Inspection on 01/06/06 for Willow House

This inspection was carried out on 1st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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 House 01/05/07

Willow House 12/10/05

Willow House 27/04/05

Willow House 02/12/04

Willow House 12/07/04

Willow House 12/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Willow House 396 Halifax Road Hightown Liversedge WF15 6NG Lead Inspector Bronwynn Bennett Key Unannounced Inspection 1st June 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow House DS0000026298.V291370.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 House DS0000026298.V291370.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow House Address 396 Halifax Road Hightown Liversedge WF15 6NG 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) 01274 872624 01274 864996 Mr Ronald Sykes Mrs Susan Morgan, Mrs Barbara Sykes, Mrs Julia McDermott Mrs Susan Morgan Mrs Julia McDermott Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2005 Brief Description of the Service: Willow House is a privately family run residential home and is located in the Hightown area of Liversedge. The home provides accommodation for up to twenty-eight ladies. It is a detached property and has had several extensions and adaptations in order to make it more accessible to the service users living there. A passenger lift links the ground and first floor accommodation. The home has two lounges and a large conservatory where service users are able to spend time with each other, watch television and participate in various activities and welcome friends and relatives. In addition there is a spacious, accessible and landscaped garden for service users in the warmer weather. Willow House has twenty-six single bedrooms and one double room; fifteen rooms have en-suite facilities. The bedroom accommodation is arranged over two floors. The home has four bathrooms; toilets are located on the ground floor adjacent to the lounge and dining areas. The home is situated on the main Halifax to Dewsbury road and is on a main bus route. The Provider informed the Commission for Social Care Inspection on the 18.5.06 that the fees range from £333 to £370 per week. There are additional charges for Hairdressing, newspapers, magazines, taxis and toiletries. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit carried out by two inspectors. The inspectors arrived at the home at 9.00am and left at 4.20pm. During this visit the inspectors spoke to some of the service users, visiting relatives, some of the staff and the home’s management. The inspectors read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the building. Prior to the inspection twenty eight service user questionnaires were sent to Willow House to obtain the views of service users living at the home. Ten completed questionnaires were returned. There were twenty eight service users living at the home on the day of this inspection. Surveys were sent to ten relatives and friends of service users, four GPs and three social workers. At the time of writing this report the inspector had received responses from four relatives and two GPs. There were no responses from social workers. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, and a pre inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: No service user moves into the home until their care needs have been assessed. All the service user questionnaires received by the Commission for Social Inspection state that service users receive enough information prior to admission into the care home. The staff continue to work hard to meet the care needs of the service users. The service users made positive comments, that the staff are helpful and supportive. The inspectors noted the staff were respectful and have good relationships with the service users and the managers of the home. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 6 There are 70 of the care staff with NVQ level 2 or above. 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. Willow House DS0000026298.V291370.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 House DS0000026298.V291370.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Service users have their needs assessed prior to admission into the care home. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users spoken to and the service users surveys clearly indicate that individual needs are assessed prior to admission into the care home. A sample of the care records audited indicated that a service user recently admitted to the home had their needs assessed prior to admission. The managers of the home said that all service users are assessed and short visits are encouraged prior to admission. Willow House DS0000026298.V291370.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Not all service users health, personal and social care needs are set out in the individual plan of care. Risk assessments are carried out but greater care is required in their monitoring. Generally the service users are protected by the homes medication policy and procedure. Service users are treated with dignity, respect and privacy. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records for three service users were audited. These records contained care plans and risk assessments. One of the care records was not up to date and did not reflect the current needs of the individual. Greater care needs to be taken to ensure all records are accurate. Risk assessments were in place and reviewed however, one of these assessments lacked sufficient detail to ensure the needs of the individual can be met. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 10 The weights of individual service users are recorded. One service user had a significant weight loss during the previous months and there was no evidence in the care records of the appropriate action being taken. A discussion with the staff indicated that the diet of the individual was been monitored but this information was not evident in the records kept. Some of the daily records audited were vague and did not fully reflect the individual’s plan of care. It was noted that the quality of recording in the night records was more detailed. Service users and one relative said they were unaware of their care plan but those who responded to the service user survey said they did receive the care and support they need. The home’s medication system was audited. The home uses a monitored dose system. One medication could not be reconciled with the records and the PRN (When required) medication had not been carried forward form the previous month. The remaining medication was accurate. The service users spoken with said that the staff are caring, helpful and supportive. Through observation the inspectors noted the services users been treated with dignity and respect. One service user said that she is treated with dignity and privacy when the staff attends to her personal care needs. Willow House DS0000026298.V291370.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Generally the service users cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home does offer a range of activities. The service user surveys indicated that there are activities arranged by the home that they are usually able to take part in. There was one comment form a service user survey that said the home could provide more mental stimulation. Service users and relatives said that visitors are always made to feel welcome on visiting the home. The service users spoken with said that they are able to see their visitors in private. The preferred activity of each service user is documented in their individual plan of care. Some of the service users spiritual needs are met by visits from the local vicar. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 12 The service users are supported to handle their own finances if they wish, with locked space available for this purpose. Individual rooms were seen during a tour of the home and service users had personalised their rooms. The inspectors noted that the staff appropriately supported the service users during mealtimes. The food served on the day of this inspection was well presented. The service users said that generally the food is good, with a varied diet been offered by the home. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 13 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 and 18. Service users, their relatives and friend are confident to in raising any concerns and complaints. The service users are protected from abuse. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The complaints procedure is available on request and in the service user guide and the statement of purpose. The home has received two complaints since the last inspection that are now resolved. The service users and relatives spoken to said that they would feel comfortable to speak to the manager if they had any concerns or complaints, and also felt confident that any issues raised would be dealt with appropriately. The staff spoken with during this inspection had a good understanding of adult protection and the relevant actions that should be taken following any allegations of abuse. The home’s complaints policy and procedure requires updating to include the information for contacting the Commission for Social Care Inspection. The training records audited showed that not all the staff were up to date with adult protection training. The manager said that the majority of staff were up to date with adult protection training, and that further training dates were booked, however some staff training records were not up to date. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 14 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 and 26. The service users live in a safe and overall a well-maintained environment that is generally clean and hygienic. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A service user commented that the domestic staff who work at the home are good, and seven of the service user surveys said that the home is always fresh and clean. A tour of the building took place as part of this key inspection. The inspectors observed the home to be clean and hygienic. The relevant staff were complimented on the standard of cleanliness throughout the home. There is an ongoing plan of maintenance in the home, with some rooms having recently been redecorated and some replacement furniture. However, the ground floor toilet facilities are showing signs of wear and tear. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 15 A bath hoist in the identified bathroom requires a replacement seat and some maintenance; this room also requires some general maintenance. There was communal soap and some body cloths in the bathrooms and toilet facilities. The use of communal soap should be discontinued to promote good hygiene and prevent cross infection. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 16 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 and 30. Staff are employed in sufficient numbers and receive induction and ongoing training. The recruitment process could be improved to ensure the service users are sufficiently protected by the home’s recruitment policy. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are sufficient numbers of staff working in the home to meet the needs of the service users. The service users survey indicates that staff are generally available when required by the service users. The two managers at the home are not identified in the homes recorded rota, and the staff surnames are not recorded. Any staff working in the care home should have their name recorded in full in the recorded rota kept. There is 70 of the care staff working in the home with NVQ level 2 or above in care. A sample of staff files were audited and held the majority of the information required. However, there was little evidence of employment history of the staff. The manager said that employment histories for potential staff are Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 17 discussed during the interview process, but this was not recorded on either the individuals’ application or on a record of the interview. The home should ensure the employment histories for all the staff working in the home are explored and recorded in the individuals file. There is some evidence of induction training and ongoing training for the staff, some of the records kept were not up to date and this should be addressed. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 18 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 and 38. The home is run and managed by managers who are fit to be in charge. Generally the home is run in the best interests of the service users. The financial interests of the service users are safeguarded. Not all the required records kept by the home are up to date and accurate. The health and welfare of service users and the staff is promoted and protected. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The managers of the home have been registered since December 2001,and both are undergoing qualifications in NVQ Level 4. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 19 The service users spoken to at the time of this inspection said that the managers are approachable and felt comfortable to discuss any concerns or queries; and were confident that any issues would be dealt with appropriately. The home has a quality monitoring system in place. Copies of the monthly management review reports are sent to the Commission for Social Care Inspection, and a random sample of anonymous questionnaires are sent to service users on a monthly basis. The managers said that a complete quality assurance tool is planned for later in the year. A sample of three service users’ finances was audited. These records were correct. Service users are supported to handle their own finances should they wish to do so and locked facilities are available in individual rooms for this purpose. As part of this inspection written records have been audited as part of the inspection process. Some records sampled lacked some of the relevant information and were not up to date and accurate. The fire records were checked and there is weekly testing of the homes fire alarm system and emergency lighting. There is an up to date fire risk assessment in place. Movement and handling training for the staff is due to be updated. The staff said they felt they had sufficient movement and handling equipment to meet the needs of the service users. Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 3 Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP8 Good Practice Recommendations Where a risk has been identified the appropriate risk assessment should be completed and kept in the service users care records. Care should be taken to ensure accurate records of “as required” and amounts of carried forward medication are recorded. Recruitment policies and procedures should be reviewed to improve the process in order to protect service users further. Records required to be held should be kept up to date. 2. 3. 4. OP9 OP29 OP37 Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow House DS0000026298.V291370.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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