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Inspection on 09/09/08 for Willow House - City of York Council

Also see our care home review for Willow House - City of York Council for more information

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Adequate service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People said the home provided a friendly and welcoming environment for them to enjoy and they receive care in a way that respects their privacy and dignity. Comments received included: "The home has a brilliant atmosphere and a good bunch of residents"" The food is always good I can have more if I want it". " The staff are lovely" " The home motivates people to promote self care" A complaint`s procedure is in place to make sure that concerns raised are investigated and dealt with. Staff are dedicated and they pick up extra shifts to help ensure that people are looked after by staff who know their needs well. They also raise funds so that people in the home can have entertainers to sing to them and Christmas presents bought for them. Training for staff is provided to make sure that care staff have the skills they need to give care safely.

What has improved since the last inspection?

Care documentation for everyone living in the home is being rewritten in greater detail, this has given care staff a lot of extra work but helps to make sure that people`s full needs are known and can be met. Medication that has to be stored at fridge temperature is now stored in a medications fridge, to make sure the medicines remain active to treat people`s condition. Staff are careful to maintain people`s confidentiality, which protects people`s privacy. Health care products are stored in a locked area, which ensures they are kept safe and are ready for use. Fire risk assessments are in place and work highlighted as being required is being prioritized to make sure people`s health and safety will be protected.

CARE HOMES FOR OLDER PEOPLE Willow House - City of York Council Willow House Long Close Lane Walmgate York North Yorkshire YO10 4UP Lead Inspector Denise Rouse Key Unannounced Inspection 9th September 2008 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 - City of York Council DS0000034914.V369379.R02.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 - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 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) www.york.gov.uk 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.V369379.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 2007 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. The home provides personal care for people aged at least 65, who do not require nursing care. There is also 1 short stay bed. Willow House 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. Bedrooms are located on both floors, with a passenger lift to aid access. The gardens have seating areas and there is a new patio with a conservatory overlooking Walmgate Bar and the Bar Walls. Fees range from £102.90 to £457.40 per week this information was provided on the day of the site visit. Additional charges are made for hairdressing, chiropody services and individual items like toiletries. The service provides an information booklet about the home to prospective people thinking of using the service. Information in the statement of purpose, service user guide and last inspection report is available to people so they can make a decision about if the home is the right place for them. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The accumulated evidence used in this report has included: • A review of the information held on the home’s file since its last key inspection. • Information submitted by the registered provider in the Annual Quality Assurance Assessment. (AQAA) • Surveys received from four people living at the home, and one health care professional. • An unannounced visit to the home, which lasted six hours, undertaken by one inspector, which included a full tour of the premises. • Evidence gained by direct observation during the site visit. This involved talking with people living at the home, the manager, administrator and other members of staff as well as one health care professional. Inspection of records, including care profiles, medication administration records, staff files and some of the home’s policies and procedures. • We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People said the home provided a friendly and welcoming environment for them to enjoy and they receive care in a way that respects their privacy and dignity. Comments received included: “The home has a brilliant atmosphere and a good bunch of residents” Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 6 “ The food is always good I can have more if I want it”. “ The staff are lovely” “ The home motivates people to promote self care” A complaint’s procedure is in place to make sure that concerns raised are investigated and dealt with. Staff are dedicated and they pick up extra shifts to help ensure that people are looked after by staff who know their needs well. They also raise funds so that people in the home can have entertainers to sing to them and Christmas presents bought for them. Training for staff is provided to make sure that care staff have the skills they need to give care safely. What has improved since the last inspection? What they could do better: Pre admission assessments undertaken should be available on each persons file, so that it is available for staff to refer too. Care plans and risk assessments should be reviewed monthly or as a persons needs change to make sure people’s current health care needs are being met. Medication procedures should be monitored to make sure systems are in place to protect staff and people living in the home. Staffing levels and the dependency of people living in the home should be reassessed to make sure that people can receive care when they want it. Management should make sure that staff can carry out activities and Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 7 undertake the laundry services, without the provision of care being adversely affected and without staff being placed under pressure. 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 - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 8 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.V369379.R02.S.doc Version 5.2 Page 9 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): Standards 3 (6 not applicable) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are fully assessed before they are offered a place in the home; this makes sure their needs can be met. EVIDENCE: Pre admission assessments are carried out by staff who are experienced at assessing people’s individual needs. The assessment provides basic information about people’s needs and their preferred social activity. Information from care managers and discharging hospitals is gained which helps to make sure people’s needs are known and can be met. Admissions are not made to the home if the assessment indicates that people’s needs cannot be met. Emergency admissions do not occur without a pre admission assessment being undertaken or the care manager providing a current care plan, to make sure that staff know what care is required. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 10 On the day of the site visit, we looked at three people’s care plans. Only one of the three people had their pre admission assessment on file. The manager assured us that these assessments had been done, but could not find them at the time. These assessments should be available to staff to ensure they have all relevant information about people’s needs. The statement of purpose, service user guide and the last inspection report is available to people. Prospective residents are able to visit the home, and stay for a meal, a day or a trial period. The manager and staff spend time with them to answer their questions, to help them make a decision about if the home is the right for them. Surveys received indicated that 50 felt they had not received enough information about the home. However two people who’s care we looked at in detail said they felt they had received enough information to make an informed decision about the home. Two other people spoken with also said they too had enough information and was assured their needs could be met. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 11 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): Standards 7 8 9 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care and their privacy and dignity is respected. However there are shortfalls relating to reviewing care plans and some medication practices, which may place some people at risk. EVIDENCE: Care documentation is being re written for all people living in the home. Care profiles we looked at were at varying stages of completion. Three people’s care documentation was inspected, care plans and risk assessment where in place although all had not been reviewed monthly. This review should be documented; to make sure people’s current needs are known and are being met. Assessments are undertaken that help people mobilise and to maintain a good diet are in place which helps maintain people’s independence and keep them Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 12 healthy. There are disclaimers for people who do not wish to be disturbed by staff during the night, which makes sure people’s privacy is respected. Care reviews are held by the manager with the resident and their family and social worker six weeks after a person is admitted, to make sure people are happy with the care and service’s they are receiving. Any issues raised at this review are acted upon. People are addressed by their preferred name. People spoken with said staff treated them with respect. One person said “ I get one bath a week, staff are not embarrassed, and I am not embarrassed, you get in the bath they do their chores”. Staff respect peoples individuality, there was many occasions seen where staff had friendly banter with people living in the home. People seemed to enjoy this and it meant there was a very homely atmosphere. Staff addressed people by their preferred names. Some people had their bedroom door keys with them, which helps people to feel in control of their home environment. Specialist equipment is available to make sure that people’s individual and special health care needs can be met. This includes profiling beds and hoists. Health care professionals visit the home as required and people are escorted to hospital appointments to ensure their health needs are met. One heath care professional said “ Staff motivate residents to promote self care” and another said “The staff are so good at Willow House, they always keep you informed of any issues so things can be dealt with”. Medication systems in operation were inspected. One member of staff is dedicated to ordering and maintaining the medication systems operating in the home. This takes some time and is good practice this helps to protect people. Staff who give out medication have received training to make sure that their skills are up to date, which also helps protect people. A monitored dosage system is used. We looked at four people’s medication administration records (MAR). One person was on Warfarin, a blood thinning medicine. Their yellow dosage card was stored with the MAR and this is good practice. Another person was prescribed a ventolin inhaler; the label for this person’s inhaler was not present. This inhaler was replaced. One person received Temazepam, which was not being recorded in the controlled medication register. This was recorded into the register on the site visit and stored in the controlled medication cupboard for safekeeping. The third person was using their own inhaler, however their care documentation and “ self administration record” said, “staff to medicate”. This was discussed with the team leader. The person was re assessed at the time of the visit to make sure they were able to give their own inhaler safely. This was then documented to make sure staff knew had responsibility for this and to maintain the person’s independence. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 13 Medication returns are documented however, only one member of staff witnesses the returns and the driver signs to say they have been accepted. To protect staff all returns should be witnessed and signed by two members of staff. Medication balances received used to be recorded on the MAR chart however they were not being recorded at present. The care leader undertakes a visual check of the clips upon delivery. The balances of medication’s received should be counted and recorded on the MAR to help protect people. Fridge temperatures were not recorded daily but periodically. These should be recorded daily to make sure that medications are kept at the correct temperature, so they remain active and safe for people to use. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 14 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): Standards 12 13 14 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can choose how to spend their time, and they receive a nutritious diet. However activities provided by staff are not frequent and this may lead to some people’s social needs not being met. EVIDENCE: People’s preferred social activities are recorded at the pre admission assessment. Some people have a “ Life profile” One said “ XXX likes to do shopping in the morning uses buses and takes themselves into town to walk through the market”. Another’s said “ XXX likes the radio, television and daily papers, goes to bed around 9.00pm and gets up for breakfast about 8.15 am”. People’s social needs are known by staff however activities happen on an “add hoc” basis when staff have a few minutes, so people do not know in advance when activities may happen. On the day of the site visit care staff came into one lounge and sang to the people who enjoyed this singing along. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 15 There is no activities coordinator at the home. Three staff spoken with said all said they felt that they did not have the quality time available to spend with people to give them social stimulation, as often as they would like. People spoken with said at the home said they knew staff were busy and they did their best to provide some activities. People generally accepted that this was how it was. Some people were surveyed who live at the home and were asked “Are there activities arranged by the home that you can take part in?” One said “usually”, one said “sometimes” and two said “never”. Comments received included “I’m not bothered about activities, we have the TV, I prefer to have a cigarette and watch TV”. And another person said, “ I like to do my own thing for activities”. However management should reassess the situation and ask everyone in the home for their views and act upon their feedback. Particular consideration should be given to those people at the home who have developed confusion or dementia whilst living there, to make sure they are gaining the social stimulation and support they need. The staff at the home have to raise money for people to have Christmas presents and provide entertainers, as there is no activities budget provided. This is commendable. There are some entertainers that visit the home. “Life skills” have been started in the home to provide some activity for those who would like to take part in dusting or baking, to help them feel valued. Some people are very independent and able and can go out for local walks and visit the shops in the area. Some go out with their families and into town. Visiting is not restricted and people who visit are made welcome. People’s religious needs are known and are met. There is visiting clergy as well as a nun who attends the home. A hairdresser visits the home weekly and people enjoy this. A chiropodist also attends to ensure people can have their feet attended to. The dining room is set with linen cloths and is well attended at lunchtime. Lunch is a sociable event. It is provided from the local hospital but there are plans that in future lunch will be prepared and cooked at the home. People spoken with said the food was good and hot enough. Some people who were not well had their meals in their bedrooms, although this was not available generally to people. Those who required a special diet had this provided, high calorie food supplements can be provided at breakfast and teatime in the home. The manager can buy other foods to supplement peoples diets as necessary to make sure peoples dietary needs are met. One person said “ I have no complaints whatsoever about the food”. And another said “ I could have more food if I wanted it, if I did I would be like Billy Bunter” another said, “The night nurses make you a cup of tea”. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 16 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): Standards 16 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home feel confident that issues raised would be dealt with; staff report any possible safeguarding issues, which helps to protect people. EVIDENCE: The complaints procedure is available to people. Complaints would be investigated and documented, and the person informed of the outcome. The manager has an open door policy anyone one can see her to make their views known at any time. People spoken with said they felt comfortable to raise any issues with the staff or manager and felt issues raised would be dealt with. There have been no complaints received since the last inspection. A safeguarding policy is in place. Staff said they knew what to do if an allegation of abuse occurred. Staff receive training in this subject. Staff inform the manager of any potential safeguarding issues. These are passed onto the protection team for their investigation and consideration. This helps to protect people. Checks are undertaken to ensure staff are suitable to work in the care industry. Staff do not start at the home before the result of police checks are known. This helps to ensure that staff who are not suitable to work in the care industry are not employed at the home. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 17 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): Standard 19 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home, which is maintained. People are protected by the infection control methods in place. EVIDENCE: The entrance to the home is secure, to make sure unauthorised people do not gain access. On entering there is a hall and dining room with admistration offices. There is a large dining room and corridors have handrails to help people who are unsteady on their feet to walk independently. Staff and people living in the home give a warm welcome to visitors. There are a number of Lounges on both floors of the home. Two are for people who like to smoke; this gives people a choice of where they would like to spend their time. Access to the first floor is by passenger lift this helps people Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 18 in wheelchairs and these with poor mobility gain access to all areas of the home. Bedrooms are personalised to make them homely. There are a variety of toilets and bathrooms throughout the home, which are located close to lounges and dining areas for people’s convenience. There is an ongoing schedule of planned maintenance and redecoration being undertaken which ensures that the home is pleasant for people who live there. A new conservatory and fenced garden with a patio area has been created. There is a small amount of work to be completed, however the views of Walmgate Bar and the Bar Walls are fantastic and this is a lovely feature, which is enjoyed by people living in the home, especially in summer. The home is clean and there is no malodour. Hand wash facilities are available in all areas of the home to help prevent the spread of infection. The laundry facilities inspected are adequate for the home. Soiled linen is handled correctly to help protect people’s health. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 19 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): Standards 27 28 29 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are looked after by dedicated well-trained staff. However staffing levels should be reassessed to make sure staff can deliver care and activities to people living in the home. EVIDENCE: Staff were friendly and approachable. Most have been working at the home a number of years and say they enjoyed the friendly atmosphere within the home. Staff are dedicated to the people who live there and often work extra shifts to cover staff shortages. Recruitment policies and procedures are thorough to make sure that staff recruited are suitable to work in the care industry. An equal opportunities policy is in place. Staff update their training to ensure their health and safety is protected and that of the people living in the home. There is an ongoing training programme in place. People are usually allocated a “key worker” who helps to support them, however two of the three people who’s records we looked at in detail did not have an allocated “key worker”, so they were being looked after by all the staff. However new people would benefit from a temporary key worker to help them settle into the home. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 20 Staff receive induction training and some have undertaken their National Vocational Qualification in Care. This helps staff feel supported and makes sure they have the relevant skills to give good care. The home has achieved over 50 of care staff that hold an NVQ in care. Some staff have also received training about the Mental Capacity Act this helps to protect people living at the home who have become confused or have developed some dementia. One senior carer is being supported to undertake a social work course; the member of staff appreciated this. Staff meetings are held to gain the views of people working at the home. Local bank staff are available to help the home cover some shifts. However there are currently a number of staff vacancies. Some staff have been recruited but have not started work yet. This is placing pressure on the permanent staff who are picking up extra shifts. Agency staff have also had to be used occasionally to help bridge the gap in staffing levels. Staff spoken with said, “Paper work and checking medication takes time. It would be nice to have a laundry person as I feel guilty when spending time in the office”. Another member of staff said, “ There is a brilliant atmosphere here, and a good bunch of residents. Some residents don’t want activities the majority do enjoy it, there is not enough time, we really need an activities coordinator”. And “ The residents have more needs, some have developed mental health needs and dementia, some courses in dementia are offered, I feel it would be handy to have dementia training for all staff”. And another said, “ There’s only 2 staff on at night time. We could do with more, there’s one senior and a carer for 33 people. However the manager does dig into the budget and put extra staff on when someone is ill, I think the council need to reassess staffing levels”. Another care leader said, “I am very busy at times with issues that occur with people who need attention. These things take us off the floor, and the carers can be quite pushed. When she can the manager helps step into the breach and gives a hand. I was pushed for time. We are particularly short especially over the weekends, we have 3 carers Monday to Friday and only 2 carers on every weekend, there’s no time for activity’s then”. Staff carry out the laundry duties and try and provide activities at the moment they said they are finding this difficult. Staff said they were concerned that people’s dependency’s, especially on the ground floor, had increased and that especially on a weekend when the care staff ratios decreases, staff could be pushed and find this difficult. This must be reviewed to make sure that staff are not placed under pressure and people can receive care when they need it. Staff also have to provide activities and undertaking their laundry duties and management should review this especially at weekends. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 21 People living in the home said “Staff are lovely, there’s now’t wrong with the staff they are lovely lasses, I may have to wait a short time as staff are often busy” Another person also said “ sometimes you have to wait a short time for staff”. Although staff said they were issues with the staffing levels people spoken with said they were independent or staff would be with then after a short time. Staff were experienced and people said staff knew them and knew what they had to do to meet people’s needs in an individual way, which they were happy with. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 22 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): Standards 31 33 35 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is managed by a competent manger and is maintained to make sure it is nice for people who live there. However there are some shortfalls relating to maintaining peoples health and safety. EVIDENCE: The manager is competent and experienced and has undertaken a course in management, which helps her run the home. The company help and support her; with service managers visiting the home regularly to monitor how the home is operating. Staff said the manager was approachable, helpful and supportive and would help them when they were busy. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 23 Quality assurance procedures are in place and these are being strengthened by the introduction of a written audit on all areas of documentation and services provided. This is to be completed from this month onwards and will enhance the checks being undertaken already relating to laundry services, medication procedures and health and safety within the home. People who use the service and their relatives are sent a yearly questionnaire to gain their views about how the home is meeting their needs and to find out about the service people are receiving. The council also carry out a full audit yearly, of invoices, time sheets, safe contents, resident’s monies and audit the property. To make sure the business is being managed appropriately. The manager and extended management team should undertake a review of staffing levels and people’s dependency’s, to make sure that staff are not being placed under pressure and can meet people’s physical and social needs. Management should gain the views of all people living at the home; about the activities being provided, to make sure people’s individual needs are being met. Staffing levels on a weekend should be reviewed to make sure staff can organise some activities if this is requested. This will make sure that all people living in the home are receiving the care and social stimulation that they need. Staff meetings are held. Residents relative meetings are not held, as these used to be planned but people did not attend. The manager has an open door policy and talks with relatives when they attend the home to gain their views. Personal allowance accounts are available for people living in the home if they do not wish to look after their own money. These were inspected and were correct and helps protect people from financial abuse. Health and safety checks and regular maintenance is undertaken to make sure the home remains a nice place for people to enjoy. Fire checks are undertaken and a fire risk assessment has been completed and is in place. Issues raised in this assessment should be undertaken to make sure people’s health and safety is protected. On the day of the site visit two people on the first floor had their bedroom doors held open by wedges, this was discussed with the manager. Fire doors must not be wedged open because if there was a fire the automatic door closures would not work and people would not be protected. Staffing levels should be reviewed along with people’s dependency’s who live at the home. This will help to make sure people’s health and wellbeing is being protected. Especially on a weekend when there are fewer care staff on duty. Any shortfalls found, should be addressed. Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 24 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 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 25 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 OP38 Regulation 12(1) Requirement Fire doors must not be held open by inappropriate means. To make sure that people are protected from harm in the event of a fire. Timescale for action 25/10/08 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 Care plans and risk assessments should be reviewed at least monthly or as a person’s needs change. This will make sure care being given is relevant and what people need. Medications received should be counted and recorded as received on the MAR chart, to protect people. Only medications that are correctly labelled should be administered. Self-administration records should reflect people’s full medication requirements and say if people Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 26 2 OP9 can self-administer inhalers safely themselves. This will promote peoples independence. Temazepam should continue to be recorded and stored as a controlled medication, to maintain good practice. Returned medications should be checked and witnessed by two staff to ensure staff are protected and mistakes are avoided. The fridge temperature should be recorded daily; to make sure storage is being provided within the correct temperature range. 3 OP12 All people in the home should be asked about the activities staff have the time to provide. Particular consideration should be given to people who are confused or have developed dementia to make sure people are receiving the social stimulation they require. There should be continued effort to provide a social programme to make life more varied for all the people living in the home. 4 OP27 There should be further consideration given for a staff member to be responsible for the laundry, so that staff can have more time to give care and organise social activities within the home. Staffing levels should be reviewed, taking into account the need to provide activities and a laundry service. Any shortfalls found should be acted upon to make sure staff are not under pressure and they can provide the services people need. 6 OP38 Work that is required as identified in the homes fire risk assessment should be completed to help keep people safe. 5 OP33 Willow House - City of York Council DS0000034914.V369379.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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