Inspection on 10/03/08 for Willow Green Care Home

This inspection was carried out on 10th March 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willow Green Care Home 23/04/09

Similar services:

22 Sandown Road

The Highlands

Turret Villa Retirement Home

Dilston College Of Further Education

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Moor House

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Park View (15)

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

CARE HOMES FOR OLDER PEOPLE Willow Green Care Home Eastbourne Road Darlington County Durham DL1 4ER Lead Inspector Bridgit Stockton Unannounced Inspection 10th March 2008 09:30 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 Green Care Home DS0000068620.V363295.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 Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Green Care Home Address Eastbourne Road Darlington County Durham DL1 4ER 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) 0191 565 2294 St Martins Care Ltd Maureen McMain Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63) of places Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing, Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP, maximum number of places 63 The maximum number of service users who can be accommodated is 63 2. Date of last inspection Brief Description of the Service: Willow Green is a purpose built nursing home in Darlington owned by St Martins Care Ltd. The home provides nursing care to 63 older people. Some of these people may also require dementia care. It is set in specious well maintained grounds, with ample car park facilities. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Willow Green Care Home. The methods I used to gather information included a visit to the home, conversations with the people who live there, their relatives, healthcare professionals and the staff. I looked in detail at the care and records of four people, examined other records and looked around the home. I spent five hours at the home. This was the first time this service had been inspected. What the service does well: The people I spoke to said they are happy with the care and support they receive. One person said ‘I am very happy living here, the staff are great ’. Another said that the staff are ‘lovely and very hard working’. Relatives of the people who live at Willow Green Care Home commented that the ‘Staff are very kind’, another said the staff are ‘brilliant’ The pre-admission assessments are thorough and the majority of people commented that they had sufficient information about the home before choosing to live there. The people who live at the home and their relatives confirmed that they know how to raise a concern or make a complaint, if they needed to. One person said ‘I would tell the staff if I have a problem’. The staff are aware of their responsibilities if they believe that neglect or poor care practice is taking place and were confidant that if they raised any issues the manager would investigate. People looked very well cared for, the atmosphere was relaxed and calm. There was a good relationship between staff and people living at Willow Green Care Home. People said they really enjoyed the activities that take place. People said they enjoyed the food they were given and said that there was a good choice. The décor is lovely and the home is furnished to a very high standard. There are thorough recruitment and selection procedures in place, to make sure that staff are suitable and safe to work with the people who live at the home. All the staff receive a range of training to equip them with the skills and knowledge they need to do their work properly. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 7 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 Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 8 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&6 Quality in this outcome area is good. People’s needs are properly assessed prior to admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans I looked at showed that comprehensive pre-admission assessments had been carried out before offering someone a place. This is to make sure that the home can meet the person’s needs. A senior member of staff visits the person at home or in hospital to discuss their care needs. Social Services assessments are also used to determine this as well; these were also available to look at. People are welcome to visit the home before reaching a decision. The home does not provide intermediate care. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 9 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 People who use the service experience good quality outcomes in this area. Good systems are in place to ensure that health care needs of the people are met. People can be confident that their privacy and dignity is protected and that they are treated with respect. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: I looked at four care plans in detail, to make sure that people’s health and personal care needs are being met in the way the person prefers. I found the plans to be comprehensive and well written. Careful and thoughtful strategies to address particular needs or problems were well documented and sensitively written. Staff showed a good understanding of how people’s needs were to be met in a planned and risk assessed way. There was evidence of involvement of specialist healthcare people such as the community psychiatric nurse, the dietician and continence nurse. During my visit I looked at how peoples medication was looked after by the staff at the home. Medication policy and procedures had not been properly Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 10 established. I asked the Primary Care Trust pharmacist to visit the home to help set up systems and act as a link person between the home, local pharmacy and G.P. practices. This has been done and good systems are in place to make sure people get their medication properly, that it is stored correctly and that repeat prescriptions are ordered on time. Some poor practice in the administration of medication was seen, and this was addressed on the day of inspection by the manager. Staff were seen to be treating people with respect and dignity and this was also reflected within the care plans. People said that the ‘girls are kind’. Another person said ‘the staff in this home are always caring, helpful and competent’. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 11 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 good The recreational and social needs of people are well catered for which enables them to make daily choices and promotes independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During my visit the atmosphere in the home was friendly and welcoming, with visitors coming and going throughout the day. Some people were enjoying chatting with each others; some were watching television. The home has an activities organiser who arranged a program of events that people at the home enjoyed doing. Also she arranged individual activity sessions with people such as hand massages or shopping trips. Everyone said the food was good, and a choice of meals was offered. The cook was spoken to about the meals; she was very knowledgeable about what people liked to eat and about what special diets some people required. One person told me ‘I eat very well, I have no complaints about the food’. The lunchtime meal looked nice and everyone said it was really tasty. People could either have their meals in the communal dining area or else in the privacy of their bedrooms. The majority of people chose the communal facilities. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. People can be confidant that their concerns and complaints are dealt with appropriately and that safeguards are in place to protect them from abuse This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are adequate written policies and procedures in place to deal with complaints and the care staff spoken to confirm they were aware of these. Staff knowledge of these help ensure that they were able to address any issues or anxieties of the residents, relatives and visitors to the home. People who live at the home told me they would speak to the manager or any of the staff if they had any concerns or complaints. Staff told me that training has taken place in the protection of vulnerable adults in abuse. I looked at two personnel files and found that staff recruitment procedures were adequate and staff were employed and deployed following appropriate checks. The staff team were clear and confident in the protection of vulnerable adult procedures. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. People live in a safe, comfortable, well-maintained and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The communal areas are furnished to a high standard, the chairs were comfortable and there were plenty of communal areas for people to use if they so wished. The décor was good and there were nice ornaments and flowers situated around the home, which made the place, feel very homely. All the bedrooms that I saw reflected the person’s individual preferences and taste. The bedroom doors all have locks, and there is a lockable storage space in the rooms. This means that people can keep their belongings private and secure. The home is fresh, clean, comfortable and well maintained. Everyone who commented agreed that the home is always well kept. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 14 Staff have had training in controlling infections and there was plenty of disposable gloves and aprons for their use. The laundry facilities were clean and well organised. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 15 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. People can be confident that staff are trained and on duty in sufficient numbers to meet their assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection there were only twelve residents at the home The rotas and staff numbers suggest that there are enough staff on duty at all times to meet the needs of the people who live at the home. The manager confirmed that as the home increases in residents that staffing levels would also increase to meet the needs of the people who live there. I looked at a selection of staff files. They all included completed application forms and two written references. The files showed that satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks have been obtained. I was assured that no new member of staff starts work until a POVA register check had been completed. Then, if the CRB check had not been received, they would work only under the supervision of an experienced staff member. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 16 The manager makes sure that staff have the necessary training to help them do their work as well as possible. There is a wide range of courses available and the records confirmed that the staff are allowed the time to attend. Staff said they enjoyed the training they had been given and said they were encouraged by the manager to attend training sessions. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &38 Quality in this outcome area is good. The home is well managed. People who live and work at the home can contribute to the decision-making processes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has the qualifications and the skills to manage the home effectively. The company sends out questionnaires to relatives, in order to gain information about how people view the service and what improvements they would like to see. Relatives said the home was very well managed, they said the manager was ‘excellent’ The operational manager visits the home and carries out audits, to make sure the home is operating to company policy. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 18 All the regular health and safety checks for the home are carried out in a timely manner. Staff have basic health and safety training. All these measures make sure that the health, safety and welfare of the people who live at the home is promoted and safeguarded. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 19 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? N/a STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that regular medication audits are undertaken to ensure that the newly introduced systems surrounding medication policy and procedures are fit for purpose when the number of people who choose to live at the home increases. Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow Green Care Home DS0000068620.V363295.R01.S.doc Version 5.2 Page 22 - 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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