Inspection on 12/10/05 for Willow House

This inspection was carried out on 12th October 2005.

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 01/05/07

Willow House 01/06/06

Willow House 27/04/05

Willow House 02/12/04

Willow House 12/07/04

Willow House 12/05/04

Similar services:

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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 12th October 2005 13:40 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.V251130.R01.S.doc Version 5.0 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.V251130.R01.S.doc Version 5.0 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 Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 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. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out during a four-hour period and was the second inspection conducted during this inspection year. The inspector carried out a tour of the building and a sample of care records; medication records and fire safety records were looked at. The inspection was conducted with the joint managers of the home and some of the service users and staff were spoken with. What the service does well: 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.V251130.R01.S.doc Version 5.0 Page 6 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.V251130.R01.S.doc Version 5.0 Page 7 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): EVIDENCE: These standards were not assessed during this inspection. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 8 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. The care records are detailed, and generally the risks are assessed to ensure the health care needs of the individual are met. Generally the procedures for medication work well but the home must take action to ensure that these procedures are followed consistently. EVIDENCE: The service users said that the staff are caring and supportive. The care records were looked at for three service users. Evidence was seen that the service users or a relative are involved in the development of care plans. The care records were reviewed and updated, and the inspector noted an improvement in the daily records. There were some risk assessments in place, however there was no risk assessment in the current records for bedrails and a health care need for a service user. This was discussed with the manager. The medication records were looked at for three service users. The home needs to take greater care in the recording of the PRN (When required) medication. The controlled drugs were checked and the inspector noted that there were signature omissions for one of the controlled medications. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 9 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. The service users are supported to exercise choice and preferences in their lives. EVIDENCE: There was evidence in some of the service user care records sampled of the individual preferences for activities and daily living. One service user said that she is supported to attend day care services and there was evidence displayed for some planned activity in the home. Some of the service users spoken to said that they are consulted and supported to make choices in their lives. The manager said that the home has tried service user meetings without success. The preferred method of consultation with the service users has been through one to one contact. The inspector advised the managers to record this individual consultation. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: These standards were not assessed during this inspection but there have been no recorded complaints since the last inspection. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: These standards were not assessed during this inspection. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were not assessed during this inspection. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 13 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): 31,38. There are two managers who are competent and fit to run the home. The health and safety of the service users and staff is promoted. EVIDENCE: A Mrs Susan Morgan and Julia McDermott have jointly managed the home since 2001. Both have attained NVQ qualifications in care and are currently working towards a management qualification. The fire safety officer has recently visited the home. The emergency lighting throughout the home is visually checked daily and recorded on a weekly basis. There was a detailed fire risk assessment in place and weekly testing of the fire alarm system and fire drills are regularly conducted with the staff. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 14 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 15 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 12/10/05 arrangements for the safekeeping, handling, safekeeping, safe administration and the disposal of medicines into the care home. Requirement 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 OP8 OP12 Good Practice Recommendations Where a risk has been identified the appropriate risk assessment should be completed and kept in the service users care records. The consultation and the decisions made by the service user about their choice of activity and preferred lifestyle should be recorded. Willow House DS0000026298.V251130.R01.S.doc Version 5.0 Page 16 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.V251130.R01.S.doc Version 5.0 Page 17 - 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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