Inspection on 11/10/07 for Willow House

This inspection was carried out on 11th October 2007.

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

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Willow House 2 Reading Road Farnborough Hampshire GU14 6NA Lead Inspector Pat Griffiths Unannounced Inspection 11th October 2007 10:00 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 DS0000069596.V353760.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 DS0000069596.V353760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow House Address 2 Reading Road Farnborough Hampshire GU14 6NA 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) 01252 522596 01252 522596 lynnecotterell@talktalk.net Willow Residential Care Limited Lynne Cotterell Care Home 18 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) Willow House DS0000069596.V353760.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 only - Code PC 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 Dementia - Code DE Dementia over the age of 65 years - Code DE(E) The maximum number of service users who can be accommodated is 18. Willow Residential Care Limited must ensure Mr M Fowdar and Mrs V Fowdar do not have direct or indirect contact with the residents or staff of Willow House. New registration 2. 3. Date of last inspection Brief Description of the Service: Willow House is located in a quiet residential road in Farnborough, within easy reach of the town centre and other local amenities. Willow House offers personal care for up to eighteen older people over the age of sixty-five years who may have dementia care needs. The home is a large house standing in it’s own grounds. The house has been altered and extended over the years and there are now four double and ten single bedrooms, none of which are en-suite. Communal areas in the home include a sitting room, a dining room and a quiet room. There is a passenger lift to enable residents to access all areas of the home. There is a small landscaped garden at the front of the house and large secure gardens at the rear, which are easily accessed by the residents. There is onstreet parking at the front of the home. The weekly fees at the home are currently £450:00, with extras such as hairdressing, toiletries and chiropody paid for separately Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) and an unannounced visit to the home on 11th October 2007. The information provided included an Annual Quality Assurance Audit [AQAA], which had been completed by the manager and returned to the commission and other information that has been provided since the home was registered. This information includes accident reports and the recent application for registration by the manager. The home is an established care home and was recently registered as Willow House Residential Care Home and is under new management. The manager and her deputy were available during the visit and provided all necessary information and assistance when required. During the visit we spoke with four visitors, eight residents, the care and domestic staff on duty and the cook. We were able to see different parts of the home, such as the kitchen, dining room, bathrooms, the garden and some of the bedrooms. Documents relating to the residents, staff, policies and procedures and documents regarding the running of the home were seen during the visit. The manager told us that the weekly fees are currently £450:00; the fees for hairdressing, chiropody and toiletries are paid separately. What the service does well: What has improved since the last inspection? This is the first visit since registration. Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 6 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 DS0000069596.V353760.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 DS0000069596.V353760.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People wishing to use this service benefit from a comprehensive pre-admission assessment of their needs before moving into the home. The home does not provide intermediate care. EVIDENCE: This was an existing home that was re-registered six months ago. We were told that the home has a website, with pictures and information about the home and a brochure is available. The statement of purpose, which contains all relevant information, is given to all prospective residents. The manager told us that it is being reviewed and will be updated to provide a statement of purpose and service users guide. Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 9 The manager told us that she visited all potential residents and assessed them before offering a place in the home. The pre-admission assessment is thorough and includes information such as their personal care needs, health needs and physical well-being, sight, hearing, mobility, medication, mental state and cognition, social contacts and relationships. The family or friends are also invited to help by providing details of the person’s life story as well as details of their likes and dislikes and interests and hobbies. The manager said that information is also obtained from the care manager’s assessment. The home does not provide intermediate care Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning ensures residents have all their needs met. Medication administration practices protect the residents EVIDENCE: On the day of the visit there were twelve residents in the home and the manager showed us that they each have an individual, personalised, plan of care. The care plans contain information such as the persons past medical history, an assessment of their activities of daily living, risk assessments, their care plans for day and night time, and a record of visits from healthcare professionals. There was written evidence that the care plans have been reviewed monthly and amended as necessary for any changes in the care needs of the residents. The plans contained thorough assessments of care and personal needs and risk assessments for different activities, such as mobility. Despite the assessments, there was little information available to indicate what Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 11 actual care was to be provided by the care staff. This was discussed with the manager and her deputy as the care plans are kept in the office and not always accessible to the care staff. The care staff write daily record sheets for each resident, which is also used at ‘handover’ to inform the staff. By the end of the visit the deputy had written brief plans of care for each resident, which would be kept with the daily record sheets. The new plans outlined the residents likes, dislikes, mobility, dietary needs, what time they wanted to get up in the morning, as well as their general activities of daily living. The manager told us that there is a key worker scheme in place, members of staff are allocated residents and are responsible for their overall care and care plan reviews, which are checked monthly by the deputy manager. The home has medication polices and procedures in place, which cover the ordering, receipt, administration and disposal of medications in the home. The medication is received into the home in ‘blister packs’, which are colour coded for different times of day. Each resident has their own medication administration record [MAR] sheet and those looked at had no gaps in recordings. It was also noted that each sheet contained an up to date photograph of the resident for identification purposes. MAR sheets are the records that are kept of all medication received into the home and are also a signed record of when medication is given to a resident. Staff that administer medication have received training and those that spoke to us were confident about their practice. During the course of the day the staff were generally observed being courteous and respectful to the residents, providing assistance in a sensitive manner. Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good quality food and their diverse needs are generally well supported. EVIDENCE: The home does not have an activities co-ordinator, but all staff are involved in providing or promoting activities for the residents and it is planned for staff to attend an activities training course. The manager told us that they promote independence and let the residents choose what they would like to do. Information about resident’s interests and hobbies is usually written in their care plans, which helps the staff to offer appropriate activities. The manager said that they have regular visits from external entertainers such as someone who reads poetry and provides musical instruments and reminescence sessions with sing-songs. A new larger television with a Freeview receiver and a DVD and video player has been provided to give greater choice and diversity of in-house entertainment. Staff told us that some of the residents have household tasks that they like to do, such as dusting, watering the plants and Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 13 one gentleman was seen setting the tables for lunch. The manager said that plans are in place to send staff on activities training courses to provide a wider range of suitable activities in the home. The home has a policy of open visiting with no restrictions but do ask visitors arriving after 8pm to telephone the home to let them know they are coming. Residents are able to make and receive calls on the homes cordless phone, but can have a telephone installed in their bedrooms at their own expense if they wish. The cook told us that the menu is planned by herself and the manager and is based on the likes and dislike of the residents. The menu is usually planned following a meeting with the residents, where they are encouraged to discuss the menu choices and different recipes. We were told that meals can be taken in the dining room or where ever the resident chooses, such as the sitting room or their bedroom. The manager said that drinks are freely available and offered regularly to the residents. The spiritual needs of residents are recorded in their individual care plans and arrangements can be made to accompany them to church or their own church or spiritual leaders can visit them at the home. Residents were observed making choices about their daily activities, such as whether to join in with activities, and whether to sit in the sitting room or spend time in their bedrooms. Staff were available to provide help or support when or if it was needed. A visitor commented ‘Mum enjoys her food now and has gained weight since she moved in’ Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training in adult protection, and the knowledge that all complaints are dealt with appropriately usually safeguard the people who use this service. EVIDENCE: The home has polices and procedures in place regarding concerns, complaints and compliments, which are also contained in the statement of purpose and on display in the homes hallway. Visitors that spoke to us said that they knew they could talk to the staff or the manager if they had any concerns or complaints and they felt confident that the matter would be responded to appropriately. Polices and procedures are in place about the protection of vulnerable adults and the action to take if there is a case of suspected abuse in the home. The staff adult protection training is provided by an external training agency. The manager told us that the induction process for all new staff included ‘whistle blowing’ and adult protection procedures. Discussions with staff indicated that they have a good understanding of abuse and will know the correct action to take if they suspect abusive practices have happened in the home. Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 15 Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service live in a safe, well maintained, clean, and hygienic home EVIDENCE: The home has a warm and friendly atmosphere and we were made welcome by staff and residents on the day of the visit. During the course of the visit the inspector saw various parts of the home, which were seen to be clean and tidy throughout and there were no undue odours. Willow House is a large detached house in a residential part of Farnborough with a large secure rear garden. Externally the house has been refurbished and accessibility has been improved with ramps fitted at the front and back Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 17 doors. The front of the house has been repainted recently and the garden landscaped. Large secure gates were also fitted at the side of the home, between the front and rear gardens. The accommodation consists of fourteen bedrooms, ten single and four double, none en-suite. There is a sitting room, a dining room and a small ‘quiet’ lounge, a bathroom on each floor as well as two lavatories and a passenger lift provides access to both floors. The kitchen and laundry are on the ground floor. Several of the bedrooms have been redecorated, as well as the hallway and dining room. The laundry and downstairs bathroom have also been refurbished and decorated and a new cooker has been fitted in the kitchen. The upstairs bathroom and a bedroom with an en-suite are being refurbished and there are plans to decorate the kitchen and sitting room. The manager told us that the sitting room would be made more comfortable and homely for the residents. We saw an empty bedroom containing two beds, one of which was against the radiator. The free-standing wardrobe was blocking the call bell system on the wall and the room looked very bare and bleak, as there was no carpet on the floor or pictures on the walls. When looking in other rooms it was apparent that there are very few carpets fitted in the home, most have lino on the floor, which is not very homely. The manager told us that she would like to have carpets on the floor but the health needs of some of the residents made this impractical. The use of specialist carpets instead of domestic ones and the use of a suitable carpet shampoo machine was discussed. The manager also said that the rooms are left bare as she encourages prospective residents and their friends and relatives to personalise their rooms by bringing ornaments, pictures and small pieces of suitable furniture. There is a programme in place for routine maintenance and records are kept. The care staff are supported by ancillary staff who do the laundry, cleaning and cooking for the residents The home has a policy in place for the control of infection and the safe handling and disposal of clinical waste. Protective clothing, such as aprons and gloves, is supplied. Visitors that spoke to us said ‘the home is always very welcoming to enter and the staff are always helpful’ ‘the house looks better now’ A resident commented ‘I like the food the home provides and the rooms are comfortable’ Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment practices and staff training protect people who use this service. EVIDENCE: At the time of the visit the home was staffed with six full-time and three parttime care assistants, with two ancillary staff for domestic duties. There are usually two staff on duty during the day, with one waking and one sleeping carer at night. The manager told us that all new staff have in-house induction training as well as complateing moving and handling and fire safety training. Staff receive regular supervision and we were told that staff training needs are identified through this process. Training records showed that staff are able to access a wide range of training and those staff spoken with said the training was of a good quality. The training records seen indicated that training was mainly up to date and on-going and included manual handling, fire safety, health and safety, infection control, challenging behaviour and adult protection. From the records seen it was apparent that only some of the staff have completed dementia awareness training. During the course of the day a Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 19 further demenatia awareness training session was booked for all staff and confirmation of the training was later sent to us. Nine of the care staff have obtained or are working towards their National Vocational Qualification in care [NVQ2], the deputy manager is currently undertaking NVQ4 and two carers have recently started their NVQ courses. One carer has also recently completed her NVQ3. The national expectation is that 50 of the staff in a care home will have an NVQ2 in care, at Willow House 100 of the staff have completed or are currently undertaking an NVQ. We were told that three members of staff are enrolled in ‘safe handling of medicine’ training course and two are doing occupational therapy training to assist them with organising appropriate activities for the residents. The home has a robust recruitment policy. Three staff files were looked and seen to contain evidence that all appropriate checks, such as obtaining satisfactory references and Criminal Records Bureau disclosures, are completed before staff start work in the home. The manager said that she and the deputy interview all new staff, ensuring that gaps in employment history are checked and written details of the interview are kept. Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are usually safeguarded by good management EVIDENCE: The manager of the home is experienced and has the necessary skills and qualifications to manage the home, having recently registered with the commission as the manager of the home. Mrs Cottrell holds both an NVQ4 in Care and achieved the Registered Managers Award in 2004 and regularly attends refresher training in mandatory courses. The manager said that she has an ‘open door’ style of management, welcoming comments and suggestions from residents, staff and relatives Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 21 We were told that quality assurance surveys are undertaken annually, with questionnaires going out to residents, their families or advocates. The results from the recent survey have not been collated yet, but the manager said that they would be made available to any interested parties. The residents have monthly meetings, to which relatives and friends are invited, and the manager said that the feedback enables the home to obtaining the views of the residents and measure their success in meeting their needs. Thank you letters and cards seen on the hallway notice board indicate that residents and their families are very happy with the care provided in the home. A visitor commented ‘Mum is happy with everything in the home’ A resident commented ‘I am glad the home is non-smoking – I gave up a year ago’ Records indicated that staff attended regular and compulsory fire and other health and safety training, the home’s fire alarm system was checked regularly and emergency plans were in place. There was a fire risk assessment for the premises and regular risk assessments of the premises were undertaken. There were also in-date certificates for the homes fixed electrical wiring, portable appliance testing and for gas safety. No outstanding health and safety issues were observed during the inspection visit and records showed that all equipment was regularly serviced. Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 22 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 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 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 3 X X 3 Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 23 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. Refer to Standard Good Practice Recommendations Willow House DS0000069596.V353760.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000069596.V353760.R01.S.doc Version 5.2 Page 25 - 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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