Inspection on 11/08/09 for Willow Tree Nursing Home

This inspection was carried out on 11th August 2009.

CQC 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.

Other inspections for this house

Willow Tree Nursing Home 11/08/08

Willow Tree Nursing Home 12/09/07

Willow Tree Nursing Home 09/10/06

Willow Tree Nursing Home 18/10/05

Willow Tree Nursing Home 20/06/05

Willow Tree Nursing Home 10/11/04

Willow Tree Nursing Home 06/05/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Willow Tree Nursing Home 12 School Street Hillmorton Rugby Warwickshire CV21 4BW Lead Inspector Sandra Wade Key Unannounced Inspection 11th August 2009 08:15 DS0000004415.V376783.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Tree Nursing Home Address 12 School Street Hillmorton Rugby Warwickshire CV21 4BW 01788 574689 01788 551791 carol.mccullough@redwoodcare.co.uk 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) Culpepper Care Limited Carol Anne McCullough Care Home 47 Category(ies) of Dementia (47), Old age, not falling within any registration, with number other category (47) of places Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Oldage not falling within any other category (OP) 47 Dementia (DE) 47 The maximum number of service users to be accommodated is 47. 2. Date of last inspection 11th August 2008 Brief Description of the Service: Willow Tree Nursing Home is registered to provide personal and nursing care for up to 47 people over the age of 65. The home can offer care for a variety of medical conditions including side affects from a stroke, naso-gastric feeding, wounds, paralysis, incontinence, Parkinson’s Disease, Diabetes, and other conditions. Following a recent extension to the home, the service also now accommodates people with dementia. The home is situated in a local suburb of Rugby approximately three miles from the town centre. It is close to local shops and a bus route. The home is set back from the road and there is ample parking available near to the entrance. The single rooms have increased from 26 to 41 and there are also three twin rooms. All rooms have either washbasins or full en suite facilities, which include a washbasin, toilet, bath or shower. There are also communal bathrooms with assisted facilities for those people who are less mobile. Each room has a call bell facility so that people can alert staff if they need assistance. There are two communal lounges and dining rooms and the communal areas are situated at each end of the home. Bedroom accommodation is now available on two floors. There are various outside areas for people to sit including courtyard type garden areas and a patio area which can be accessed Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 5 from the large lounge. The home is staffed by a complement of qualified nursing staff and care assistants. The fees for this home range from £300 to £850, these are published in the Service User Guide. These are subject to change and persons may wish to obtain more up-to-date information from the service. Extra charges are made for hairdressing, newspapers, chiropody, dry cleaning, treatment by dentists or opticians or the purchase of clothing and personal effects. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 6 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 focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This unannounced inspection took place between 8.15am and 8.55pm. Two people who were staying at the home were ‘case tracked’. The case tracking process involves establishing an individual’s experience of staying at the home, meeting or observing them, discussing their care with staff and relatives (where possible), looking at their care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. A completed Annual Quality Assurance Assessment (AQAA) was received from the service prior to the inspection detailing information about the care and services provided. Information contained within this document has been included within this report where appropriate. Records examined during the inspection and in addition to care records, included staff training records, staff duty rotas, kitchen records, accident records, complaint records, financial records, maintenance records and medication records. Because people with dementia are not always able to tell us about their experiences, time was spent in one of the lounges observing what it might be like for people living in the home. Both breakfast and lunchtimes were also observed. A tour of the home was undertaken to view specific areas and establish the layout and décor of the home. What the service does well: The admission process is managed well with people being given the option to make trial visits to the home to make sure they are happy before they decide to stay. Staff are friendly, caring and supportive towards people and positive comments were made about staff. This includes “we are very pleased with the care and attention provided”, “they look after me very well”, “staff are very good”, “if you are alright with them they are alright with you”. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 7 People observed and spoken to during the inspection seemed content and happy with the care they are receiving. There are staff who are trained ‘Assessors’ for the moving and handling of people. This means staff can easily access training in this area to make sure they can move and handle people safely. A good choice of meals and home cooked food is available for people to enjoy. The home has been awarded the “Gold Standard” for their food hygiene inspection demonstrating they are working to high standards in the kitchen. A ‘Quality Manager’ visits the home on at least a monthly basis to monitor the quality of care and services provided and ensure people’s needs are being met effectively. What has improved since the last inspection? What they could do better: Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 8 The Statement of Purpose and Service User Guide holds information about the care and services provided but is not sufficiently detailed and therefore needs to be reviewed. This is so that people can have access to up to date information about the home. Care plans relating to wounds must be clear in demonstrating any progress or deterioration and any wounds the person may have. This is so that staff are clear on what actions are needed to manage these to promote healing. The management of pressure sores (red/broken areas of the skin) must be effective to prevent people from experiencing further deterioration of the skin. Risk assessments must be clear in identifying actions needed to ensure these are managed appropriately. Clear systems must in place for the management of challenging behaviour. Staff need to be clear about which incidents are to be recorded and who they should be reported to. This is so the home can demonstrate that challenging behaviour is being identified and managed appropriately to maintain the safety of other people and staff in the home. The management of medication needs to be improved to ensure the health of people living in the home is maintained. Improved systems are needed to help people with dementia make a choice of meals such as picture menus or showing people the meals they can choose from. This is to help them make the right choice when deciding what meal they would like. The policy in relation to management of abuse needs to reflect current Local Authority guidelines to ensure any allegations are managed appropriately and people are safeguarded. Staff duty rotas need to demonstrate that there are sufficient numbers of staff on duty to provide effective care and services to people consistently. The refurbishment plan in place to address décor in the older part of the home now needs to be carried out. This includes new carpets in bedrooms where these are worn and marked so that people have a pleasant and comfortable environment to live in. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 9 order line – 0870 240 7535. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 10 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 Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 were assessed. People using the service experience good quality outcomes in this area. Information about the home is available to people so they can make an informed choice on whether to stay and people’s needs are assessed prior to their admission to make sure these can be met by staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a combined Service User Guide/Statement of Purpose document available in the home which gives information on the care and services provided. This also contains the summary inspection report and a Statement of the Terms and Conditions for the home to allow a prospective resident to make an informed decision on whether to stay at the home. The manager states in the AQAA provided to us that a copy of the Service User Guide is provided to all prospective residents. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 12 The Statement of Purpose (forming part of the combined document) did not contain all of the required information. The document viewed contained limited information on the accommodation such as lounges, dining rooms, facilities in bedrooms and gardens. There is also no schedule of room sizes as required. There is no reference to any specific facilities or systems in place to support people with dementia and no information about staff being suitably trained in dementia care. Fire/emergency procedures were not detailed only a reference to say these could be obtained on request. The complaints procedure does not include details of the Local Authority where complaints should be directed if people are not happy with responses from the home. This means that information may not be readily available if people should choose to request more detailed information about the home. This document should be kept in an area which is easy for visitors to the home to access. The assessment process was discussed with the manager. She confirmed that each person’s needs are assessed before they come to stay at the home. She explained that this is done in the person’s own home or hospital and sometimes she takes a member of staff with her. The manager explained that in the case of one person that is now in the home they visited them several times prior to them coming to stay. A trial visit was offered which they agreed to and they came to the home for afternoon tea. The person then decided they wanted to stay. Assessment records were available on care files viewed and care needs identified had also been fully detailed in care plan records so these could be met by staff. Due to the nursing and dementia diagnosis of people case tracked it was not possible to discuss the admission process with them to confirm their experiences. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were assessed. People using the service experience adequate quality outcomes in this area. People can be confident that their privacy and dignity will be promoted, but the absence of effective recording and monitoring systems means people cannot be confident their health care needs will be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information recorded in the service’s AQAA states there are “up-to-date completed care plans for each resident which include assessment tools” (these being assessments in relation to risks of poor nutrition, falls and breakdown of the skin which could lead to wounds). There was evidence that care plans are in place and are reviewed at least monthly. However the way care plans are structured makes it difficult to Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 14 always identify people’s current needs. For example, one person’s care plan described a wound to their body. The evaluation sheet listed dates when a number of wounds had been identified. It was not clear which, if any of these wounds, had healed and if the person still had any wounds. There was no wound chart in place to show this. References to dressings being renewed did not consistently state where the dressings were being applied to. A member of staff was able to confirm that the person had two wounds but this information could not be confirmed in the records. The member of staff said there should be a wound chart on the file but could not locate this. There were ‘turn charts’ held on a separate file to the main file and a member of staff said the person was being “turned three hourly”. This was not indicated in care plan records we looked at, there was only a reference to the person being “checked” three hourly. A second care plan file was viewed for a person who had a pressure sore. The pressure sore care plan contained an instruction to staff to refer to the ‘wound care plan’. The care plan stated the person had a red area on their hip. A wound chart showed that over a week later this had developed into a 3cm by 4cm wound. Staff explained the reasons why the wound had deteriorated, but there was no risk assessment detailing these reasons or how staff should manage this to prevent further deterioration of the wound. There was no indication on the records of how often the dressings were to be changed. It was also not evident from the records whether a specialist Tissue Viability Nurse had been contacted for any advice. Staff told us that one person could display challenging behaviour, particularly when receiving personal care and would hit out at staff. A care plan for behaviour was located but there was no specific instruction to monitor this or record any incidents that occurred. A member of staff told us that they used to write details of the behaviours in the care plan and we asked to see this information. The member of staff spent some time trying to find where details of the aggressive incidents had been recorded and found a behaviour chart which was not dated and did not appear to be current. Staff were unable to confirm whether they were recording specific incidents of aggressive behaviour. This means an accurate account of any challenging behaviours may not be identified and appropriate actions might not have been taken to manage this. Records showed us that between May and June this person had lost a significant amount of weight. The June entry on the sheet stated “weigh in one week” there was no evidence seen in records to show this had been done. This would suggest staff were not monitoring the person’s weight as identified in the care plan and the absence of effective monitoring could have placed the person at risk of further weight loss and poor health. The person was weighed nearly three weeks later when there was an increase in weight recorded. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 15 The medication records were viewed for five people. The amount of medication received was not recorded onto the Medication Administration Records (MARs) and so it was difficult to audit whether medication received, given and remaining was correct. One medication prescribed was not available in the medication trolley but had been signed for the day before suggesting it was available then. A member of staff checked the medication cupboards to see if any more was available but there was not. It was not evident that when the last of the medication had been used the day before, appropriate action had been taken to obtain some more. A medication had been prescribed to give ‘half to one’ tablet three times a day. The medication chart was not legible to determine if half or one had been given and it was therefore not clear if this was being given as prescribed. Staff signatures on the MAR chart indicated that medicine had been given when it was not available. A controlled drug’s register was held and showed there was 610mls of one medication remaining. On checking this with a member of staff it was agreed there was actually 745ml remaining. This demonstrates that this medication is not being administered as required and we asked the manager to investigate this. One medication had been prescribed to be taken twice a day but was not being given twice a day as prescribed. The MAR chart had several gaps showing that it was being given “PRN” which means it was being given ‘as required’. One medication pack contained six tablets but there were seven days to go until the end of the medication period. It was not clear whether an extra tablet had been requested for the person so this did not run out. Another medication had five days to go but there was only one tablet remaining. A member of staff checked to see if there was any more and there was not so they re-ordered this during the inspection. The dosage for this medication had been crossed out from two to one, but there was no signature or record of the GP having changed the dosage. It was evident in some instances that staff were signing the MAR charts as well as trying record a code to indicate a reason why the person may not have taken their medication. It was therefore difficult to determine, whether medicine had been given as prescribed or whether it had been refused by the person for whom it was intended. A requirement included in the last inspection report to carry out an assessment of medication has been removed as this no longer meets current Care Quality Commission guidance. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 16 The privacy and dignity of people was maintained during the inspection and no concerns were identified. When using the hoist staff checked people were appropriately covered and talked through the process to prevent them feeling anxious. Staff assisted people to their rooms to provide personal care and changes of clothing. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. People using the service experience good quality outcomes in this area. People are supported to enjoy a range of social activities and meals to promote their health and wellbeing. People are given some choices in how their care and services are provided to help them maintain their independence. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA states that the home has two Activity Co-ordinators and records of activities, celebrations and external entertainers are kept. It was confirmed that two Activity Co-ordinators are employed with one being allocated to each lounge. They also are known as ‘breakfast assistants’ as they help and support people to eat during breakfast time. In the new lounge/dining area where most of the people have dementia, the social activity person was observed to interact well with people around the room. It was clear she had a good knowledge of what people liked to talk about and she gained positive reactions from people when sitting and talking to them. For a Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 18 period of time she had several people seated around a table and discussed a book about a local area. Everyone seemed to enjoy this. She then gave some individual attention to one person who was sitting alone. She asked them if they would like to look at some pictures in a book that they had brought into the home with them. She then spent some time talking about it to them. Care files contained some details of what people liked to do socially as well as social activities they had done. An ‘Activity Schedule’ was available detailing daily activities although staff said this is not always followed. They sometimes decide on a different activity to do. The AQAA states that there has been additional reminiscence resources made available such as a rummage box, dolls and soft toys. It also states that a ‘cinema/activity room’ with large flat screen television and DVD has been developed. This was identified during the inspection. A new vegetable/flower courtyard has been created since the last inspection with raised beds so that people can reach them. The manager explained that people had helped to plant various herbs and vegetables. Those seen included mint, sweet corn, radish, green beans and tomatoes. The home now has chickens which the manager said had been accepted well. A new chicken pen had been built to make sure they did not wander inside the home. Mealtimes were observed and including breakfast where a choice is given each day of cereals and toast as well as a cooked item such as scrambled eggs, bacon and mushrooms or sausage and beans. Menus had been reviewed since the last inspection to include more details on the choice of meals, snacks and drinks provided although it was not evident that picture menus had been considered for those people with dementia. Menus seen showed there was a good range of meals being provided. These included steak and kidney pie, haddock, cottage pie, lasagne, roast turkey all served with vegetables. At lunchtime people with dementia were asked what they would like from two choices of meals. People were not shown the meals to assist them in making their choices. Some people with dementia cannot remember what a meal is just by telling them the name. The meal was a choice of gammon or smoked haddock. Meals looked appetising and people seemed to enjoy them. Although people were given options to make a choice of meals, they were not always given choices in other areas. For example they were given their lunchtime meal with sauces already on them and juice was just poured into glasses without asking if this was what they wanted. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 19 A person spoken to during the inspection said they liked the food. Some people needed to be assisted to eat by staff and this was done sensitively and patiently. People being assisted seemed to enjoy the meals and adapted cutlery and spouted beakers were being used where required. The kitchen was viewed and good stocks of both fresh and dried produce were available. Records confirmed that the home were awarded the ‘Gold’ standard for their food hygiene inspection demonstrating they are working to high standards in the kitchen. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. People using the service experience adequate quality outcomes in this area. There are systems in place for the management of complaints and abuse but these do not reflect local and current guidance to ensure any allegations are managed appropriately and people are safeguarded. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection we have received two complaints. These were about the management of care for two people. Both of these were investigated by Social Services with the co-operation of the provider. Suitable responses and actions had been taken by the home to address these. A complaints procedure is in place and this is detailed in the Service User Guide. This does not include details of the Local Authority where people should have the option to direct their complaints if they are not happy to pursue their concerns with the home. Although the manager had the letters available relating to the complaints it was not evident there was a complaints register in place. This would help to demonstrate that the home are open to receiving concerns by allowing staff to Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 21 record any issues of concern reported to them so they can be followed up accordingly. A policy is in place for managing allegations of abuse but this did not clearly state the reporting process so that it was clear which people must be contacted. This policy also did not fully reflect the Local Authority guidelines in relation to safeguarding people to make sure any allegations of abuse are managed appropriately. Staff spoken to said that if a complaint was reported to them they would refer it to the manager. The same applied to any allegations of abuse. There were no indications that staff were aware of the other people that would need to be contacted in the event of abuse. The AQAA received from the manager states that all staff have received a copy of the abuse policy and have been made aware of procedures relating to abuse. Training records provided do not show which staff have completed training in this area. A member of staff confirmed they had not completed training recently. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. People using the service experience good quality outcomes in this area. The home is subject to ongoing improvements so that all areas are of an equal high standard of décor and people can enjoy a comfortable homely and pleasant environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection an extension has been built onto the home creating a number of additional bedrooms, a new lounge/dining area, ‘cinema/activity room’ new kitchen and new patio/courtyard garden areas. The new second lounge/dining area is large, spacious and light with wooden flooring and new furniture. It has a large flat screen television on the wall and Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 23 various seating areas with sofas as well as chairs. There is a good choice of places to sit and there is clear picture signage around the building to direct people with dementia to where they may want to go. There are mirrors, clocks and pictures on the walls as well as flower arrangements to make the communal areas look more homely. The new bedrooms are furnished to high standards and have flat screen televisions with connection points for sky and internet (which can be used on the television screen) and a private telephone. Bedrooms are on two floors and there is a passenger lift to ensure people with mobility problems can access their rooms easily. The entrance to the home is currently laid with stones which can be difficult underfoot for some people. The provider explained with all the extension works they needed the ground to fully “settle” before the final surface is completed. There are however some areas that are paved to help people with mobility difficulties or who are in wheelchairs access the home more easily. The home has under floor heating which can be controlled from each individual bedroom and there is a ‘sprinkler’ system in place to protect the home in the event of a fire. There are various outside areas for people to sit out and enjoy including a vegetable garden with radishes, parsley, sweet corn and strawberries etc. In the older part of the building some of the carpets look worn and marked and need to be replaced. The provider said that a refurbishment plan was in place for the older part of the home to raise the standard of décor to that of the new part. The hot water taps checked in two rooms were running cold water although the provider established it had been hot in the morning. The provider agreed to investigate this and take any necessary actions to make sure the people in these rooms had hot water. Since the last inspection new equipment has been obtained for the laundry to support the laundry needs of the home effectively. There were clearly identified baskets for dirty and clean washing. Red bags which disintegrate in the washing cycle were also available for heavily soiled items. The handwash sink was blocked by red bags and containers preventing staff from accessing this to wash their hands. The manager said that the containers were due for collection. During the tour of the home bedrooms viewed did not have hand towels and face flannels available. The manager explained these had been removed for washing and would be replaced when people returned to their rooms in the Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 24 evening. This means that if people choose to return to their rooms during the day they do not have these facilities available to them. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were assessed. People using the service experience adequate quality outcomes in this area. The needs of people are being met by the staff but it is not clear the deployment of staff and staff training is consistent to support people effectively and safely at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: At the time of this inspection there were 41 people living in the home so the home was not operating at it’s full capacity. Staff were busy throughout the day undertaking their duties and were caring, friendly and supportive towards people when assisting them. A questionnaire returned to the home from a relative stated “X has only been in Willow Tree since X we are very pleased with the care and attention provided”. A person spoken to during the inspection said “they look after me very well” and “if you are alright with them they are alright with you”. Visitors spoken to during the inspection said they thought there were enough staff around and stated “staff are very good”. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 26 Staff are allocated each day to the different areas of the home. They aim to have one nurse and three or four carers plus a breakfast assistant on duty during the morning and one less carer in the afternoon. At night there is one nurse who works across the home and three or four carers depending on the needs of people. The manager said it was planned that they would have two nurses at night when the numbers increase. Duty rotas seen confirmed that most of the time these numbers are achieved but there are occasions when they are not which means we cannot be sure there are sufficient staff on duty consistently. During the four weeks commencing 19 July to 15 August there were three occasions when the manager is indicated to have worked as the second nurse as opposed to working in a supernumerary capacity as required. This means that the manager would not have been available to cover any management duties or emergencies as she was working as the second nurse on the floor. This issue has been raised with the manager during previous inspections to the home because this practice could place people in the home at risk. There were two occasions when there were five carers on duty during the morning and not six or seven that the manager aims to provide. There were two nights where insufficient numbers of carers are indicated on the rota. Although an “N” is indicated on the bottom of the rota suggesting extra staff are needed there are no names of staff or agencies listed to confirm these staff were obtained. A member of staff spoken to said there were “just” enough staff and the “mornings were the worst”. It was suggested that they would like more time to spend with people between completing all of their duties. Since the last inspection the home have introduced a new “Check It” system which means each time staff enter a bedroom to support someone this is recorded on a hand held device. The device generates questions for staff to answer so it is clear what support was given such as providing a drink, toileting or turning them in bed. This information can then be uploaded onto a computer system which the manager is able to view. This helps her to determine how much support people need and if extra staff are required. As this system is new and still in the process of being fully established, the outcomes of this were not evaluated. The home employs specific staff to do catering, laundry and cleaning. Duty rotas showed that staff are not available each day to complete these duties. There are no domestic staff included on the rotas at weekends and a laundry person only works three days per week over a two week period. Staff rotas show that kitchen staff finish their shift at 2pm so it is not clear who completes kitchen duties after this time. This issue was raised at the last inspection and a recommendation made for duty rotas to clearly demonstrate sufficient staff are available to cover these services effectively. The manager advised that a new Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 27 laundry person was due to start working in the home the day after the inspection to help improve this service. A review of two staff files was undertaken to confirm that the staff recruitment process is managed appropriately to safeguard people living in the home. All of the required records were in place including Criminal Record Bureau (CRB) checks and two written references. A list of staff that had completed a National Vocational Qualification II in Care was provided by the manager. The National Minimum Standards stipulate that 50 of staff should have achieved this. This list showed that out of 25 staff, twelve staff had completed this training and more were either completing it or were on a waiting list to do this. The manager said that new staff complete induction training based on the “Skills for Care Common Induction Standards”. This training allows staff to build up their competencies over a number of weeks so that they can care for people safely and appropriately. Training booklets were seen to confirm this training was in place although no completed booklet were seen. The manager said that staff keep these themselves and she ‘signs off’ each section when staff have achieved the level of competency required. The Annual Quality Assurance Assessment (AQAA) document forwarded to us does not indicate that any new staff have completed this induction training despite there being a number of new staff who have commenced working at the home since the last inspection. The manager explained that if staff have an NVQ qualification when they commence, then they would complete a more basic induction training so they are not repeating training they have already done. The manager told us that the senior care staff and quality manager complete in-house training and they also have three in-house manual handling training assessors. This means that these staff can assess carers when moving and handling people and when using the hoist to make sure they are doing this in a safe way. A training schedule completed by the manager shows that there are some staff that have not completed all the statutory training such as food hygiene, fire and moving and handling. A member of staff spoken to confirmed they had completed moving and handling training but not food hygiene and fire training. The manager has acknowledged in the AQAA that increasing staff training is something they could do better. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 28 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 and 38 were assessed. People using the service experience adequate quality outcomes in this area. People cannot be confident that the service is always being managed in their best interests. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a registered manager that is qualified and experience to manage the home. She is supported by a deputy manager and duty rotas show that at least one of them is available six days per week. The manager has attained the National Vocational Qualification IV in Care qualification as well as the Registered Managers Award and has worked in the home for many years. She became the manager of the home in 2002. The manager regularly attends Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 29 training to update her knowledge to ensure the home can continue to be effectively managed. Since the last inspection she has completed training in “managing difficult people and situations, medication and care plans, safe use of bedrails, fire safety and supervision” Further training had also been organised including dementia care. This inspection has highlighted some management areas which need to be improved. We did not receive the AQAA from the home when we asked for it and we made the manager aware of the importance of returning this in the timescale given so we have the opportunity to request questionnaires from people who use the service or their representatives. The information we receive from surveys helps us to further support the inspection. Medication management has not improved since the last inspection. It was not evident sufficient actions have been taken to ensure this is managed effectively. Duty rotas still do not contain sufficient information about staff available. Therefore people who use the service cannot be sure there are always sufficient numbers of staff on duty to meet their needs. Records show that statutory training is still not up-to-date for staff working in the home. It is also evident that the manager continues to work on the floor as a second nurse as opposed to in a supernumerary capacity. This means the manager is not always available to complete management tasks. These ongoing issues must be addressed to ensure effective management of the home. Quality monitoring of the service includes sending out ten questionnaires every six months to people and their representatives for completion. This year eight responses in total had been received out of the twenty sent. This quality monitoring system is not reaching all people living in the home and their representatives on an annual basis which means the home are receiving limited independent information on the quality of the care and services from people using the service. The manager says she sees people and talks to them so knows what there views are but these views cannot be demonstrated to us or members of the public. The manager advised that relative meetings are no longer held due to poor attendance. The quality manager does however visit the home regularly to undertake her own quality monitoring. Records showed that she speaks to two people who use the service as well staff and reviews records and the environment. She completes a report of these visits and gives it to the manager so that she can follow up any actions as appropriate. No concerns were raised by staff, people living in the home or visitors during the inspection. Visitors spoken to said that any requests they made of staff were carried out and they were “happy” with the home. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 30 There were thank you cards on display in the reception area, one stated “thank you for all the care and attention and understanding shown to X and myself during our stay at Willow Tree”. Another stated “Thank you for all you did for dad. His days with you were made special because he was allowed to live his life the way he wanted, he was so happy there”. Systems for managing people’s money are in place. This includes an invoicing system as well as “pocket money” accounts. Receipts are obtained for any transactions undertaken and records viewed were accurate in relation to transactions undertaken and money remaining. A review of accidents and incident records was undertaken. It was not evident that those accidents which could impact on the wellbeing of people or which involve medical intervention are being reported to us as required. The manager agreed to address this. A review of the Health and safety checks confirmed these had been carried out within the appropriate timescales. This included checks for gas, electrics, hoisting equipment and the lift service. Water temperatures had also been monitored and recorded to ensure these were not too hot to scald people. Since the last inspection a new maintenance “Check It” system has been introduced. This involves the use of a hand held device which the maintenance man uses each time he checks equipment. For example when he enters a bedroom he enters the bar code into the device from whatever piece of equipment he is checking such as the bed or wheelchair. This then generates a series of questions which have to be answered to show that the piece of equipment has been checked and is safe. This information then is transferred from the device onto a computer so that the manager and provider can check all maintenance checks have been carried out as required. Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 31 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 32 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 OP7 Regulation 15 Requirement There must be clear records of how challenging behaviour is to be monitored and managed. This is to ensure a safe and consistent approach by staff in protecting people in the home. The Care plan/Risk Assessment documents must include clear information on how wounds and pressure areas are to be managed. This is to ensure there is a safe and consistent approach by staff in providing care. Medication must be administered as prescribed so that people who use the service can be confident that their healthcare needs are being met. Medication Administration Records must show when medication has been administered and must also include the reason why any medication was not administered as prescribed. This is so it is DS0000004415.V376783.R01.S.doc Timescale for action 29/11/09 2. OP7 15 29/11/09 3. OP9 13 14/11/09 4. OP9 13 14/11/09 Willow Tree Nursing Home Version 5.2 Page 33 clear how the person’s medication has been managed. 5. OP9 13 Staff must record the amount of medication received so a regular audit of medication can be carried out to show people have received their medication as prescribed. Action must be taken to ensure sufficient medication is readily available to be administered as prescribed. This is so people are not placed at risk of not having their medication. Staff must complete statutory health and safety training and attend regular updates. Training must include, basic food hygiene, moving and handling and the prevention and control of infection, so that the service can be confident that staff have the knowledge and skills they need to safeguard the people who use the service. Accidents and incidents which require medical intervention and impact on the wellbeing of people must be reported to us. So that people who use the service can be confident that the service is being managed in their best interests. 14/11/09 6. OP9 13 14/11/09 7. OP30 18 13/12/09 8. OP37 37 14/11/09 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 OP14 Good Practice Recommendations Systems for determining choices of people with dementia need to be reviewed. For example picture menus and DS0000004415.V376783.R01.S.doc Version 5.2 Page 34 Willow Tree Nursing Home showing meal choices at mealtimes. This will help promote choice and help them to accept meals they will enjoy. 2. OP16 A complaints register should be available to staff where records can be kept of any complaints received, investigated and resolved. Records should show the timescales, investigation process and outcomes to demonstrate these have been managed effectively. The complaints procedure should include the Local Authority contact details so that complainants can refer any concerns to them for investigation if they wish. The procedures for managing any allegation of abuse should clearly state the reporting process and how this is to be managed (in addition to reporting any incidents to the provider). This is so that staff are fully aware of what happens when an allegation of abuse is reported and are clear on their responsibilities in protecting the person. Hot water in bedrooms needs to retain its temperature so it is warm enough for people to wash in comfort. Hand towels should be made available at all times so that people can dry their hands. The worn and marked carpets in the bedrooms around the older part of the home should be replaced as soon as possible so that people can live in a pleasant and homely environment. An additional nurse should be employed so that the manager can work in a supernumerary capacity. This will ensure she has the time needed to focus on the management of the service and be available to respond to any emergencies. Duty rotas need to be consistent in showing who is on duty each day. This is to demonstrate there are sufficient numbers of care staff as well as ancillary staff on duty to meet the needs of people living in the home. Training schedules should be sufficiently detailed to show that staff are completing statutory training as well as training in relation to the needs of the people using the service. This includes suitable training in dementia care. Quality monitoring systems should enable all people who use the service, their representatives and/or other interested parties to have the opportunity to express their views on the quality of the care and services being provided. The outcome of any quality audit should be made available to stakeholders and used to improve the service. DS0000004415.V376783.R01.S.doc Version 5.2 Page 35 3. OP16 4. OP18 5. OP19 6. OP19 7. OP27 8. OP27 9. OP30 10. OP33 Willow Tree Nursing Home Willow Tree Nursing Home DS0000004415.V376783.R01.S.doc Version 5.2 Page 36 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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