Inspection on 01/05/07 for Willow House

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 01/06/06

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 Unannounced Inspection 09:00 1st May 2007 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.V333519.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.V333519.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 willowhouse@tesco.net 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.V333519.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2006 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 12.4.07 that the fees range from £339.69 to £385.00 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.V333519.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 visit. The inspector arrived at the home at 9.00am and left at 4.00pm. During this visit the inspector spoke to people living at the home, visiting relatives, some of the staff and the home’s management. The inspector read records relating to people living at the home and the staff, looked at how medication is given and carried out a tour of the building. Prior to this site visit the Commission for Social Care Inspection sent questionnaires to some people living at Willow House. Seven questionnaires were returned. There were twenty eight people living at the home on the day of this visit. Surveys were sent to fourteen relatives, five GPs and three social workers. Seven relatives and two GPs have responded. Other information used as part of the inspection process was a pre inspection questionnaire completed by the management. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: What has improved since the last inspection? Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 6 There has been some general maintenance work carried out at the home since the last visit by the CSCI. Action was taken on the day of this visit to repair the identified bath hoist. 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 House DS0000026298.V333519.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.V333519.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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. People’s needs are assessed prior to their admission into the care home. EVIDENCE: The care records looked at showed evidence of a social workers assessment. The managers said that all people are assessed and short visits are encouraged prior to admission. Willow House DS0000026298.V333519.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 and 10. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. Not all people’s health, personal and social care needs are set out in their individual plan of care, and their healthcare needs are not being fully met. People are generally protected by the homes medication policy and procedure. People are treated with dignity, respect and privacy. EVIDENCE: The care records for three people were looked at. The records held some good basic information. One of the records had a care plan but this was not up to date. Two records did not contain a care plan. Greater care must to be taken to ensure all records are complete and accurate. Risk assessments about preventing pressure sores (tissue viability)and eating/drinking (nutrition) had not been completed in two of the records looked at. One record did contain risk assessments but these had not been reviewed for some time, and it was difficult to establish their accuracy. Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 10 The home has been working towards recording information through a computer programme. However, the way in which this has been managed has led to the required information not being recorded properly. The weight of individuals was recorded but no nutritional assessments had been completed. One person had a significant weight loss and there was no information to show that the appropriate actions had been taken. The appropriate professional must be consulted where there are any concerns about an individual’s healthcare. Where an individual is over the age of sixty-five then there must be a risk assessment in place for tissue viability (to measure the risk of developing a pressure sore). A falls risk assessment and manual handling assessment must be in place when required. The daily records did contain some basic information about how people had spent some of their day. But they were unable to reflect the care currently being given, as this was not available in the care records looked at. The people spoken to during this visit said the staff looked after them well. Visiting relatives said they were very satisfied with the level of care being provided by the home. People who responded to the survey said the staff listened and acted on what they said, and the staff are available when needed. The home’s medication system was audited. The home uses a monitored dose system. This means most medication in the home is given out from sealed foil strips to prevent errors. All medication could be reconciled with the records kept. Through observation it was noted that people living at the home are treated with dignity and respect. Willow House DS0000026298.V333519.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 and 15. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. Generally people’s cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. People are able to exercise choice and control over their lives. The home provides everyone with a varied and nutritious diet. EVIDENCE: The home offers a range of activities. Three people who responded to the survey said there are “always” activities arranged, three said there are “usually” and one person said there are “sometimes” activities arranged by the home that they can take part in. The people spoken with and some visiting relatives said that visitors are always made to feel welcome on visiting the home. People are able to receive their visitors in private should they wish to do so. The preferred activity of each person was seen in the individual records looked at. Some of the service users spiritual needs are met by visits from the local Church of England and Catholic Church. Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 12 People 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 people have chosen to personalise their rooms. The home offers a four weekly menu with a choice meals made available on request. People were seen being appropriately supported by the staff during mealtimes. The food served on the day of this visit was well presented. People spoken to during the visit said the food was good. Four people who responded to the surveys said they “always” liked the meals served at the home. And three people said they “usually” liked the meals at the home. One individual commented that they had wholesome and plentiful food. Willow House DS0000026298.V333519.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. Generally, people who use the service and their relatives are confident to in raising any concerns and complaints. People living at the home are protected from abuse. EVIDENCE: The home has a complaints policy and procedure in place. The managers said that since the last visit by the CSCI there have been two complaints made to the home that are now resolved. Visitors spoken to during this visit said they would feel happy to speak to the management and staff to raise any concerns or make a complaint. Five people living at the home who responded to the survey said they knew how to make a complaint. However, two people said they did not know how to make a complaint. Everyone who responded to the relative survey knew how to make a complaint to the home should they need to. All staff working at the home have received training in the protection of vulnerable adults. Willow House DS0000026298.V333519.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. People live in a safe and overall a well-maintained environment that is generally clean and hygienic. EVIDENCE: The surveys received by the CSCI said the home is fresh and clean. On the day of this visit the home was clean and odour free. Some people’s rooms were seen and had been personalised by the individual. There is an ongoing plan of maintenance in the home. And since the last visit by the CSCI some individuals’ rooms have been redecorated and a toilet has been redecorated and the flooring replaced. The manager said that there are plans to update the main communal toilet facilities on the ground floor. This Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 15 area of improvement was raised at the last visit to the home and should be addressed. A bath hoist in the identified bathroom requires a replacement seat and some general maintenance. This matter was highlighted at the previous visit to the home. Immediate attention was given to this area with works were being carried out throughout this visit. There was communal soap and some body cloths in a bathroom. This practice must stop. The use of communal soap should be discontinued to promote good hygiene and prevent cross infection. The home has washing facilities that that meets disinfection standards. The laundry floor was in need of repainting and separate hand washing facilities need to be made available in order to meet standards for infection control. This was discussed with the managers who agreed to take immediate action in the matter. Willow House DS0000026298.V333519.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. 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. EVIDENCE: Some positive comments were made about the staff such as, people are treated respectfully and the staff are very helpful. There are sufficient numbers of staff working in the home to meet the needs of the service users. The information received through surveys completed by people who use the service indicates that the staff are available when required. Staff surnames are not recorded in the staffing rota. Any staff working in the care home should have their name recorded in full in the recorded rota kept. This was raised at the last visit to the home. The manager agreed to take immediate action to address this matter. The information received by the CSCI shows there are 84 of care staff working in the home with NVQ level 2 or above in care. Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 17 A sample of staff files were audited and held the majority of the information required. However, there were gaps in the employment history of the staff. The home should ensure the employment histories for all the staff working in the home are explored and recorded in the individuals file. The staff receive induction and ongoing training. The managers said that the home is working towards providing training that meets Skills for Care Standards. Training in Health and Safety, Food Hygiene and infection control is planned for all staff throughout the year. Willow House DS0000026298.V333519.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 and 38. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. 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 people who use the service. People’s financial interests 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. EVIDENCE: The managers of the home have been registered since December 2001, and both are undertaking NVQ Level 4 qualification. Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 19 A relative commented in the survey that they felt the home was well run and comfortable. In order to make sure they provide a good service, 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 people who use the service. However this information is not published in the home. The management said they are awaiting further information from the CSCI before implementing a quality assurance tool. Staff receive supervision but there are no staff meetings or meetings for people who use the service. This was discussed during this visit. The implementation of such meetings should be considered to ensure the views of everyone are sought. A sample of three individual finances were checked. These records were correct. People 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 visit written records have been audited. Some records sampled lacked information relating to individuals healthcare needs and lifestyle. This matter was raised at the last visit to the home. The fire records were checked and there is weekly testing of the homes fire alarm system and emergency lighting. A sample of maintenance records looked at was up to date. Willow House DS0000026298.V333519.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 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Willow House DS0000026298.V333519.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. 1. Standard OP7 Regulation 15 Requirement Timescale for action 01/06/07 2. OP8 13.3 & 17.1 Schedule 3. The home shall consult the individual or their representative and develop a care plan. The plan will show how the individuals needs, in relation to their health and welfare will be met by the home. The plan must be made available to the individual. And the plan will be kept under review. Where a risk has been identified 01/06/07 the appropriate risk assessment must be completed and kept in the individuals care records. Such assessments may require an additional care plan for example, nutrition, tissue viability and where there is a risk of falls. The registered person shall make 01/07/07 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Facilities for hand washing must be sited in the laundry room. 3. OP26 13.3 Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 22 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 OP27 OP29 Good Practice Recommendations The staffing rota should include all staff names in full. Recruitment policies and procedures should be reviewed to improve the process in order to protect people who use the service further. Records required to be held should be kept up to date. 3. OP37 Willow House DS0000026298.V333519.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 House DS0000026298.V333519.R01.S.doc Version 5.2 Page 24 - 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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