Inspection on 09/01/07 for Willow Grange

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 Elizabeth Mackle Unannounced Inspection 09 January 2007 08.45 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.V307261.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.V307261.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 7063087 info@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.V307261.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. 21 April 2006 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 which 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, laundry and hairdressing salon. The home has a passenger lift. There are car parking facilities to the front of Willow Grange. The gardens to the side and rear of the property and an inner courtyard can be accessed by wheelchair users. The home has a varied activities programme on offer. The scale of charges range from £390-£450. Items not included in the charges: hairdressing, chiropody, newspapers, and private telephone. Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects the finding of an unannounced fieldwork visit conducted over the course of one day by two inspectors. During the visit the inspectors received assistance from the registered manager and the deputy manager, and both were helpful and informative. There were 38 people resident in the home at the time of the visit. Prior to the visit the acting manager had completed a pre-inspection questionnaire, which provided information about the home, residents and staff. Questionnaires sent to the home for circulation to a random sample of residents, relatives and visiting professionals had not been returned. A further supply of questionnaires was circulated on the day of the visit, and four questionnaires completed by residents were received at the end of the visit. Information given in the questionnaires was generally favourable about life in the home, although all four stated that they “never” knew how to make a complaint. One resident stated on the form “think very happy home to live in”; another resident wrote “not enough toilet paper in toilet”. Information was also gathered on the day of the visit by speaking with eight residents, two relatives and six staff members including the manager and deputy manager; staff were also observed performing their duties. Communal areas in the home, and a number of bedrooms were viewed. The selection of residents care records were sampled, together with staff recruitment documentation, and a range of other care and health and safety documentation was viewed. What the service does well: The home provided prospective residents with good information about the services and facilities provided, and with opportunities to spend time in the home; this enabled people to have some knowledge of what life in the home was like. Residents with treated respectfully by staff and their right to privacy promoted and upheld. There were no rigid rules in the home. Residents were able to take part in a range of activities of their choice, and to spend time with their families/friends, which enhanced their quality of life. The dietary needs of residents were well catered for with a balanced and varied selection of food available that met their needs and tastes. Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 6 Relationships between staff and residents were good. Comments from residents included: “all of the staff are great here”; “the staff are all kind, they’re fantastic. “We’re all friends”; “I can’t fault the manager and the staff”. Staff recruitment practices were robust, and this helped ensure that residents were protected. What has improved since the last inspection? What they could do better: Improvements were needed in relation to planning and delivery of care, and in the way medicines were managed in order to ensure better outcomes for residents. A lockable facility needed to be made available to all residents, in their rooms, so that they could safely store valuables or items that they wished to keep private. The home needed to ensure that all complaints were recorded in order that residents were protected. In order to ensure a more comfortable and safer living environment for residents a number of issues to be addressed in relation to the environment; these included: provision of an assisted bathing facility, ensuring that en suite showers are fit for purpose, the fitting of handrails where possible, and increasing dining space. Cleaning and hygiene practices within the home needed to be more thorough. Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 7 A review of the skill mix and staffing levels on night duty were required to ensure that staff had proper supervision arrangements and that residents were able to exercise more choice. Resident’s bedroom doors need to be fitted with automatic closures that would activate in the event of fire, to help ensure the safety of residents and staff. 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 DS0000044889.V307261.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.V307261.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The Statement of Purpose and Service Users guide documents provided sufficient information to ensure that prospective residents had enough information to make an informed choice about whether the home would be able to meet their needs. Prospective residents and their families were encouraged to spend time in the home before making a decision to move there; this enabled them to have some knowledge of what life in the home was like. EVIDENCE: The home had a comprehensive Statement of Purpose that contained all information required by the regulations, including a description of the range of services and facilities available in the home, details of the organisational structure, a copy of the complaints and procedure and sample menu. Within the document reference is made to “the National Care Standards Commission” and this needed to be amended to read “Commission for Social Care Inspection”. Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 10 The Service User guide had recently been revised, and was up to date and informative, and this helped ensure that residents were aware of the services available in the home. The document had not been produced in large print, audiotape, or other suitable formats for people with poor eyesight, although there was a note on the service user guide indicating that the guide could be made available in large print if required. It is important that potential residents with poor eyesight have equal access to information about the home and this needs to be readily available so that people do not have to ask for it to be produced. Copies of the service user guide were not seen in residents’ bedrooms, although the manager said that a copy had been circulated to each room. There was no copy of the last CSCI inspection report on display. Residents received a contract of the terms and conditions of residency when they were admitted to the home, and there was evidence that these were comprehensive and had been signed as agreed by either the resident and or representative. A comprehensive pre admission assessment of individual care needs was undertaken. Prospective residents were encouraged to spend time in the home before deciding if it would meet their needs and expectations, and whether they would wish to live there. One resident said, “I was given a list of places to look at and I came here and had dinner. “I can’t fault the manager and the staff” Intermediate care was not provided at the home. Willow Grange DS0000044889.V307261.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Inconsistencies in the planning and delivery of care could lead to potentially poor outcomes for some residents. The arrangements for receipt, administration and disposal of medication were not sufficiently robust to prevent potentially poor outcomes for some residents. EVIDENCE: From the care records sampled standards were found to be variable. Although an assessment was carried out on each resident when they were admitted, this was not always carried out fully, for example, in one of the care records sampled the sections on foot care, personal safety, social activities had not been completed. In another the records in respect of past medical history, life history, preferred mode of address had not been completed. This information is important to help ensure that there is an individual approach to caring for each resident. In one of the care records sampled no care plan had been drawn up for a resident who had been in the home for some months. Generic pre-printed Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 12 care plans, which had not been personalised to the individual resident, were in use. It is essential that such care plans are tailored to reflect the needs of the individual resident to ensure that each resident received individualized care. A number of the care plans viewed had not been signed or dated by the staff member who had completed them. There was little evidence that reviews were taking place, with the exception of those done by Social Services. Nutritional risk assessments had been undertaken and residents were weighed regularly, and records kept, so that any significant changes could be identified and appropriate action taken. Other risks assessed for individual residents included accidents, moving and handling and skin care, and there was evidence that these were reviewed approximately every four weeks. The moving and handling risk assessments did not include detail of the action to be taken in the event of a resident falling, and this is important to ensure that the residents and staff are protected from risk. Daily progress notes were kept in relation to each resident, and these were generally detailed and informative; they indicated the general condition of the resident, including changes in their condition, and good details of their preferred activities. Records were also kept of any discussions between staff and relatives/friends of residents. Residents had access to a range of other professionals as required, such as district nurse, general practitioner and chiropodist, optician, dietitian, and separate records of these visits were maintained giving brief information of the intervention and outcome of the visit. Residents generally appeared to feel comfortable and safe living at the home. One resident said “you could have a shower every day if you wanted one”; another resident said “I had a split on my heel so the chiropodist was sent for and put a dressing on it, and I had my eyes tested a few weeks ago.” More attention to personal care needs was required at times to ensure that the health and dignity of the individual was upheld, for example, a number of residents had dirty and long fingernails; several of the women residents were not wearing stockings or tights and one resident was wearing ill fitting shoes. A resident who was being cared for in her room following a fall earlier in the day, had not been properly washed and still had blood in her hair; the staff call bell had not been placed within her reach. The systems in place for the receipt, storage and disposal of medication required to be further strengthened. Drugs received into the home were checked and signed for by only one person and this practice does not provide sufficient safeguards. A system also needed to be developed in relation to the return of controlled drugs to the pharmacy; the controlled drugs register indicated that some medication that was no longer in use, was still held in the home, when this was not the case. It is essential that detailed records are maintained of all medicines returned to the pharmacy so that there is a clear audit trail. A number of medicine administration charts (MAR) were sampled. Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 13 One medicine administration chart that had been handwritten did not have a second staff signature. The label on eardrops for one resident stated “apply when required as directed”, and did not state the frequency; this lack of clarity may prevent the resident from receiving the correct treatment. The actual number of tablets administered in respect of variable dosages was not always recorded on the MAR charts. This means it is not possible to accurately audit the drug and also that the effectiveness of the prescribed treatment cannot be monitored. One MAR chart did not evidence that medicine had been given twice a day as prescribed. It was stated that the resident may have refused the medication, but this was not recorded on the chart. Photographs were not available on MAR for some more recently admitted residents, and it is important that staff are able to confirm the identity of residents before administering medication. At the time of the visit there were no residents who were administering their own medication. Senior staff carried out regular medication audits in order to identify errors and improve practice. There was no senior carer on night duty, and this meant that day staff gave out night-time medications, including night sedation, before they went off duty. This was not satisfactory as it meant residents had little choice when they received their night-time medication. There was no clinic room in the home, and medication was stored in a built-in locked cupboard at the end of a corridor, and in medication trolleys in another part of the home. Staff were observed to be supporting residents in a pleasant and respectful manner, and did not enter residents rooms without knocking. Residents were able to have a private telephone line installed in their bedroom if they wished, and a pay phone was located in a private area of the home for residents’ use. Residents also had access to a cordless phone that they could use in the privacy of their own rooms. Privacy locks had been fitted to the bedroom doors helping to enhance the residents’ privacy, and these could be over-ridden by staff in an emergency. At the time of the fieldwork visit six residents had a key to their own bedrooms and this promoted their privacy and independence. It was concerning to note that lockable facilities within the rooms were still not available for all residents. One resident said, “ I don’t have anywhere to lock my jewellery away”. It is important that all residents have access to a lockable facility in their rooms in order to store items of value or items that they wish to keep private. Residents care records were securely stored and this helped to ensure that confidentiality was maintained. Willow Grange DS0000044889.V307261.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There were no rigid rules in the home. Residents were able to take part in a range of activities of their choice, and to spend time with their families/friends, which enhanced their quality of life. The dietary needs of residents were well catered for with a balanced and varied selection of food available that met their needs and tastes. EVIDENCE: The home employed an activities organiser 25 hours a week; her working hours were flexible and this ensured that residents also had activities available every other weekend. There was a variety of activities on offer for residents to participate in both in house and outside of the Home, and these included mobility sessions, indoor bowls, knitting, karaoke, piano playing and singing, bingo. One resident played the piano every day for fellow residents, and this was very popular. Residents also went out once a month for a pub lunch, and this included people in wheelchairs as well as those who were more mobile. A good range of seasonal activities had been provided during the Christmas period. Records were maintained of all activities that residents had taken part in. Residents who were cared for in their rooms had access to activities such as one-to-one poetry reading and conversation. A small budget was provided Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 15 by the home to fund activities and a number of fundraising initiatives were also carried out, including a summer fayre, raffles and selling Christmas cakes. On the day of the fieldwork visit a bingo session was taking place, and this was well attended by residents, and a mobility session was planned for the afternoon. Residents spoken with said they were able to decide how they spent their day, and were generally happy with the activities offered in the home. Residents were able to spend time on their own or with friends/family, watch television in their rooms or in the lounge, or join in activities. One resident said, “I can have my meals here (in the room) or in the dining room”. Another resident said “I joined the bingo but found it was too early – I’d prefer to do something in the afternoon”. There were no rigid rules at Willow Grange. There was an open visiting policy and visitors were made to feel welcome. The family of one resident who were visiting commented, “we feel she is well cared for, and she enjoys the company here”. Residents were able to spend time with family and friends both within and out of the home, and this was important to maintain their independence and individuality. One resident said “I am going to the shops in Solihull with my daughter this afternoon.” A number of residents had also chosen to attend a local day centre. There was evidence of good relationships between residents and that friendships had flourished. One resident said, “we have become very close friends here – we are like-minded”. The home had a well-equipped hairdressing salon, and a regular hairdresser who attended the home once week, which seemed to suit the needs of most residents. Residents had opportunities for religious expression, and were encouraged to maintain contact with their own church and attend services as far as possible. A Church of England Communion service was held each month, and a lay person of the Roman Catholic faith attended the home regularly. For residents not of the Christian faith, staff were confident that links could be established with any appropriate religious adviser of the residents’ choice. The menus, which operated on a four week rolling programme, identified a good range of nutritious and varied meals on offer. Discussions were held with the cook who displayed a good knowledge of the individual needs of residents. A list was displayed in the kitchen showing which residents required special diets such as low fat or diabetic, and this also included information about food that residents were allergic to and any individual likes and dislikes. Information was held about when residents’ birthdays occurred, and a birthday cake was provided by the home. On the day of the visit supplies of fresh fruit was limited and there were no fresh vegetables; it was explained that this was because ordering was done once a week, and another delivery was not due for two days. It is important that ordering of fruit and vegetables is done on a frequent basis to ensure that they are always available to residents. The manager agreed to ensure that Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 16 ordering of supplies was to be done twice a week. Meat was delivered to the home weekly. One resident said “at first there was no regular cook; it’s becoming smoother now. “ We have a choice of meal”. A number of residents spoken with mentioned that breakfast was served very early. One resident said, “it is one of the things that could be altered”, and another resident said “You have to eat to a timetable here – I used to have breakfast at 10am sometimes in my flat”; however another resident commented “I wake early and like to have breakfast early”. The cook confirmed that breakfast times were flexible, with cereal, toast and tea available to residents from 6.45 am, and a cooked breakfast was also available after she came on duty at 8 a.m. She said that she had recently been reminding all residents that breakfast times were flexible, and that they could chose to have a later breakfast if they wished. The manager was advised that the arrangements for breakfast needed to be monitored to ensure that all residents were aware that they had a choice of when to eat. The dining room was bright and pleasant, but space was limited, providing seating for only 28 residents, and this limited residents’ choices. New tables and chairs had recently been provided. A number of residents took lunch in their rooms, and others in the lounge. One resident said, “I don’t mind where I sit for my lunch”. The dining room tables were attractively set, each with table linen, place mats, and condiments available. Residents were offered a choice of cold drinks. The menu for the day was displayed on a dry wipe board, although this did not accurately reflect what was on offer, as there were no fresh vegetables available. The choice of main course was lambs liver with bacon or Cornish pasty, with creamed potatoes and mixed vegetables. The pudding was eve’s pudding and custard. The menu for tea consisted of cheese and potato pie with plum tomatoes, or a selection of sandwiches. Lunch was served in a relaxed, unhurried way, and the food looked appetising, was well presented, and portions were of a good size. There were adequate numbers of staff on duty and staff were seen to be anticipating the needs of residents in a sensitive and appropriate manner, for example helping them to be seated, and with cutting up food as necessary. This promoted the dignity of residents and ensured that their needs were met. One resident said, “the dinners are lovely, but they don’t do the toast well enough”. Another resident said, “The food is terrible – half cooked”. The inspectors were told that hot drinks and snacks were available for residents throughout the night. Special diets could be prepared for reasons or health, taste or religious/cultural preferences, and halal meal could be ordered from a local butcher. Hygiene standards in the kitchen were good, with records of cleaning and fridge temperatures maintained. All food in the refrigerators was covered and dated and a system of stock rotation in operation. Willow Grange DS0000044889.V307261.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 inspected at least once during a 12 month period. 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 the service. The home has a comprehensive complaints policy, but the failure to record all complaints received may potentially result in poor outcomes for residents. Adult protection procedures in the home helped ensure that residents were protected. EVIDENCE: The complaints procedure was on display in the reception area of the home, and included all relevant information. Since the last fieldwork visit a random inspection had been carried out by CSCI in April 2006 in response to two complaints, containing a number of elements, received by the Commission. A number of complaints were upheld by the inspectors at this time and Immediate Requirement notices were issued in respect of the following: improvement in staffing levels on night duty; provision of staff supervision; infection control procedures; recording of accidents; risk assessments; mandatory training for staff. A complaint in relation to failing to maintain observation charts was also upheld. A number of other complaints were not upheld. The complaints log was viewed and four complaints had been recorded as received by the home since the last random inspection in April 2006. The Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 18 complaints were about issues such as the standard of cleanliness in the home, the smell of urine in a resident’s room, that fire doors were being propped open that a resident did not have eye drops administered as prescribed. There was also an allegation of theft of jewellery from a resident. The complaints log contained the name and address of the complainant, a summary of each complaint, the name of the person responsible for carrying out the investigation, what the outcome was, and copies of any correspondence relating to the complaint. The records demonstrated that the management team had investigated the complaints that were recorded in a timely and appropriate manner. However it was concerning that a number of complaints had not been recorded, including one allegation of theft from a resident and another regarding noise levels and disturbance in the car park of the home at night, although there was some indication that these matters had been investigated. A resident had made an allegation in October 2006 and this had been appropriately referred as an adult protection matter. The outcome was that the allegation was unsubstantiated, but there was no record of the allegation in the complaints log. It is essential that all complaints are appropriately recorded so that the home can demonstrate that the matter has been appropriately investigated in a timely way, and what the outcome was. No complaints had been received by CSCI since the last fieldwork visit. Information on adult protection was available in a folder; this included the home’s Adult Protection Policy, and copies of Birmingham’s multi-agency guidelines on protection of vulnerable adults and the Department of Health’s “No Secrets” document. The folder also contained information that was out of date and needed to be removed in order to avoid confusion. The policy on adult protection needed to be revised and updated to include the local multiagency guidelines and to ensure that staff were clear about what they were required to do in the event of any allegation of abuse, in order to protect residents. The majority of staff had received training in elder abuse during 2006 and this helped ensure that residents were protected. Willow Grange DS0000044889.V307261.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The constraints of layout of the building and current use of space meant that residents choices were limited, for example, there was no bath available, leading to potentially poor outcomes for residents. Poor hygiene practices may increase the risk of cross infection. EVIDENCE: The reception area of the Home was comfortable, although formal in style, and a variety of information was clearly displayed. Throughout the home the decoration, furnishings and fabrics were rather worn and dated. The stair carpet was worn on the edge of some of the stairs, and ill fitting in places, and this may present a hazard to residents, staff and visitors to the home. A number of areas in the home were clean and fresh, however a smell of urine, was evident in other areas, for example, in the communal areas, and some of the corridors and bedrooms. In the communal toilet/shower room on the first floor a new floor covering had been fitted, and some improvements made to Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 20 the tiling and decoration. However, a urine spillage was found on the toilet seat, and there were no disposable towels or hygienic hand soap available. It is essential that people are able to wash their hands after using the toilet to reduce the risk of cross infection, and to maintain their own personal standards of hygiene. It was observed that a carer who had been giving personal care to a resident in the bedroom, came out of the room still wearing surgical gloves and disposable apron; this practice increases the risk of cross infection and should not occur. The standard of cleaning in the home has been the subject of complaints, and this, together with the issues of decoration and fabrics need to be addressed in order to ensure that residents are provided with a clean, comfortable and hygienic environment in which to live. The lounge on the ground floor was spacious, homely in style and furnished to a reasonable standard. The bedrooms of a number of residents were viewed, and generally found to be clean, comfortable, spacious, and had been personalised to suit the needs and tastes of the individual resident. A staff call system was provided in each bedroom. The layout of the building and current use of space continued to impose a number of limitations and difficulties, and these had an impact on the residents in their daily lives, and on staff in the performance of their duties. Some of the corridor areas were narrow and had no handrails, and this meant that residents who were frail or who had mobility problems did not have their independence promoted. The home still did not have assisted bathing facilities, and this meant that residents who preferred to have a bath were unable to do so. Although a number of residents had an en suite toilet and shower in their rooms, the showers remain difficult to use because of the step up. This further restricted residents’ choice, as they had to use the communal shower room on the first floor. The inspectors heard that consideration was being given to converting one of the bedrooms into an assisted bathing facility. There was an area on the lounge floor that was markedly sloping, and this may pose a hazard for residents, staff and visitors who may be at risk of tripping. Although staff reported that there had not been any falls or accidents in this area, it will be necessary for a risk assessment to be undertaken with a view to identifying and minimising any risk to people. Space in the dining room was limited. and this restricts residents’ choice about where they have their meals. An earlier plan to extend this area did not appear to have been progressed. There is no clinic room in the home for the storage of medication and medicine trolleys. Space in the laundry was limited and an ironing board and iron had been placed in the corridor nearby; the iron, although switched off, was still hot; this arrangement may pose a risk to residents and needed to be reviewed with a view to finding a safer area where the ironing could be done. Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 21 The home had only one small office for staff use and this was cramped and had limited space for files and office equipment. The home did not have a dedicated staff room or a room where staff handovers between shifts could take place in privacy. Staff having a break were using an open plan area within the home, and this was also used for staff handovers. As this space was also used by residents to sit quietly or to receive visitors in, this meant that there were times when residents had to move, thereby limiting their choices. The arrangement also failed to ensure that confidentiality could be adequately maintained. There was a pleasant courtyard/garden area for residents to enjoy in warmer weather. A lock had recently been fitted to a side gate leading to the main road, and this enhanced security for residents. The garden area was well maintained, easily accessed and was suitable for wheelchair users. A passenger lift was provided to the first floor. The temperature within the Home was comfortable on the day of the visit. There were suitable sluicing facilities available. Two part-time staff managed the laundry function, and the system for dealing with residents’ personal laundry seemed to be efficient. Hygienic hand washing facilities were appropriately located throughout the Home. Willow Grange DS0000044889.V307261.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to the service. Although adequate staffing levels were maintained throughout the day time hours, staffing levels at night, and the lack of proper supervision arrangements, may fail to safeguard residents. Recruitment procedures were robust, helping to ensure that residents were protected. EVIDENCE: Duty rosters demonstrated adequate numbers and skill mix of staff during the day time hours. However, it was noted that staffing levels at night appeared insufficient for the number of residents, taking into account dependency levels and the layout of the building. The manager stated that night staffing levels had been reduced because occupancy levels had fallen a few months ago. An Immediate Requirement notice had been issued in respect of this in April 2006; another Immediate Requirement notice was issued at the time of the fieldwork visit. There was no senior carer rostered on night duty at the time of the fieldwork visit, and this meant that night medication was given to residents by the day staff before they went off duty. Of the three care staff on night duty, one person was designated as “in charge” of the span of duty each night. It was clear from the minutes of various meetings that concerns had been voiced by staff members and others in relation to how the home functioned at night. It will be necessary for the management to conduct a review into the functioning Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 23 of the home at night, with a view to ensuring more robust management arrangements, more choice for residents, and appropriate staff skill mix. Staff recruitment files sampled contained all information required by the regulations, including a completed application form, two references, and evidence that Criminal Records Bureau and POVA register checks had been carried out before commencing employment, together with declaration of health. Notes had been kept of the interview process in line with good employment practice. All these systems help ensure that residents are protected. New staff were issued with a contract of terms and conditions of employment. One member of staff said, “There is a homely atmosphere here, it is lovely to sit and talk to the residents. “The management are very efficient.” One resident said, “All of the staff are great here”; another resident said, “the staff are all kind, they’re fantastic. “We’re all friends”. Newly appointed staff undertake induction training, and a new induction package had recently been developed by the training co-ordinator. A training needs analysis had been undertaken, and training records evidenced that staff received mandatory training, although it was noted that some staff had not received training in moving and handling, food hygiene or health and safety. Training delivered during 2006 included protection of vulnerable adults, incident and accident reporting, infection control, dementia awareness, and customer care. Training in fire safety, food hygiene and first aid were scheduled to take place in January 2007. Just under 50 of care staff had completed National Vocational Qualifications level 2 or above, and a number of staff were in the process of completing the course. Willow Grange DS0000044889.V307261.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There were systems in the home for obtaining the views and opinions of residents, and for monitoring the quality of the service offered and these helped ensure that residents felt they had a voice. The systems in place to protect the health and safety of residents needed to be further strengthened to ensure that residents are fully protected. EVIDENCE: The registered manager had just recently returned to work following a period of maternity leave, during which time temporary management arrangements had been in place in the home. She is an experienced and competent manager with many years experience of working in a care home setting, and was supported in her role by a committed and experienced deputy manager. The registered manager had successfully completed NVQ level 4 in management Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 25 during 2006 and was in the process of completing the Registered Managers Award. There were no minutes of meetings with residents available. However, one resident said, “I have been to one meeting”. There were some mechanisms in place for consultation with residents, and for quality monitoring. A residents survey had recently been undertaken, and among the points raised by residents were requests for more benches outside the home, further opportunities for outside visits, and that call bells were not accessible. The Registered Provider regularly undertook quality monitoring visits and reports of these were forwarded to CSCI. It will be necessary for the home to have an annual development plan, based on a systematic cycle of planning, action and review, reflecting aims and outcomes for residents. There was evidence that staff meetings did occur on a fairly regular basis, and minutes were maintained; however these were often undated so that it was not clear when particular issues had been discussed. The staff did not manage the personal finances of residents and this was the responsibility of the residents’ families. A small amount of money was held in a locked cabinet in the staff office, for residents’ day-to-day expenses such as hairdressing, newspapers. All expenditure was signed for by two people (either the resident and one staff member, or two staff members), and receipts were kept; access to this money was strictly limited. With the exception of one bedroom, none of the bedrooms had magnetic door closures, and a small number of doors were found propped open so that the resident felt less isolated. In order to ensure the safety of residents it is essential that these doors, which are fire doors, are not propped open. Records of incidents and accidents were maintained, but needed to be more specific in relation to immediate action taken and how to prevent a recurrence. Health and safety checks of equipment used at the Home were undertaken including the fire alarm system, emergency lighting and thermostatic water valves. Willow Grange DS0000044889.V307261.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 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 1 2 1 X X 1 3 1 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Willow Grange DS0000044889.V307261.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. 1 Standard OP1 Regulation 5 Requirement The Registered Manager must ensure that the Statement of Purpose and Service User Guide are available in a format suitable for intended residents. The Registered Manager must ensure that a copy of the most recent CSCI inspection report is available in the home. The Registered Manager must ensure that each resident has a plan of care generated from a comprehensive assessment. The Registered Manager must ensure that the care plan sets out clearly for each resident what the care need is and how that care need is to be met, and that they are signed and dated. Timescale for action 01/06/07 2 OP1 5(1)(d) 01/03/07 3 OP7 15 01/03/07 4 OP7 15 14/05/07 Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 28 5 OP7 15 The Registered Manager must 01/03/07 ensure that care plans are reviewed and 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 three timescales of 26 August 2004, 31 March 2005 and 01/11/05 not met. The Registered Manager must 01/04/07 ensure that moving and handling risk assessments include the action to be taken should a resident fall. (Timescales of 01 July 2005 and 01/11/05 not met) The Registered Manager must ensure that all the personal care needs of residents are met. 6 OP7 13(5) 7 OP8 12(1)(a) 08/02/07 Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 29 8 OP9 13(2) 9 OP10 12(4)(a) The Registered Manager must 01/04/07 ensure, in respect of medications: a) that medication received into the home is checked and signed for by two members of staff; b) that there is a system for recording the disposal of all controlled drugs; c) that MAR charts that are hand-written must have the signature of two members of staff; d) that the instructions for the administration of medication are clear; e) That all medication is given as prescribed, and if not, the reasons are recorded; f) that the amount of medication administered, in the case of variable doses, is recorded; g) that there is a photograph of the resident attached to the MAR chart. h) that nighttime medication is administered at the correct times, and as far as possible to meet the needs and wishes of the resident. The Registered Manager must 30/05/07 ensure that risk assessments are 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) Not assessed on this occasion. Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 30 10 OP10 12(2(m) 11 16(2)(i) 12 OP15 16(2)(i) 13 OP16 `s 17(2) 14 OP18 12(1)(a) 15 16 OP19 OP19 13(4)(a) 23(2)(d) The Registered Manager must ensure that a lockable storage facility is available in each residents bedroom. (Timescale of 01/12/05 not met). The Registered Manager must ensure that the arrangements for breakfast are flexible and meet the needs of the residents. The Registered Manager must ensure that there is an adequate supply of fresh fruit and vegetables available in the home. The Registered Manager must ensure that a record is kept of all complaints made, and that this includes details of investigation and any action taken. The Registered Manager must ensure that the home’s Adult Protection Policy is revised and updated to include the relevant multi-agency guidelines The Registered Manager must ensure that the stair carpet is refitted/replaced. The Registered Manager must ensure that a programme of routine maintenance, redecoration and replacement of furniture is implemented. 01/03/07 08/02/07 08/02/07 08/02/07 01/04/07 01/04/07 01/03/07 Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 31 17 OP19 13(4)(c) 23, 18 OP24 16(2)(c) The Registered Provider must ensure that a review of the internal environment and use of space is undertaken with a view to: a) ensuring that handrails are fitted where possible; b) creating an assisting bathing facility; (this is an outstanding requirement from previous inspections 31/03/05 and 30/06/05 c) ensuring that en suite showers are fit for purpose; d) assessing the risks posed by the lounge floor, and taking any remedial action necessary; e) Increasing dining space; (this is an outstanding requirement from previous inspections 31/03/05 and 31/07/05 f) Creating a secure and serviceable storage area for medicine trolleys and medicines; g) Ensuring that a safe space is provided for the ironing of laundry; h) The creation of a suitably sized and private space for staff handover. The Registered Manager must ensure that comfortable seating is provided in all bedrooms and this must be fit for purpose. Not assessed on this occasion. The Registered Manager must ensure that the premises are kept clean, hygienic and free from offensive odours. The Registered Manager must ensure that disposable soap and towels are available in toilets. 01/05/07 01/03/07 19 OP26 16(1)(2) (j)(k) 13(3) 14/02/07 20 OP26 08/02/07 Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 32 21 OP26 13(3) 22 OP26 12(1) 16(1,2) 13 23 OP27 18(1)(a) 24 OP27 18(1)(a) 25 OP30 13(5)18 (1) The Resident Manager must ensure that staff adhere to procedures for control of infection. Immediate requirement for infection control procedures to be reviewed and updated. Appropriate equipment must be available in the room for the service user with MRSA. Wet and soiled pads must be disposed of immediately. Not assessed on this occasion. The Registered Manager must ensure that adequate staffing levels are maintained on night duty to meet the assessed needs of the residents. The Manager received this in the form of an Immediate Requirement. Previous timescales of 14/09/05 and 21/04/06 not met. The Registered Manager must ensure that the staffing skill mix on night duty ensures that the assessed needs of residents can be met, and provides adequate supervision for staff. The Registered Manager must ensure that all staff have undertaken training in moving and handling and health and safety. Previous timescales of 01/12/05 and 01/12/05 not met The Registered Manager must ensure that there is an annual development plan for the home, based on a systematic cycle of planning, action and review, reflecting aims and outcomes for service users. The system for formal staff supervision and appraisal must be up to date. Not assessed on this occasion. DS0000044889.V307261.R01.S.doc 08/02/07 01/05/07 11/01/07 01/03/07 01/06/07 26 OP33 24(1)(a)( b),(2)(3) 01/09/07 27 OP36 18(2) 30/04/07 Willow Grange Version 5.2 Page 33 28 OP37 17(1-3) A written record of action taken following accidents involving residents must be kept. Timescales of 15/10/05 and 21/04/06 not met. The Registered Manager must ensure that the bedroom doors are not propped open. Remedial action must be undertaken to address the few requirements outstanding following the most recent Fire Safety inspection. (Timescale of 01 June 2005 not met) Not assessed on this occasion. 01/03/07 29 30 OP38 OP38 23(4)(c) 13(4)23 (4) 08/02/07 14/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP35 Good Practice Recommendations It is recommended that the menu displayed accurately reflects the meals on offer. 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. Not assessed on this occasion. 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 Previous recommendation from last inspection. It is recommended that minutes of staff meetings are appropriately dated. 3 OP38 4 OP38 Willow Grange DS0000044889.V307261.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Birmingham 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. 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