Inspection on 23/01/06 for Willowcroft

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Willowcroft 22/07/08

Willowcroft 03/09/07

Willowcroft 08/01/07

Willowcroft 31/08/05

Willowcroft 15/03/05

Willowcroft 27/10/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Willowcroft Odstock Road Salisbury Wiltshire SP5 4JL Lead Inspector Karen Mandle Unannounced Inspection 23rd January 2006 10.45a 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 Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willowcroft Address Odstock Road Salisbury Wiltshire SP5 4JL 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) 01722 323477 The Orders Of St John Care Trust Miss Susan Tiller Care Home 42 Category(ies) of Dementia - over 65 years of age (21), Learning registration, with number disability over 65 years of age (1), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (1), Old age, not falling within any other category (21) Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of services who may be accommodated at any one time is 42 No more than 21 service users in the category Old Age may be accommodated at any one time No more than 21 service users with dementia over the age of 65 years may be accommodated at any one time The only service user who may be accommodated in the home with a learning disability aged 65 years and over is the male service user currently in residence in that service category The only service user who may be accommodated in the home with a mental disorder aged 65 years and over is the male service user currently in residence in that service category 31st August 2005 5. Date of last inspection Brief Description of the Service: Willowcroft is registered to provide personal care only for 42 older people aged 65 years or older, 21 of which may be suffering from Dementia. The home is purpose built with two floors offering communal space on each floor. The home provides all single bedroom accommodation. A large well maintained garden is to the rear of the building. The home is well situated on the south side of the city of Salisbury, close to all amenities and facilities that Salisbury offers. The home is owned by the Orders of St Johns Care Trust. The Registered Manager is Miss Sue Tiller. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 10.45 and was completed at 3.30pm. The Registered Manager Sue Tiller was available to assist the inspector and projects an open approach to the inspection process. The inspector was able to freely tour the building, visit with service users and talk with the staff. The inspector reviewed the care records of 5 service users. The medication procedure was reviewed. The home was providing care to 37 service users at the time of the inspection. Mr Colin Titcombe care services manager was present during the feed back session. What the service does well: What has improved since the last inspection? The care records have improved relating to the daily report and content of the information with evidence of monthly reviews taking place of the care plans. Increased interaction between the service users and staff was observed providing a relaxed and friendly atmosphere in the home. This may be in part due to the increase in staffing levels since the previous inspection. An activities person is in post providing increased social activities for the service users. Building work was in progress to kitchenettes on the ground floor and an assisted bathroom. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 6 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. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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 Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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): 3 A clear admission procedure is in place and care needs assessed. The pre admission assessment document presents as complex and may not be readily understood by service users. EVIDENCE: The Registered Manager conducts a pre admission assessment for each service user prior to admission taking place ensuring that the home is able to meet the personal care needs and social care needs of the service user. However the current assessment tool used, which is the long-term care needs assessment document from the care plan format is not appropriate. This document was implemented by the organisation The Orders of St John Care Trust and not the home. The organisation is currently reviewing the document. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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): 7,8 and 9 The standard of documentation in the care plans has improved however the care plans do not fully address all aspects of care. EVIDENCE: Each service user is provided with a care plan. The inspector reviewed 5 care plans. A general improvement to the standard of detail within the daily records was seen. The short- term care plans provided more information relating to the service users’ current care needs and were reviewed monthly. However due to the removal of several key documents from the care plan system, again by the organisation, the care records cannot fully support all care needs of the individual service users. The organisation should also consider implementing a nutritional risk assessment ensuring that all dietary needs are being met especially for those service users suffering with dementia. A care plan, which was in place for a service user receiving respite care, had not been reviewed from the service users’ previous admission. The admission had taken place two months ago during which time the care needs of the service users may or may not have changed, however the care plan should have been reviewed at the time of admission ensuring that all care needs of the service users are supported through the care plan. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 10 Willowcroft is not registered to provide nursing care therefore the Community Nursing Team attends to any nursing needs. Evidence of this taking place was clearly documented in the care records and a communication book was in place between the Community Nurses and the care staff of the home. The service users the inspector spoke with were satisfied that their health care needs were being met. However several service users were suffering with Dementia, which did make communication limited. Clear records of when a GP visit took place were evident. Due to the lack of key documents in the service users’ care plans such as the pressure area risk assessment it remains impossible to fully assess if all health care needs of the service users are being met. The medication procedure was assessed. It is recommended that the stock control will be monitored ensuring that unnecessary stock medication is not kept in the home. The medication policy and sample signature sheet were not seen with the medication records. A self-medication risk assessment had not been completed for those service users wishing to self medicate. The procedure for obtaining antibiotics following a GP’s visit was fully discussed. The inspector raised concerns about the amount of time from when the GP visits a service user and prescribes antibiotic treatment to when the treatment begins. The inspector was able to evidence a treatment not being commenced until 9pm the following day after the GP’s visit had taken place. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 11 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): 12 A structured activities programme is in place. However due to the number of service users the home is registered to provide for, the amount of activities hours provided may not be sufficient to meet the social care needs of the service users group. EVIDENCE: An activities person is employed to provide 20 hours per week of social activities. A group activity was observed taking place in the communal room upstairs during the inspection. Nine service users were either participating in the activity or were watching the events of the activity with good interaction noted between the two members of staff and the service users. A record is maintained of all activities. The home is registered to provide care for 42 service users 21 of which may suffer with dementia. The organisation should consider that with the number of service users and with the dementia category of care, if 20 hours per week of social activities is sufficient to meet the social care needs of the service users. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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 and 18 A complaints policy and procedure is in place. A vulnerable adults procedure is in place and staff are fully informed of how to use the procedure. EVIDENCE: There is an organisational complaints procedure in place, a copy of which is situated in the entrance hall to the home available to both service users and visitors to the home. All service users are provided with a copy of the complaints procedure. The CSCI have received two formal complaints one of which was investigated by the Registered Manager and the other by the CSCI. The complaint investigated by the CSCI related to supervision of health care needs of a service user. The complaint was upheld. An “Abuse” policy is in place supported by a “Whistle Blowing” policy. The local vulnerable adults procedure the “No Secrets” document was seen in the care office and the staff has received training in abuse awareness. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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 and 26 Willowcroft is generally well maintained providing a safe environment for service users to live in. Infection control measures had improved apart from the laundry facility. EVIDENCE: Willowcroft is a purpose built home, which is generally well maintained. The inspector was able to freely tour the building and visit many areas of the home. The communal areas are spacious both upstairs and downstairs with smaller sitting areas provided where service users were observed interacting with each other. The home had various refurbishment programmes in progress at the time of the inspection continuing to improve environmental standards, a bathroom on the ground floor and kitchenette both in the process of being refurbished. The home is furnished through out in a domestic fashion. The inspector visited with six service users in their bedrooms. All the bedrooms were homely with many personal items seen. Service users who spoke with the inspector were satisfied with the accommodation provided. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 14 The home was cleaned to a good standard and no unpleasant odours were detected at any time during the inspection. Infection control measures were in place. However the laundry facility was viewed and dirty linen was seen on the floor increasing the risk of cross infection. The laundry facility was not sufficiently clean above the tumble dryer where a build up of dust was seen, again this increases the risk of cross infection with in the home. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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 and 29 An improvement to staffing levels was seen providing increased support to service users. The homes’ recruitment practices are satisfactory apart from ensuring that all employees provided proof of identification. EVIDENCE: On the day of the inspection the home was providing care for 37 service users out of a possible 42 service users, which the home is registered to provide for. The staff available to support the service users was; The Registered Manager, 1team leader, 3 carers, a support worker and a trainee carer. The activities person worked from 10am to 2pm. The administrator, two domestic staff and laundry person were also available. The Manager informed the inspector that the support worker and trainee carer did not support service users with personal care but did other duties, which helped to support the daily care needs of the service users. This staffing level is considered an improvement from the staffing levels observed at the previous inspection, which took place August 2005. However the home will need to continue to monitor staffing levels against the dependency levels of the service user group especially when sickness occurs with the staff and agency staff is not available. Two employment files were seen which did not have proof of the person identification. All other required employment procedures were in place such as police checks and references. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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): 36 and 38 Staff are not provided with regular supervision. Appropriate health and safety checks are made within the home ensuring that service users are living in a safe environment. EVIDENCE: The issue of staff receiving regular supervision at appropriate intervals was raised with the manager Sue Tiller who informed the inspector that this procedure had not been fully implemented at this time. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 17 Fire records indicated that weekly checks of the fire alarm system was taking place, and the emergency lighting was being tested monthly. An independent company were conducting a fire risk audit at the time of the inspection. Evidence of the staff being provided with regular fire training was available. Accidents are fully recorded and audited. The lifting hoist is regularly serviced. Health and Safety issues are addressed and the home is well maintained providing a safe environment for both service users and staff. Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 3 Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 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 OP3 Regulation 14(1c) Requirement The Registered person will not use the long-term care document as a pre admission document as this document is not suitable for this purpose and could not easily be used in consultation with the Service User prior to admission. This requirement is outstanding from the previous inspection. 2. OP7 15 The Registered person will ensure that the Keyworker document is used as Service Users made references regarding the Key worker relationship. This requirement is outstanding from the previous inspection. 3. OP7 15 The Registered person will ensure that a pressure area risk assessment is completed for all Service Users. This requirement is outstanding from the previous inspection. 28/02/06 28/02/06 Timescale for action 28/02/06 Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 20 4. OP7 15 5. OP19 23 The Registered person will ensure nutritional risk assessments are in place to fully monitor service users dietary needs. The Registered person will replace the carpet in the downstairs dining room. This requirement is in progress. The Registered person will ensure that when a service user is re admitted to the home for respite care that the care plan is fully reviewed on the day of admission. The Registered person will review the homes’ procedure for obtaining and commencing medication following a GP visit. The Registered person will ensure that a self-medication risk assessment is completed and regularly reviews take place to ensure the safety of the service user who is self medicating. The Registered person will ensure that all eyes drops are dated from the time of opening. The Registered person will ensure correct procedures are in place for storage of dirty laundry in the laundry facility and the cleaning of the laundry facility. The Registered person will ensure that all employment files contain proof of identification. The Registered person will ensure that all staff will be provided with regular supervision. 28/02/06 01/04/06 6. OP7 15 28/02/06 7. OP9 15 28/02/06 8. OP9 13 28/02/06 9. 10. OP9 OP26 13(2) 13 01/02/06 28/02/06 11. 12 OP29 OP36 19 18(2) 28/02/06 01/04/06 Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 21 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 OP12 Good Practice Recommendations The Registered person should continue to monitor the amount of hours that the activities are provided within the home to ensure that the social needs of the service users are fully met. The Registered person should continue to monitor the staffing levels ensuring that the staffing levels are appropriate to meeting the needs of the service users dependency levels. The Registered person should observe the amount of stock medication kept within the home. 1 OP27 1 OP9 Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Willowcroft DS0000028288.V275555.R01.S.doc Version 5.1 Page 23 - 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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