Inspection on 21/02/06 for Willow House - City of York Council

This inspection was carried out on 21st February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willow House - City of York... 09/09/08

Willow House - City of York... 23/10/07

Willow House - City of York... 09/11/06

Willow House - City of York... 08/11/05

Willow House - City of York... 25/02/05

Willow House - City of York... 16/10/04

Willow House - City of York... 27/02/04

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

CARE HOMES FOR OLDER PEOPLE Willow House - City of York Council Willow House Long Close Lane Walmgate York North Yorkshire YO10 4UP Lead Inspector Jean Dobbin Unannounced Inspection 21st February 2006 09:20 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 - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 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 - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow House - City of York Council Address Willow House Long Close Lane Walmgate York North Yorkshire YO10 4UP 01904 630 437 01904 466232 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) City of York Council Mrs Joyce Handy Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: Willow House is a care home on two floors, which was purpose-built about 40 years ago and is run by City of York Council. It is situated less than 15 minutes walk from the centre of York, inside the historic city walls, and with Walmgate Bar close by. There are small shops and a public house within a short walking distance. The home provides personal care for 32 residents aged at least 65, who do not require specialist care. There is also 1 short stay bed. Bedrooms are located on both floors, with a vertical passenger lift to aid access. The lawned gardens with seating areas lead onto the bar walls and there are car parking facilities on site. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This summary relates to an unannounced visit on Tuesday 21st February 2006. The inspection lasted over 6 hours including preparation time. The manager was present for the whole of the visit. There was the opportunity to examine some residents’ files and look at how those residents’ needs are addressed. Policy documents and the recruitment file of the newest employee were also looked at, as well as the home’s accident record book. There was a tour of the home and the opportunity to observe staff interacting with residents, both in a caring situation and at lunchtime. Much of the time was spent talking with residents, members of staff, a relative and two visiting healthcare professionals. What the service does well: What has improved since the last inspection? There is ongoing development of the care plans to address individual needs. Suggestions from meetings held within the home generate small changes. There are growing links with community groups to further develop social events at the home. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 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 - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 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 - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prospective residents have the opportunity to discuss what help they will need prior to moving to the home. EVIDENCE: A number of service files were examined and residents were asked about the process prior to moving to Willow House. All the files looked at had a preadmission assessment in place. One resident recalled being visited in hospital and being asked about the help they needed. They said that they had been reassured by the process and had felt safe when moving to the home. Another resident said there had been a discussion at their home, which made them feel less anxious about having to leave their home. Another said that an unplanned short stay confirmed that the move was the right one for them. Residents can feel confident that staff will discuss whether their needs can be met, prior to making the decision whether to move to Willow House. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 Residents’ personal, social and health needs are well addressed, however further risk assessment development would help identify residents who are at greater risk. EVIDENCE: Four service files were sampled during the inspection. These demonstrated that residents had individual care plans, which were fairly consistently presented, so were easy to read. The short stay residents rely on their pre admission documentation to identify their needs, but staff must ensure risk assessments are completed to enable carers to provide safe, appropriate support. Care plans are generally reviewed monthly. This review should where possible include discussion with the resident, who can then say what is important to them. Staff can then make sure that the plans are still valid and appropriate. One resident said that they assumed that there was paperwork about their care but it had never been discussed with them. There are some risk assessments in place, however the staff have no way, currently, of recording the weight of the less able residents to ensure that they are maintaining a stable weight. Sitting scales are required for this purpose. Residents can then be reassured that their health is being monitored. The accident book showed that several of the residents had had what appeared to Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 10 be simple falls within the home. Residents need ‘falls risk assessments’ to enable staff to explore whether subsequent events could be prevented. At this time the home uses ‘working files’, where current documentation of several residents are stored in one file, for ease of access. This is not good practice and all residents should have an individual file to comply with data protection law. (All residents already have separate files where less current information is stored). Residents said that they could request a visit from their GP if they wished. A visiting GP commented that they felt the home provided a good service, with prompt and appropriate referrals to them, when necessary. There was evidence of these referrals in the files. Another visiting professional was very complementary about the home. They felt staff were very ‘on the ball’ and knowledgeable about the residents. This suggests that time is spent talking with individuals to understand what matters to them. Residents can be reassured that their own particular health and personal needs will be discussed and recorded. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Residents say that the lifestyle and choices offered at Willow House are all that they could have hoped for. The meals are well presented and varied, with residents’ preferences being addressed when possible. EVIDENCE: Residents spoken with said they were happy living at Willow House. Comments included “I love it here,” and “I’d recommend it”. There are a number of sitting areas including a lounge for those wishing to smoke. Several of the bedrooms are very individual, with staff recognising that resident’s choice may mean that the room is homely, comfortable and personalised rather than well decorated, or easy to maintain. Residents can see their visitors at any time, and several walk to the local shops or pub. There are some activities organised within the home such as games, social evenings and music ‘sing-alongs’. There are links with community groups, with staff looking to develop these further. One resident wished for more contact with her local church and another talked about her old links with the Salvation Army. The manager was receptive to exploring these suggestions. Residents spoken with felt that the staff had time to talk with them and that the home supported them in maintaining their chosen lifestyle Residents were generally complementary about the meals at Willow House, which has a two-week rotating menu. The dinners are not prepared on site Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 12 and the manager has worked with the external catering service to ensure there are appealing menu choices for the residents. There are continental-style breakfasts, with a cook preparing the evening meal, which includes home baked cakes. Residents say that alternatives at teatime are available if the menu choices are not liked. The staff can provide simple hot snacks at lunchtime, as an alternative to the cook/chill meals provided, if the resident wishes. The cook reported that she does not actively ask for residents’ views about the meals she prepares, and this could be an area for her to develop. The manager, however, is able to gain feedback from residents, both informally, in meetings and through communication with her staff. Actively encouraging residents’ views enables participation in menu development. One resident said that they wished they could have egg and bacon for breakfast now and again, and the manager said that this could be looked at. At lunchtime one resident was observed being assisted by a carer, who was stood up at the table. Carers need to be seated whilst assisting at mealtimes, showing their commitment to, and importance of the task. The resident can also see the carer, there is the opportunity for improved communication, and they are more able to make choices about what they eat. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents have their complaints acknowledged and treated seriously; and staff are alert to any signs of abuse that may be carried out against residents. EVIDENCE: There have been no complaints at Willow House since the last inspection. All residents spoken with were clear about whom they should speak with if they had any concerns that needed addressing. They were also all confident that their problem would be taken seriously. One relative spoken with was also aware of the policy. They said that they did have a concern some time ago, but they spoke with the manager, who resolved the issue promptly and appropriately. They said they had “every confidence” in the complaints process at Willow House. Residents can be reassured that complaints will be taken seriously. Staff spoken with, were aware of their responsibilities in responding to an allegation of abuse and also recognised the seriousness of such an event. Residents can feel confident that staff are alert to any signs of neglect. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 Residents live in a clean, well-maintained home, free of unpleasant odours. EVIDENCE: Residents live in a clean and well-maintained environment. There was no evidence, when walking around the home, of soiled articles being handled inappropriately. Staff spoken with, were aware of their responsibilities in preventing the spread of infection by good practice. The laundry area was clean, organised and locked, when not in use. Staff were knowledgeable about how soiled items are washed. Those toilet areas seen were very clean and uncluttered. There were no malodours. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 15 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): 29 There is a robust recruitment policy designed to protect residents, however employees records must be stored within the home. EVIDENCE: The recruitment file of one of the newest employees was examined. Although there were two references in the file, the application form was missing. When this was obtained urgently by fax from York Council offices, at the inspector’s request, the documentation was still incomplete, and it was not known why there were gaps in their employment record. The employee is from overseas, however there was no evidence to show whether any checks had been made to ensure their suitability to work with vulnerable adults. York City Council has a robust recruitment policy however the complete documentation must be kept at the home (A requirement from the previous inspection). The recruitment policy ensures that residents are in safe hands. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 16 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): 37 Documentation recording residents’ personal details and care needs should be stored in separate files EVIDENCE: Standard 37 was not fully inspected, however it was noted that the management team use a system whereby current documentation of several residents are combined in one working file. These notes should be separated to ensure that maintaining the confidentiality of residents’ details is not compromised. Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 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 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 X Willow House - City of York Council DS0000034914.V275714.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 Care Standards Act 2000 OP29 Regulation N/A Requirement The Certificate of Registration must be displayed in a conspicuous and public place within the home The registered person must ensure that documentation relating to staff, and outlined in Schedule 4, paragraph6, is available and maintained within the home Timescale for action 01/04/06 2 17(2) 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Falls risk assessments should be carried out on all residents to identify those at greater risk of falling in order to try to put systems in place to reduce the risk Residents should have their weight monitored, according to their risk assessment, to ensure staff are alerted to changes. All documentation relating to individual residents should be stored in individual, named files. DS0000034914.V275714.R01.S.doc Version 5.1 Page 19 2 OP37 Willow House - City of York Council Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. 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