.2 Page 29 2 3 4 OP7 OP9 OP9 5 6 7 8 9 10 OP10 OP15 OP16 OP19 OP19 OP19 11 12 OP19 OP21 Willow Grange 13 OP21 All communal toilets should be regularly checked to ensure they are tidy and adequately stocked with disposable towels. The registered provider should consider whether the ground floor front room by the reception is suitable for continuing use as a bedroom . An audit of notices in the building should be carried out, removing those that no longer serve useful purpose, and concentrating on ensuring that those that do serve a useful purpose are understood by residents. The programme of fitting suitable magnetic closures to bedroom doors should be accelerated, with priority given to those rooms where residents wish their doors to be open. 14 OP24 15 OP33 16 OP38 Willow Grange DS0000044889.V335074.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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.V335074.R01.S.doc Version 5.2 Page 31 - 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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