Inspection on 04/07/05 for Willow View

This inspection was carried out on 4th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Willow View 06/10/08

Willow View 09/10/07

Willow View 16/10/06

Willow View 15/12/05

Willow View 10/11/04

Willow View 13/05/04

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

CARE HOMES FOR OLDER PEOPLE Willow View 1 Norton Court 201 Norton Road Stockton-on-Tees TS20 2BL Lead Inspector Jane Bassett Unannounced 4 July 2005 10:00 am 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 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 B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Willow View Address 1 Norton Court 201 Norton Road Stockton-on-Tees TS20 2BL 01642 550935 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Health Care) Mrs Tracy E Daley Care home only 35 Category(ies) of DE(E) - Dementia over 65 (35) registration, with number of places Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions of registration. Date of last inspection 10/11/04 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 B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection the inspector spoke to two residents, three family members, four staff and the manager. It was not possible to get feedback from the majority of the residents due to their capabilities and frailty, however the inspector noted that all appeared settled and comfortable in their surroundings. Documentation including plans of care and staff records were examined. A tour of the building took place. The inspector spent a total of five hours at the home. What the service does well: What has improved since the last inspection? Redecoration and refurbishment to the ground floor dining area has improved the environment and residents comfort. It is hoped that further development will include new furniture in the ground floor dining room and refurbishment to the first floor dining room. Lumpy pillows noted at the previous inspection have been replaced. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 6 Medication administration records have been developed further with regard to issues raised at the previous CSCI inspection and recent audit carried out by the supplying pharmacist. 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 B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 standard(s) 3 & 5 The admission procedure carried out by the home was found to include assessment of care needs for individual residents. This should ensure that care needs can be met. EVIDENCE: During the inspection four residents plans of care were examined, including two files of residents recently admitted. These were found to contain evidence of pre admission information gathering carried out by the home and assessment of need carried out by the residents social worker. The manager told the inspector that residents and families are encouraged to visit the home prior to admission. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 9 One family member who spoke to the inspector confirmed that staff from the home had carried out a pre admission assessment where care needs, and preferences were discussed. They also confirmed that they had the opportunity to visit the home prior to admission. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, & 10 Evidence was seen that indicated residents care needs are met and any changes in health are followed up promptly and appropriately. The homes system for administration of medication was found to be satisfactory promoting the safety and wellbeing of service users. EVIDENCE: During the inspection four residents files were examined. These were found to contain evidence of assessment, care planning, agreements to plans of care, evaluation and review. Files also contained evidence that residents have access to their own GP’s, District Nurses, chiropodists and other health professionals as required. Families who spoke to the inspector confirmed that they were satisfied with the care received and the attitude of the staff. One relative said that you ‘can’t fault the staff’, another commented on the friendly but respectful approach of the staff. A family member told the inspector the staff ‘ never loose patience’. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 11 Families who spoke to the inspector confirmed that they were informed of changing health care needs and these were acted upon promptly and appropriately. Due to the resident’s frailty and capacity it was difficult it ascertain their opinions, however one resident spoke of staff being ‘very good’. Staff who spoke to the inspector were able to describe in detail the needs of individual residents and how these are met. All spoke of respecting resident’s privacy and dignity, and the importance of treating people as individuals. The inspector observed a good interaction and rapport between staff and residents, needs were seen to be addressed with respect. An audit of medication found no major issues with ordering, storage administration and return of medication. Recommendations made at the previous inspection with regard to recording on Medication Administration Record charts have been acted upon. The home has recently had an audit of systems carried out by their supplying pharmacist; recommendations highlighted at the time have been acted upon. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 14 Social activities are available for those who wish to participate and socialise, visitors are encouraged and welcome. EVIDENCE: Whilst it was difficult to ascertain the resident’s views and opinions on their lifestyle the inspector did observe good interaction between staff and residents. One resident spoke of being ‘happy here’. All residents observed appeared to be settled and comfortable in their surroundings. Staff who spoke to the inspector were able to describe how they promote choice and independence where possible. All spoke of respecting resident’s privacy and dignity, and the importance of treating people as individuals. The home employs an activities co-ordinator. Staff told the inspector that activities can be limited due to residents capabilities however residents are encouraged to participate in such activities as baking, quizzes `and sing a longs. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 13 Families confirmed that visitors are encouraged and made to feel welcome. One visitor told the inspector that they were always offered a cup of tea, another commented on the support the staff had given in assisting her relative to visit her partner in hospital. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Staff demonstrated a commitment to the protection of the residents that they care for. Families expressed confidence in the way the home dealt with concerns, however documentation should be maintained in such a way as to promote objectivity and confidence in the process. EVIDENCE: The home has a policy on dealing with complaints. Complaints were seen to be recorded however this did not always include details of outcomes and complainants satisfaction. Families who spoke to the inspector said that they were aware of how to raise concerns and any issues raised had been acted upon promptly and appropriately. Staff who spoke to the inspector confirmed that they had received training in relation to protection of vulnerable adults from abuse. All staff spoken to were aware of the actions that would be taken should a concern be identified and were able to demonstrate a commitment to protecting residents safety and wellbeing. Staff confirmed that they were aware of the complaints procedure; all said any issues raised are listened to and are acted upon appropriately. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26. The home was found to be clean and generally odour free. Some refurbishment work has been carried out in the ground floor dinning room, however replacement of carpeting to the smokers lounge and repainting to external woodwork would further improve the environment for the resident’s comfort. EVIDENCE: The ground floor dinning room has recently been redecorated and new wooden flooring provided. Furniture has been repaired as recommended at the previous inspection. The manager informed the inspector that the dining tables and chairs were to be replaced shortly, the residents having chosen the colour scheme. The manager also said that the first floor dining room was to be refurbished in the near future. Carpeting in the smokers lounge should be replaced due to fading and marking to the area close to the external doors. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 16 External woodwork requires attention as paintwork was noted to be flaking. Resident’s bedrooms seen were found to be personalised to taste with ornaments and pictures. The manager told the inspector that ‘lumpy’ pillows seen at the previous inspection have been replaced. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, & 30 Evidence seen on the day of the inspection indicated that residents current needs were being met, however there needs to be an agreed acceptable staffing structure that must be implemented within the home to ensure that the continuing needs of the residents are met at all times. EVIDENCE: Three staff file of staff recently recruited were examined, these were found to contain appropriate documentation including evidence of a Criminal Record Bureau check and PoVA first check carried out prior to employment. Four staff training files were examined these contained evidence of staff training including NVQ, Protection of vulnerable adults from abuse, moving and handling, fire safety, safe handling of medication and infection control. Staff who spoke to the inspector confirmed training was available and encouraged. The manager told the inspector that the planned training for the near future included updates on manual handling, fire safety; supervisory skills for senior care staff, food hygiene, risk assessment and NVQ’s for the ancillary staff. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 18 Staff and families told the inspector that there were sufficient staff on duty to meet the needs, however staff could be extremely busy limiting the time that can be spent with residents. The manager told the inspector that Four seasons have issued new staffing grids, however there was not a copy of one available to examine, the home was expected to supply one carer for each seven residents during the day and one to ten on a night. The home was accommodating 24 residents at the time of the inspection, however there were only 3 care staff and manager on duty. Four Seasons must provide and comply with an appropriate staffing grid with regard to resident numbers, category of care and dependency levels. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34, & 35 Evidence indicated that there is an open door policy, issues are listened to and acted upon appropriately promoting residents wellbeing. Recording of resident’s personal allowances should be developed for the protection of residents and staff. EVIDENCE: The manager has recently successfully completed the registration process as required at the previous registration. All visitors and staff who spoke to the inspector stated that the manager was approachable and issues raised were acted upon appropriate. Regulation 26 visits are carried out and reports made available to the Commission for Social Care Inspection. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 20 Four Seasons Health Care have provided a financial statement and Company Directors report as required at the previous inspection. The home continues to use a joint bank account for the retention of resident’s personal allowances and maintain computerised records of individual accounts. The home retains receipts for all transactions, however there are not always records of two signatures for each transaction as confirmation. Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 x x 3 2 x x x Willow View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 22 yes 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 27 Regulation 18 Requirement The home must provide and comply with an appropriaste and agreed staffing grid with regard to resident numbers, category and dependancy levels. The home must maintain service users personal monies and records of such in accordance with Regulation 17 of the Care Homes Regulations 2001 for the protection of both residents and staff. (previous time scale of 1st February 2005 not met) Timescale for action By 1st August 2005 By 1st October 2005 2. 35 17 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. 3. Refer to Standard 16 19 19 Good Practice Recommendations Complaints recording should include details of outcomes and complainants satisfaction to promote objectivity and confidence in the process. Carpet in the smokers lounge should be replaced due to fading and marking. External woodwork should be repainted due to flaking paint. B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 23 Willow View Commission for Social Care Inspection Unit B, 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 © 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 View B51-B01 S18 Willow View V23559 040705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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