CARE HOMES FOR OLDER PEOPLE
Willow View 1 Norton Court 201 Norton Road Stockton-on-Tees TS20 2BL Lead Inspector
Neil McKenzie Unannounced Inspection 15th December 2005 09:30 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 View DS0000000018.V267477.R01.S.doc Version 5.0 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 View DS0000000018.V267477.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Willow View Address 1 Norton Court 201 Norton Road Stockton-on-Tees TS20 2BL 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) 01642 550935 Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Tracy Elaine Daley Care Home 35 Category(ies) of Dementia - over 65 years of age (35) registration, with number of places Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: Willow View is a care home providing personal care for older people with dementia. The home is situated at Norton Court close to local shops, amenities and public transport. It is approximately two miles from Stockton town centre.The home is a two-storey purpose built building providing 35 single bedrooms all with en-suite toilet facilities.There are two lounges, one smokers lounge, two dining rooms, one sensory room and a pleasant garden area for residents to use.The home provides car parking for visitors.The manager has recently completed the Registration process. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was done by one inspector who arrived at the home without letting the staff and residents know he was going to visit that day. The preinspection questionnaire was returned to CSCI before the inspection. The inspector started the day by being shown around the home by the deputy manager. During the inspection the inspector spoke to two residents, two family members, two care staff, the maintenance worker and the deputy manager. The inspector looked at maintenance, health and safety records. Documentation that included training records, finance records and the staff rota. The inspector observed and noted how staff and residents interacted with each other. The inspection took five hours. The inspector was made very welcome. What the service does well: What has improved since the last inspection?
Since the last inspection there has been further refurbishment of the home providing a more pleasing and comfortable place for residents to live in. New furniture has been brought for both dining rooms, the upstairs dining room has a new wooden floor, and the residents smokers lounge has a new
Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 6 wooden floor and furniture. There is also a ‘quite’ room recently decorated for residents and family members to eat and meet in. Residents’ personal allowances’ is protected more by the introduction of two signatures on all exchanges of money. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were looked at during this inspection. The home does not provide intermediate care. EVIDENCE: Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were looked at during this inspection. EVIDENCE: Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 15 Family members are made to feel welcome and are encouraged by staff to visit although they felt that there could be more entertainment in the home for residents. Residents are presented with a choice of food and are able to choose when they wish to eat. EVIDENCE: Speaking to visitors they felt that there could be more entertainment for residents during the day,’ to me it is very satisfactory but I wish they would play some decent music as well as the television’. The home employs an activity worker and the deputy manager confirmed that she is limited in providing and encouraging activities/entertainment as she has to support care staff in their work. This is due to a vacant post Staff who spoke to the inspector was able to describe how they promote choice and independence with food and spoke of the importance of treating residents as individuals’, ‘There is a set menu and there is two choices but we ensure peoples’ likes and dislikes are recorded in the file and it is really important to know if they need a special diet’. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 11 Food is served up in recently decorated and refurbished dining areas with an additional ‘quite’ room if residents and visitors wish to have a meal in privacy. Tea and snacks are available on request and as one resident commented, ‘the food is really good and if I do not want a big breakfast I do not have to have it’. One relative who visits daily eats at the home with his wife for which he pays a £1.00 per meal,’ there is plenty of good food with fresh vegetables. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a complaints system but this requires further development. EVIDENCE: A complaints procedure was in place and as one relative said,’ if I had a problem I know what to do and who to ask’. However, the recording system still needs to include whether the complaint was upheld or not and whether the complainant was satisfied with the outcome of the investigation. This issue is outstanding from the last inspection. There had been no recorded complaints since the last inspection. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 21 24 The residents on the whole live in a well maintained home although the downstairs bathrooms required maintenance and the utility rooms new locks. Individual bedrooms were homely although a recent fire officers’ report recommends that all bedroom doors are fitted with self-closures and smoke seals within the next 6 months. EVIDENCE: Both dining rooms and the smokers’ room have new furniture, wooden floors and there is a freshly furnished and decorated ‘quite’ room available for residents and their visitors. The deputy manager and maintenance worker were able to confirm that this refurbishment programme is to extend to other interior and exterior parts of the building. However, the downstairs bathroom must have a new bath before it is used again as it is broken and previously chipped, and the downstairs shower room requires a re-tiled shower basin, a blind and a shower curtain for privacy.
Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 14 The two utility rooms require new fitted locks to replace the bolts so as to protect residents from entering and using the sinks that have unregulated water temperatures. The bedrooms seen appeared to be personalised with ornaments, pictures and furniture belonging to residents. As one resident commented,’ what your’ sitting on is my mothers’ chair and my nephew brought me that television’. The building and bedrooms would be made safer for residents, as recommended by the fire service, if they were fitted with self-closures and smoke seals. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 Evidence from the day indicated that residents need are being met, however the agreed acceptable staffing levels for the number of residents living in the home was not being met. EVIDENCE: On the day of the inspection there were 25 residents living in the home. 4 staff had been on the 8am to 2pm shift, 3 were due for the afternoon and evening shifts and 2 for the night shift. It is recommended in the staffing requirements good practice guidelines displayed in the home’s office that for 25 residents there should be a minimum of 4 staff between 8am and 9pm. Since January 2005 the number of staff completed NVQ level 2 has increased from 41 to 65 . Both staff interviewed had completed their NVQ,’ we do get a lot of opportunity to do a lot of training and I have just finished my NVQ 3’. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 38 The residents’ benefit from a well run home that seeks the views of relatives and residents and promotes health and safety. Recording of personal allowances have been developed since the last inspection to ensure there are two signatures when money is exchanged. EVIDENCE: The home has a monthly audit carried out by the Regional Manager and this was last done in November 2005. In addition there are meetings to seek the views of residents and this was last done in June 2005. In this meeting residents were asked and involved in choosing colours for the upstairs dining room. Residents also suggested that the tuck shop could sell other stuff besides sweets such as tights, pens, paper and stamps. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 17 The last meeting arranged to seek the views of relatives was cancelled because no one came. A relative was able to confirm that has in the past been approached by staff who ask him how things are from his point of view. The organisation also publishes results of resident surveys and the last one was a year ago in December 2004. In this survey 100 rated the choice of meals available as good and 90 reported the atmosphere in the home is good or excellent. One resident who had just moved into the home said,’ it is better than the last one’. Details of health and safety were made available through the pre-inspection questionnaire and the inspection. Maintenance arrangements such fire equipment, water temperature, and hazard substances were in place. It was noted by the inspector that water in the top floor bedrooms took 3-5 minutes to reach the desired temperature. The maintenance worker had just completed training on COSHH. All COSHH risk assessments had recently been reviewed by the service manager. The maintenance worker himself provides regular fire training awareness to all staff. Recommendation from a recent fire inspection requires all bedroom doors to be fitted with self-closures and smoke seals within the next 6 months. Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X 2 X X 3 X X STAFFING Standard No Score 27 2 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 Requirement The home must comply with an appropriate staffing ratio with regard to resident numbers, category and dependency levels.(Previous time scale of 01/08/05 was not met) The home must provide suitable washing facilities to residents in the downstairs bathrooms by replacing the bath and the shower basin The home must comply with the last fire inspection report to install self-closures and smoke seals to all bedroom doors. Health and safety of residents must be maintained by ensuring that locks are installed to the utility rooms to prevent access to unregulated water temperatures Timescale for action 15/12/05 2. OP21 23 28/02/06 3 OP38 12 31/05/06 4 OP38 12 15/12/05 Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP16 OP12 Good Practice Recommendations Complaints recording should include details of outcomes and complainants satisfaction to promote objectivity and confidence in the process. Consideration should be given to the suggestion that there could be more activity and entertainment in the home Willow View DS0000000018.V267477.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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