Inspection on 08/07/08 for Willow Lodge

This inspection was carried out on 8th July 2008.

CSCI found this care home to be providing an Good 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.

Other inspections for this house

Willow Lodge 14/06/07

Willow Lodge 27/11/06

Willow Lodge 09/05/06

Willow Lodge 11/01/06

Willow Lodge 11/07/05

Willow Lodge 09/02/05

Willow Lodge 07/07/04

Willow Lodge 04/02/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Willow Lodge Osborne Gardens North Shields Tyne & Wear NE29 9AT Lead Inspector Suzanne McKean Key Unannounced Inspection 8th July 2008 09:00 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 Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Lodge Address Osborne Gardens North Shields Tyne & Wear NE29 9AT 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) 0191 296 4549 0191 296 4570 Willow.Lodge@fshc.co.uk Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (1) of places Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One place is registered to provide respite care and the person admitted may be in either the PD or OP category. One place is registered to provide respite care for named person under pensionable age. One named service user under pensionable age may be admitted to the home. No further admissions are to take place in this category without prior agreement of CSCI. 14th June 2007 Date of last inspection Brief Description of the Service: Willow Lodge is a purpose built care home with nursing that shares the site with its sister home Willow Court. The home is over two floors and each floor has en suite bedrooms, lounges and dining rooms. The first floor is accessible via the stairs or a passenger lift. There are a number of specialist bathrooms, shower and toilet facilities close to residents’ rooms and communal areas. The grounds are flat, and are accessible to wheelchair users. Some local amenities are within walking distance and the home is close to the local bus routes. There are car-parking facilities to the front of the home. Willow Lodge provides nursing and social care to older people. The home charges fees of between £332.94 and £400.78 per week depending upon the needs and requirements of the individual residents. As the home provides nursing care the free nursing care element of the funding is provided in addition to the costs charged to the resident. The home provides information about the service through the service user guide. A copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Willow Lodge DS0000028828.V368059.R01.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 2 star. This means the people who use this service experience good quality outcomes. Summary: This is an overview of what the inspector found during the inspection. How the inspection was carried out:Before the visit: We looked at: • Information we have received since the last visit on 19th June 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 8th July 2008. During the visit we: • • • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. Spoke to residents and their representatives to get their views. Asked for the view of visiting professionals. We told the manager what we found. What the service does well: The manager is very competent and puts the interests of the residents at the centre of his practice. The residents and relatives said that they found the staff Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 6 and manger to be very approachable and made comments such as, “my relative gets good care and I am happy with the home and the staff” and “the Manager always do what he says he will do”. Staff work with people in a way that respects them as individuals and they provide good personal and nursing care. The residents have their nutritional are well needs met from food that is nutritious, well presented and tasty. The residents are very happy with the choices they are given and the standard of the food being served. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willow Lodge DS0000028828.V368059.R01.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 Lodge DS0000028828.V368059.R01.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessment of needs are always carried out and provide sufficient information to ensure residents are appropriately placed and there needs can be met. EVIDENCE: The inspected contained the necessary information to show that assessments are carried out before any resident is admitted to the home. The Four seasons documentation is detailed and contains the necessary information for the staff to make a judgement on offering a place to residents. These assessments then form the basis of the care planning process for the resident. Residents said that they were given the opportunity to visit the home before they decided to move but the majority had relied upon their family to choose for them. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems ensure that health and social care needs are delivered in a respectful way and the care plan documentation shows how this is achieved. EVIDENCE: The manager is not a registered nurse although he does have a good knowledge of the care needs of the residents and has appropriate qualifications to be the registered manager. He has therefore ensured that the nursing care in the home remains of a good standards by having a deputy with extensive experience in nursing older people. The staff have a good understanding of the relative roles and responsibilities of the senior staff in the home and this works well. All residents have a care plan which includes a detailed assessment and a plan of care. Four care plans were looked at as part of the case tracking process and were a good standard. The care plans show that the personal and health Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 11 care needs of the residents are being met. The record of the resident’s fluid intake is recorded effectively and was up to date and accurate. One of the care plans was particularly well developed and was person centred. This was a resident with particularly complex needs and it was noted that the care was well planned and consultation had been carried out with a broad spectrum of professionals as well as the resident and their representatives. Risk assessments are completed for: prevention of falls, wound care, moving and assisting, and there is good care planning around areas such as continence promotion. There is an assessment to look at residents’ food and fluid intake and these show if a fluid balance record is required. Residents access NHS services and facilities as necessary. The care plans showed that specialist advisors are used for individual residents. The home liaises with the General Practitioners who provide care to the residents. The care was being given by staff who were pleasant and courteous and number of residents were enjoying the staffs company. Residents were dressed for the activities they were undertaking and looked smart and tidy. A number of residents were positive about the care being given. An example of this is “Its nice here” and “the staff are lovely”. The care plans contain an improved social assessment. These are completed to sufficient standard to allow staff to plan a good social programme for the individual. Medicines management was appropriate. The staff record the medicines correctly when they are ordered. The prescriptions are then checked when they are received in the home from the General Practitioners and are then sent to the Chemist for dispensing. The medicines received from the pharmacy are checked against the record of what was ordered and prescribed so that any errors can be picked up. Medicines no longer required are disposed of safely. No resident manage their own medication. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are well supported to spend their leisure time and are supported to maintain contact with their families and the local community. EVIDENCE: The home now employs a full time activities co-ordinator. She has extensive experience in care work and is now working in the new role using her skills. There was evidence of an organised social programme being offered and residents when asked felt that “there are things going on if I want to take part”. During both visit the residents were occupied in a variety of ways and were watching television or sitting in the lounges. Some were sitting in their rooms watching television or reading. There are newspapers, magazines and library visits. Mrs Matthews, the social activities co-ordinator was helping the residents in a crafts session and were making mobiles. Some of the were being displayed in the corridor from a previous session. Although not all of the residents were taking part some were sitting watching what was happening with interest. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 13 There is now a loop system installed in the home to assist people with a hearing loss, this is to be commended. The residents said that their visitors are always made welcome, could visit at any time and in private. People are able to bring their own possessions with them from home such as furnishings and keep sakes. This has made their own rooms individualised, reflecting their lifestyles and personalities. There has been a recent survey of the resident’s opinions of the food being offered. A number of suggestions were made and there have been subsequent changed to the menu. The most up to day one is being tried and there are plans to modify it further should it be necessary. The way the menus are presented are particularly good. They are detailed and show the options, which are varied. There is a choice of either a continental or a cooked breakfast and during the first visit the residents were being offered assistance with the meal. It was presented well and the staff were being courteous and helpful. The food was and was tasty and served at an appropriate temperature. Cold drinks were given throughout the meal. Staff served tea or juice to residents during the lunch meal. There was also the opportunity for the residents to have “seconds” and a particular resident had a second helping and said that he quite often did, as it was usually really nice. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is active in dealing with complaints and protection issues and service users’ interests are safeguarded. EVIDENCE: The company has comprehensive policies and procedures available setting out how to make a complaint. This is being followed by the home. The procedure is displayed in the home and the staff knew how to deal with any complaints that are raised with them. The complaints records were clear, and included the investigation and the outcome. The residents spoken to were aware of the complaints policy and said that they would know who to speak to if they had any concerns. There are policies and procedures in place for Adult Protection. The staff have received in house training about how to deal with alleged abuse in the last twelve months and this training is ongoing, as not all staff have received it. There is also now a programme of sending the staff to complete external training from the local authority, a number of which have already attended. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a suitable, well decorated and clean environment to meet service users needs and maintain the safety of the occupants. EVIDENCE: The home was purpose built for the client group and as a result has good-sized corridors and is designed to allow service users to use the entire home with ease and in safety. The decoration is in keeping with the style of the home and the furnishings are suitable for the residents living in the home. There is now an ongoing redecoration plan including identification of equipment and furnishings needed. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 16 The residents spoken to were happy with the decoration and maintenance standards. The home is clean and was odour free. The residents’ bedrooms were personalised reflecting individual choices and preferences and all residents asked about their bedrooms said they were happy with the decoration and that they were kept clean by the staff. All bedrooms have an on suite toilet. The laundry was clean, organised and well equipped. The sluices were tidy, clean and odour free and the disinfectors operational. Staff followed infection control policies throughout the day. The light and emergency call cords were all clean and all emergency cords reached skirting level. There are sufficient numbers of bathrooms and communal toilets for the numbers of resident in the home, however these are now in need of updating and redecoration. One in particular had damage to the tiling and was in an unsafe condition. Another of the bathrooms had a damaged assisted seat and could not be used. The manager has plans to make the bathing facilities more useful for this client group by converting tow bathrooms (one on each floor) into a shower room. This would be a positive way to develop the service. There are lounges and dining rooms on each floor and these were clean, tidy and furnished to a satisfactory standard. They also now have large television screens set onto the wall and can be watched easily. This combined with the loop system improves the enjoyment for the residents. The laundry is separate from the resident’s areas and was organised and clean. The staff have some knowledge of infection control policies and procedures and the acting manager confirmed that they have received training in infection control as part of both the induction and ongoing training programmes. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is very skilled, well trained and competent staff employed in sufficient numbers to make sure that they can provide good care to the residents. EVIDENCE: Staff records are completed in line with the company policies and procedures, including two references and a completed application form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. There has been ongoing success in employing care and domestic staff and the new manager has been appointed although he is not yet permanently in post. The current staffing levels being provided for the numbers and categories of residents living in the home are: 2 6 5 1 3 qualified nurses care staff care staff qualified nurse care staff 8am to 8pm 8am to 2pm 2pm to 8pm 8pm to 8am 8pm to 8am DS0000028828.V368059.R01.S.doc Version 5.2 Page 18 Willow Lodge This number has been previously agreed. There is now adequate domestic and laundry staff employed over a seven-day period. The staff files showed evidence of two references, Criminal Record Bureau (CRB) checks, proof of identity and medical health checks. Qualified nurses have their Nursing and Midwifery Council Personal Identity Number (PIN) checked to ensure they are registered to practice. Care staff are encouraged to complete National Vocational Qualifications in Care (NVQ). The home now has more than the required 50 of care staff who have completed NVQ to level 2 and further progress is being made. Fire instruction and drills for staff is up to date and ongoing training is planned according to the training schedule. Moving and handling training is up to date and ongoing training is planned for continuing to update staff as necessary. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management systems are working effectively to protect service users and staff and to meet their needs. EVIDENCE: The home has been without a permanent manager for some time although one has now been appointed. Mr Collinson the new manager was able to be present during the inspection visits, as he has started working for some f the time in the home prior to taking up his post. He is already familiar with the company’s policies and procedures and was very clear about the improvements he Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 20 planned to make in the home. He must apply to the Commission for Social Care Inspection to become the registered manager once formally in post. Formal supervision for care staff is up to date. The manager takes the necessary action to ensure the health and safety of the service users. This is supported by the policies and procedures and by discussion with the Manager. During the visits the relatives visiting were chatting in a very positive way with the staff. The manger is attempting to make him available for visitors and residents as much as possible, and was observed introducing himself to visitors. The personnel records kept in the home of residents who are receiving assistance to manage their finances are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place. The personal allowance records examined allowed the audit of individual residents moneys to ensure that it is being managed effectively. The home is awaiting guidance to ensure that all residents’ money is kept in a way, which can make sure that they can accrue interest on their savings. The home have taken steps to limit the amount of money held by them and have sought alternative ways of achieving this depending upon the individual residents financial situations. There has been recent improvement in the system of quality control in the home. Each of the homes in the company have been required to complete an extensive audit of a number of areas for example care plans, control of infection and medicines. This is being analysed centrally and an action plan developed to make the necessary improvements. Residents’ personal allowances are held in a central non-interest bearing account. The Company is planning to change the system to enable residents to get interest on their own money. This has not yet happened. The home maintains detailed records of all transactions with cross-referenced receipts. Two people sign all of the transactions. All utility contracts were available and up to date. Accident recording and reporting is in place and the manager is completing monthly analysis. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 21 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 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 13 Requirement The planned improvements must be made to the bathing facilities to make them suitable and safe for the residents to use. Timescale for action 01/10/08 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 OP31 Good Practice Recommendations The manager should progress with an application to become registered with the Commission. Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Willow Lodge DS0000028828.V368059.R01.S.doc Version 5.2 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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