Inspection on 09/10/07 for Willow View

This inspection was carried out on 9th October 2007.

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 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 View 06/10/08

Willow View 16/10/06

Willow View 15/12/05

Willow View 04/07/05

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 Key Unannounced Inspection 09:30 17th October 2007 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.V351967.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 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 willow.view@sshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd Position Vacant Care Home 35 Category(ies) of Dementia - over 65 years of age (35) registration, with number of places Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 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 and a garden area for residents to use. The home provides car parking for visitors. Information received by the inspector indicated fees charged by the home range from £390 to £425 per week. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report includes information obtained from an Annual Quality Assurance Assessment (AQAA) completed by the manager of the home. Two visits to the home were carried out, the first visit was unannounced. During the visits, which lasted a total of seven hours the inspector walked around the building and looked at documentation including staff records and residents files. The inspector spoke to five residents, four staff members, and the manager. As the inspector walked around the home she carried out indirect observation of interactions between residents and staff. Whilst it was difficult for the inspector to obtain the views of the residents all appeared settled and comfortable in their surroundings. The manager commenced employment in January 2007 and is to submit an application to CSCI for registration. What the service does well: What has improved since the last inspection? Since the last inspection Four Seasons Health Care have appointed a permanent manager at the home. Staff who spoke to the inspector told her they now have clear lines of management and communication. Evidence was seen that indicated people are enabled to raise issues and any concerns. Work has been carried out to develop the recording of assessments and plans of care, however this is not consistent in all the resident files. Two of the four files seen by the inspector contained written information that enabled her to gain an understanding of that person, their history, their current needs and how these were met. The information in the other two files was not as comprehensive. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 6 Work has begun to improve the environment. Carpeting has been replaced in the ground floor corridor and first floor lounge. The ground floor shower room has been refurbished, dining room furniture and some bedroom furniture has been replaced. Decoration has been carried out in a number of bedrooms and dining room. The cleanliness of the home has improved since the previous inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 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.V351967.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standard 3 were looked at. People who use the service experience good quality outcomes in this area. Prospective people to use the service have their needs assessed prior to admission to the home. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: During the inspection two files of residents recently admitted to the home were examined. Both were found to contain information from the authority funding that person’s care. The manager of the home told the inspector that wherever possible she would visit the person prior to their admission to carry out an assessment. If there was a request to admit someone as an emergency, information would be obtained from that person’s social worker in a telephone call and obtained in writing as soon as possible. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 9 The home does not offer intermediate care. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 7, 8, 9, & 10 were looked at. People who use the service experience adequate quality outcomes in this area. The health and personal care that people receive is based on their individual need. The principles of respect, dignity and privacy are put into practice. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: A total of four residents files were examined during the inspection. All were found to contain assessment documentation, including dependency assessment, nutrition, continence, moving and handling and falls risk assessments. Two of the four files were found to contain evidence of review of assessments. The recording in two of the dependency assessment tools seen contained a lot of additional information relating to that person, their needs and lifestyle. The other two contained scoring only with no additional information. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 11 Two of the four files contained a general risk assessment and one a risk assessment in relation to the storage of medication in the person’s own room. The falls risk assessment in one of the files and the continence assessment in another were not completed. All had plans of care that were reviewed on a regular basis. These included a plan of care specific to the residents needs during the night. Plans of care would benefit from further development to include details of the individual’s capabilities and preferences. All files seen contained daily records and evidence of regular weight checks. Other documents indicated there was contact with GP, district nurse and other health professionals as needed. On the first day of the inspection records were seen to be stored in a room that is accessible to all within the home. The records had been moved to a more secure location by the second visit. Whilst it was difficult for the inspector to obtain the views of the residents all appeared settled and comfortable in their surroundings. Those who spent time with the inspector expressed a general satisfaction with their care and lifestyle. One person said ‘Its nice here’ another ‘I am happy’. Residents appeared to be appropriately dressed with the exception of a number of ladies who were all seen to be bare legged without stockings or tights. Staff who spoke to the inspector were able to demonstrate through response to questions understanding and knowledge of individuals needs and how these are met. A random audit of ordering, storage, recording, administration and disposal of medication found no major concerns. There was no evidence that plans of care identifying how care staff deal with as required medication or refusal of medication have been developed. The inspector was told all staff who administer medication have received training with regard to safe handling of medication, however there is currently no system to check competency of practice. The inspector was also told further training is planned to take place. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 12, 13, 14, & 15 were looked at. People who use the service experience good quality outcomes in this area. People who use the service are able to make choices about their life style. Social and recreational activities meet individual’s expectations. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Whilst it was difficult to get feedback from the majority of residents due to their capabilities and frailty, it was noted that all appeared settled and comfortable in their surroundings. A good rapport was observed between staff and residents. Staff were also able to demonstrate through response to questions and observation, residents are given choice in activities of daily living and are treated with respect. The home employs an activities coordinator five days per week. An activities programme and details of future activities were seen to be displayed in the home. Recent activities included a sing a long party, bingo, quiz and dominoes. The inspector was told future activities planned included trips out and a party. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 13 A record is kept of activities each resident participates in, this was seen to include comments as to the involvement and enjoyment of the resident. Staff told the inspector there were links with local churches. Visitors are made welcome and can visit in either the lounge or privacy of the person’s own room. The home has a four-week menu that offers a choice at each meal. Catering staff have been issued with ‘Food for thought’ guidance by Four Seasons Health Care. The inspector was told the home now operates a system where menu choices are discussed with residents the day previously and preferences are recorded. Residents who spoke to the inspector all said they enjoyed the meals provided. A lunchtime meal was observed. The meal was seen to be well presented and unrushed. Both dining areas were seen to be pleasantly decorated, new furniture had been provided in the first floor dining room. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 16 & 18 were looked at. People who use the service experience good quality outcomes in this area. People who use the service are able to express their concerns and have access to an effective complaints procedure, are protected from abuse and have their rights protected. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The complaints policy was seen to be accessible to all. Records of complaint seen on the day of inspection were found to contain information regarding the complaint, investigation and outcomes. Information in the AQAA submitted by the home indicated the home had received 3 complaints and made 1 safeguarding referral in the previous 12 months. The manager has recently held a meeting for residents and families. Staff confirmed that they have received guidance with regard to the protection of vulnerable adults from abuse. All staff spoken to were aware of the actions that must be taken should a concern be identified and were able to demonstrate a commitment to protecting residents safety and wellbeing. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 19 & 26 were looked at. People who use the service experience adequate quality outcomes in this area. The physical design and layout of the home enables people who use the service to live in a safe, well maintained and generally comfortable environment. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: On the first day of inspection it was seen that a large amount of refurbishment was taking place. Carpets have been replaced in the ground floor corridors and first floor lounge. The inspector was told that first floor corridor carpets were also to be replaced. The first floor dining room has been decorated and furniture renewed. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 16 The ground floor shower room had been refurbished and work was underway to refurbish and replace the bath to a first floor bathroom. Another bathroom is currently being used as a storage room. During the inspection resident’s bedrooms were seen to be personalised to taste with furniture, ornaments and pictures. The damaged bedroom door identified at the previous inspection had been replaced. Privacy curtains were seen to be missing from glass panes in a number of bedroom doors. A number of bedrooms have been decorated and new furniture provided, however the bedding in a number of rooms was seen to be old and worn. The inspector was told there is an ongoing programme of refurbishment to bedrooms. Work has been carried out to external paving to make it level. On the day of the inspection the home was found to be clean tidy and generally odour free. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 27, 28, 29, & 30 were looked at. People who use the service experience good quality outcomes in this area. Staff at the home are trained and in sufficient numbers to support the people who use the service. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: On the first day of inspection the there were 27 residents accommodated at the home. A staffing rota seen indicated that there was one senior care assistant and three care assistants on duty during the day and one senior care assistant and two care assistants on the night. The home also employs laundry, catering and domestic staff. Staff who spoke to the inspector told her there were sufficient staff on duty to meet residents needs. During the inspection files of two staff recently recruited were examined. These were found to contain the appropriate documentation, including an interview record sheet. However the second reference in one of the files was verbal with no written confirmation. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 18 Training records seen indicated 13 care assistance had received moving and handling training, 16 Fire safety training and 7 Protection of adults from abuse since January 2007. Other records and information in the AQAA indicated a number of staff have completed training in relation to basic induction, infection control, health and safety, dementia awareness, first aid, and safe handling of medication. 45 of the care staff have achieved NVQ at level 2 or above. Staff who spoke to the inspector confirmed they received both formal and informal supervision. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 31, 33, 35, & 38 were looked at. People who use the service experience good quality outcomes in this area. The management and administration of the home is based on openness and respect and has effective quality assurance systems. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The manager has been in post since January 2007 and is to submit an application to register. Staff who spoke to the inspector told her communication was good, and there are now clear lines of management and support. Any concerns raised are listened to and appropriate actions are taken. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 20 The inspector found evidence of recent resident, relative and staff meetings. Monthly regulation 26 visits take place and reports were made available to the inspector. The manager has also to complete a 3 monthly team audit that looks at all aspects of the service provided. Accidents were seen to be recorded appropriately. Records of weekly fire tests, fire risk assessment and individual room assessments were evidenced. The inspector was told work in relation to the fire officers report regarding installation of smoke seals to bedroom doors has been carried out as required at the previous inspection. Information contained in the AQAA indicated the home has a range of policies and procedures, and these were reviewed in March 2006. Other information in the AQAA indicated that the home and equipment are maintained as required. The home continues to use a joint bank account for the retention of resident’s personal monies, however individual computerised records are maintained for each person. Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 22 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 The responsible person must ensure that all appropriate assessments are completed and reviewed as required. The responsible person must ensure that care plans in relation to the use of as required medication or refusal of medication are developed. The responsible person must ensure two satisfactory written references are obtained prior to employment of staff. Timescale for action 01/01/08 2. OP9 13 (2) 01/01/08 3. OP29 19 01/12/07 Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 23 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. 4. Refer to Standard OP7 OP9 OP10 OP19 Good Practice Recommendations Plans of care should be developed to include individual’s capabilities and preferences. Medication training and supervision should be developed further to include assessment of competency to practice. Care staff should ensure female residents have access to their own tights/ stockings/ socks and are assisted to wear their own preferred garment. The programme of refurbishment should continue to include. 1) Renewal of carpets to first floor corridor. 2) Provision of privacy curtains to all bedroom doors with a glass panel. 3) Continued refurbishment of resident’s bedrooms. 4) Continued replacement of bedroom furniture. Continued replacement of bedding and pillows. A programme of training should continue to ensure all staff receive appropriate training and a minimum of 50 of care staff achieve NVQ at level 2 or above. An application for registration should be submitted by the person managing the service. Individual bank accounts to be obtained for residents. 6. 7. 8 OP30 OP31 OP35 Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern No.1, Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow View DS0000000018.V351967.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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