Inspection on 27/04/05 for Willow House

This inspection was carried out on 27th April 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 12/10/05

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 27 April 2005 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 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 J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willow House Address 396 Halifax Road Hightown Liversedge WF15 6NG 01274 872624 01274 864996 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr R Sykes, Mrs B Sykes, Mrs S Morgan & Mrs J McDermott Mrs Susan Morgan Care home only 28 Category(ies) of 28 places - Old age registration, with number of places Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 2 December 2004 Brief Description of the Service: Willow House is a family run private residential care 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 where service users can walk 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 now has four bathrooms, with the recent commissioning of a supported bath. 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 J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and a tour of the Willow House building was carried out. Seven service users, four relatives and six staff were spoken to throughout the inspection. What the service does well: What has improved since the last inspection? The home has taken action since the last inspection and fitted coded locks to areas where hazardous substances are stored and the homes laundry room. On looking in service users’ care records the inspector noted a general improvement in individuals’ daily records and this improvement should continue. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 standard(s) 3 There are systems in place to obtain pre-admission assessments and information about service users’ needs following admission. Action needs to be taken to ensure that these are used consistently. EVIDENCE: Assessments and care plans were seen. A service user had been admitted to the home four days prior to this unannounced inspection. The service user’s social services community care assessment and the assessment from the previous care home were seen within the individual personal file. However, on the day of inspection the home had not commenced working with the service user in completing their plan of care for daily living. The inspector spoke to staff and the homes manager about this. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 standard(s) 7,8,9,10,11. The staff team attend to the health and personal care needs of the service users. Care records for service users are generally good but some lack attention to detail. Procedures are in place for the administration of medication and these generally work well, however these need to be followed consistently. EVIDENCE: The care records for three service users were looked at in detail on the day of the inspection. The inspector saw evidence of service users daily records; these were particularly well detailed for service users night requirements. The home should continue working towards making service users daily records person-centred and staff should evidence how service users needs have been met. One service user had been admitted only four days prior to the inspection. Generally individual plans of care were good, however there was a lack of attention to detail and an example of this is the lack of detail for one service users oral care plan. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 10 There were some risk assessments in place but two service users did not have risk assessments in place for bedsides and wheelchairs. There was evidence that service users and their relatives had been involved in the development of individual plans of care. The inspector looked at plans of care for individuals with specific health care needs and observed nursing reports. Where one service user had treatment for pressure area care documented in the district nursing notes, this was not evidenced in the individual’s personal plan of care. Pressure relief equipment is received on loan from the district nurse team. Continence advice is obtained via the local hospital continence advisor. The inspector was informed that should the mental health of a service user deteriorate the community mental health team would be contacted. The individual weights of service users are recorded on a weekly basis, however these records are difficult to trace and should be recorded in the appropriate section of the individuals care records. Specific wishes after death were seen in individual service user records. The inspector saw evidence of the staff training module for death and dying. The service users preferred term of address is identified in the individuals care records. Screening was seen in shared rooms to promote the privacy and dignity of individuals. The inspector looked at medication records for three service users. A service user who wished to self medicate was discussed in detail with the homes manager. On the day of inspection there were omissions of signatures for the morning medication that had been given. Medication carried forward from the previous month was not brought forward to the present MAR recording sheet, therefore records, and amounts, did not correspond. This practice is not acceptable and must be addressed. Controlled drugs were checked and the inspector observed the correct records been kept for such medication. An administrative error was identified and the inspector discussed this with the homes manager who rectified the error immediately. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 standard(s) 12,13,14,15. The home is working well in enabling service users to maintain contact with family, friends and the local community. Service users can follow their interests. This could be developed by setting up a service user and relatives forum to provide the opportunity for involvement and the sharing of information. EVIDENCE: Service users are offered the opportunity to develop interests and activities within the home and within the local community. One service user attends the local day care centre and another service user attends a luncheon club on a weekly basis. On the day of this unannounced inspection an entertainer was visiting the home. Service users are advised of activities via a notice board and staff spoken to advised the inspector that service users are informed verbally of planned activities. The local church offers a religious service every two weeks. The inspector was advised that the home has an open visiting policy, that service users are able to choose whom they wish to see, and are able to see visitors in private. Service users are able to handle their own finances for as long as they wish or able to do so. Service users are able to bring personal possessions with them Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 12 when entering the home; the inspector saw evidence of this during a tour of the building. The homes manager spoke with the inspector and advised that they will inform service users of external agents, for example, advocates to act in service users best interests if required. On the day of inspection the main meal of the day was lamb or chicken, served with a choice of vegetables and pineapple sponge and custard for sweet. The home has a four weekly menu in place and individual dietary needs are catered for. Service users spoken to advised the inspector that their meals were “ nice” and “very good”. It was also observed by the inspector that meal times were relaxed, unhurried and paced to suit individual service user needs. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 standard(s) 16,17,18. The staff have an awareness of adult protection. Systems are in place to deal with service users’ money in a way that protects their interests. Service users have exercised their right to vote. The residents felt able to raise concerns. EVIDENCE: The home’s complaints procedure was seen on the day of inspection. One complaint has been received by the CSCI during the last year as is ongoing. The inspector was advised that where service users lack capacity, they are supported to access advocacy services. The inspector observed some service users participating in postal voting. The home has a whistle blowing policy in place. All staff receive adult protection training as part of their induction, all staff have received updates on this training during the previous four months. Staff spoken to by the inspector had a good understanding of the necessary action to take should there be any allegation of abuse. The service users spoken to during the inspection said that they would feel confident to speak to staff or the manager if they had a complaint. Three service users’ monies were checked on the day of inspection and all were correct. The homes policy for monies and valuables is evidenced in the service user guide. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 standard(s) 19,24,25,26. The home is well maintained. The home was clean on the day of inspection, however action should be taken by the home to deal with any odours. EVIDENCE: The inspector was advised that routine maintenance is ongoing, however there are no records kept for the maintenance programme. On the day of inspection the grounds of the home were safe and tidy. Service users’ bedrooms are generally well furnished and equipped, however consideration should be given to the cabinet in a bedroom identified at the time. This piece of furniture should be risk assessed or moved in order to promote service users’ and staff safety. Odour was discussed with the homes manager relating to a bedroom. Emergency lighting is provided throughout the home but no weekly records are kept as is recommended. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 15 The COSHH cupboard and laundry room are now fitted with coded locks. The homes last environmental health check was completed 19-1-05 and the requirements of the local fire service were completed 8-12-04. During a tour of the building the laundry facilities were well organised and free from odour. The home has a policy in place for clinical waste. Staff have access to protective clothing and suitable hand washing facilities. A smell of urine was noted in a bedroom on the ground floor, the inspector spoke with the manager about this matter. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. The home should keep of copy of the rota for all persons working in the care home and a record of what is actually worked. The home has taken positive steps to ensure that staff are trained to the required standards. EVIDENCE: A record is kept showing care staff on duty at any time of the day and night. However there is no ongoing rota kept for additional staff that works at peak times. The homes management team provides any additional rota cover. There is no ongoing rota kept for domestic staff and the inspector spoke with the manager about this issue. There are two waking night staff the home has a third person on call. Two of the homes senior care assistants hold NVQ Level 3 and two staff are ongoing in working towards this qualification. NVQ level 2 is either achieved or ongoing for the remainder of the care staff team. The employment records were looked at for three staff as part of the inspection. All records had the two required references and the necessary police checks had been completed. Staff have received a copy of the code of conduct and practice set by the GSCC. The home is in the process of recruiting a volunteer. The inspector was advised that any volunteers would undergo the relevant recruitment, selection process that will include the required police checks. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 17 The home presently has a training officer and offers an ongoing training programme. All new staff receive induction training, and the home offers a detailed training programme that is specific to the needs of the service user. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36,37,and38. It is positive to see that the home actively seeks feedback from service users via the homes annual questionnaire and regular consultation with individual service users; however, this feedback may be improved if the home was to consider service user meetings. The home should continue to give service users the opportunity to help maintain their own personal records. The home must commence the recording emergency lighting checks on a weekly basis. EVIDENCE: The managers advised the inspector that they are continuing to work towards the NVQ Level 4 in management and care. The manager advised the inspector that annual questionnaires given to service users and their relatives are responded to; an example of this is the home purchasing a cordless telephone following a suggestion by a service user. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 19 The inspector was advised that the home has tried service user meetings in the past but did not find them successful. The manager explained that service users are spoken to daily by the manager and asked for feedback regarding services within the home. The inspector observed service users and their relatives being advised that the home was undergoing an unannounced inspection. Service users financial records were checked on the day of inspection. Written records are maintained for individual service users monies and receipts are kept. Service users monies and any valuables were seen to be stored securely on the day of inspection. Formal staff supervision is completed for all staff. The inspector saw evidence of this in three staff records. The manager advised the inspector that any volunteers would be given formal supervision and induction training. The homes manager informed the inspector that service users have access to their records and the opportunity to contribute to their personal records. The inspector observed in care records that one service user had contributed to their own plan of care. The manager informed the inspector that the annual movement and handling training had taken place in February 2005, that all senior cares and night staff have completed First Aid Training. Staff receive fire safety training as part of their induction training and take part in fire drill training. Fire tests are completed weekly and although emergency lighting is visually checked on a daily basis, these checks are not recorded weekly as is recommended. The requirement from the last inspection relating to the safe storage of COSHH products is met, and all such products are stored safely. Certification relating to Gas and Electric (PATS Testing) is up to date. Risk assessments were seen in place and the inspector was advised that these are updated six monthly or more regularly if required. The inspector observed service user and staff accident records. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 2 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x x 2 x 3 3 3 2 Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 21 no Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2) Timescale for action The registered person shall make 27.4.05 arrangements for the recording, handling, safekeeping , safe administration and 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. 3. 4. 5. 6. 7. Refer to Standard 3 7 8 18 24 26 27 Good Practice Recommendations Service users should be consulted as soon as possible following admission in order that a plan of care can be formulated The home should continue working towards ensuring service users daily records are person -centred and staff evidence how service users needs have been met. Pressure area care should be documented in the individual care records aswell as the district nurse care notes. Service users or their relatives should be advised when their money reaches the homes liability limit. The cabinet in the identfied bedroom should be risk assessed or moved. The home should address the odour to the identified bedroom. A recorded staff rota showing which staff are on duty at any time during the day and night and in what capacity is J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 22 Willow House 8. 9. 33 38 kept. The home should consider service user meetings to provide the opportunity for group discussion. Emergency lighting checks carried out by the home should be recorded weekly. Willow House J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 J51J01_s26298_Willow House_v223751_270405.doc Version 1.30 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. 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