Inspection on 03/09/07 for Willowcroft

This inspection was carried out on 3rd September 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 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 08/01/07

Willowcroft 23/01/06

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 Sally Walker Key Unannounced Inspection 9:15 3 September 2007 rd 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.V346567.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. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 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 Mrs Marilyn Crothers 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.V346567.R01.S.doc Version 5.2 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 8th January 2007 5. Date of last inspection Brief Description of the Service: Willowcroft is registered to provide personal care for 42 older people aged 65 years or older, 21 of whom may have dementia. The home was purpose built by the local authority in the 1970’s. Residents’ accommodation is to 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 situated on the south side of the city of Salisbury, close to all amenities and facilities that Salisbury offers. The registered provider is the Orders of St Johns Care Trust. The Registered Manager is Mrs Marilyn Crothers. She came into post in April 2007 and was registered on 17th July 2007. The care staffing rota provides for a care leader and 4 staff during the mornings, a care leader and 3 staff during the afternoons and evenings and 3 waking night staff. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 3rd September 2007 between 9.15am and 4.40pm and on 4th September 2007 between 9.40am and 3.50pm. Seven residents and three staff were spoken with. Mrs Marilyn Crothers, manager, and Heather Mudie, locality manager, were present during the inspection. As part of the inspection process surveys were sent to the home to gain the views of the residents, relatives and health care professionals. Comments can be found in the relevant section of the report. The anonymous comments were shared with Mrs Crothers at the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 6 Some action had been taken to ensure that a suitable assessment document is in place. Staff were contributing to feedback on the use of the format currently being piloted by the organisation. Some progress had been made to ensure that all care needs are identified in care plans. Some progress had been made to ensure that all residents have assessments of their risk of developing pressure sores and poor nutrition. Body maps were being used to record full details of any marks or wounds to residents. This included not relying on district nursing notes as evidence of treatment and healing. The care plans of those people who regularly used the respite service were reviewed and revised on the day of their admission. A programme of improvements to the environment is in good progress. The home has significantly improved its cleaning with no unpleasant odours detected at any time. The recruitment to all the housekeeping posts and a support carer means that care staff are not covering these duties as well as care. The staff training programme has improved with more relevant training being sourced locally. 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. Willowcroft DS0000028288.V346567.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 Willowcroft DS0000028288.V346567.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home assesses all potential residents care and support needs so that they can decide if needs can be met. The home does not provide intermediate care. EVIDENCE: Some action had been taken to address the requirement that an appropriate pre-admission assessment document was in place. This was to gain sufficient information from potential residents and their carers so that a care plan could be established. The organisation was piloting a new format. However the document was lengthy with many sections that were not always appropriate to determine, when people were first assessed. Many of the questions were a tick list with little space to enter specific need. There was little room for the assessor to record the often complex care needs of those potential residents who may have a dementia. As a consequence, the assessors were writing their own additional notes. As a matter of good practice this included the more Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 9 specific personal information needed in order to compile a care plan. Some of the documents were not signed by the assessor and were not dated. Mrs Crothers also included a format where potential residents and their families could record the resident’s life history to aid the assessment. One of the residents wrote in a survey form: “My son checked out Willowcroft for me and told me all about it.” A relative wrote: “The brochure was informative Sue Tiller (the manager then) was most helpful and our decision finally rested on our ‘gut feeling’ – Willowcroft had a good feel about it. It might have been helpful to have been linked with a residents family member for an informal chat.” Willowcroft DS0000028288.V346567.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): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs were being met but this is not always evidenced in the records. Care plans are varied in the detail recorded. Personal care and support needs are well documented. Social histories give a fuller picture of the person. Individual risk management is not monitored or related to the care plan. Residents could administer their own medication following a risk assessment. Systems were in place to ensure safe handling of medication. EVIDENCE: All residents had a care plan. Some progress had been made to address the requirement that all care needs must be recorded in residents care plans. One care plan identified how staff were to manage behaviours. Other care plans identified residents preferred routines with the giving of personal care. One care plan identified strategies for a resident who was assessed as resistant to care. One care plan identified strategies for supporting a resident with a visual Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 11 impairment. Part of the requirement stated that the care plans must include guidance to staff on how those assessed needs were to be met and monitored. Care plans were variable in their detail of how some residents’ diabetes was managed. Some progress had been made to address the requirement that an assessment is completed for each resident as to their risk of developing pressure sores. Assessments had been carried out but care plans did not detail how any risk was managed. A number of care plans stated that if red marks appeared on residents skin, a senior staff or district nurse should be made aware. Clearly this is too late. Records suggested that there was little understanding of preventative measures in pressure area care. One newly admitted resident had not had their risk of developing pressure sores assessed. The district nursing service had provided training in tissue viability. It was reported that Sally Jones, the organisation’s nursing advisor, was also to provide training. Mrs Jones was to provide charts for staff to weigh each resident and to establish their body mass index. Mrs Crothers said that all care staff were to be trained in care planning as part of the launch of the new recording format. Action had been taken to address the requirement that full details of wounds or marks were regularly recorded to monitor progress in healing. This included the home keeping their own records and not relying on the district nursing notes which may be kept in the home. It was advised that all separate entries on the body maps should be dated so any patterns or progress could be established. Some progress had been made to address the requirement that assessments and monitoring are carried out with regard to residents’ risk of poor nutrition. Assessments had been completed but these assessments were not being cross referenced into the tissue viability assessments. One assessment did not answer all the questions which would give an inaccurate final score. Food and fluid intake charts were kept where indicated. One resident’s case file showed that when concerns were noted about weight loss they had been referred to their GP. Their diet had also been changed to provide softer food that was easier to digest. Although an organisational policy was awaited on intimate personal care giving from a member of staff of a different gender, care plans recorded individual residents’ preferences. All personal care was carried out in private. Mrs Crothers had asked residents and their families to fill out the life history forms and scrap books. This was to supplement information already gathered about residents’ social histories and lifestyles. Mrs Crothers said that families had told her that they had enjoyed collating this family history and celebrated their relatives’ lives. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 12 Action had been taken to ensure that the care plans of those residents who frequently used the respite service were reviewed on the day of their admission. This was to establish whether there had been a change in need. One of the relatives wrote in a survey: “I feel that sometimes [the resident] is not getting enough fluids and needs constant supervision.” Another relative wrote: “Although called a care home I feel there is a very fine line between caring and nursing care and my [relative] is bordering on nursing care.” The inspector witnessed a very good response from staff to an emergency call where a resident had fallen in their bedroom. The care leader with the delegated responsibility for the administration and control of medication explained the system. Residents could administer their own medication following a risk assessment. Most of the residents had their medication given by staff. Staff could only administer medication once a care leader had assessed their competency. Competency was then assessed every 6 months. The home operated a monitored dosage system put up by the supplying pharmacist. There was one medicines trolley for each floor. The medication administration record for one resident who was prescribed a medication to be taken at 7.30am had 6.30am recorded in their care plan. One medication that was to be administered only when required did not have guidance in their care plan as to what triggered an administration. It was advised that records must be kept of all unused and unwanted medication at the time of being discontinued rather than weekly as they are returned to the pharmacist. Pre-packaged medication should be returned in its packaging. Blister packs should be returned unopened. Regular audits of the medication were carried out. One care leader had identified an anomaly in the medication of a resident admitted that day and checked with the GP for the correct prescription. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes effort to ensure that they know about residents’ social history so that they can meet their needs. The activities co-ordinator ensures that different activities provide good outcomes for residents with different abilities and interests. A good range of activities is provided in the time allocated. Contact with families is encouraged. Contact with the locality is improving. Those residents who have capacity can retain some control over their lives. There is a good range and variety of meal provided. EVIDENCE: Some of the residents were having a leisurely breakfast when the inspection started. Those residents who were having their meal in their bedrooms had time to get up and get themselves dressed in their own time. The atmosphere in the home for that busy time of day was relaxed. Those residents who could decide chose where to spend their day. Others relied on staff for direction. There was little evidence in the records on how staff were enabling residents to make decisions or choices. However it was clear from talking to some residents that they exercised choice in their daily lives. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 14 A member of staff is employed to organise activities from 10.00am to 3.00pm, for 4 days a week. Care staff were expected to provide activities at other times. The home would benefit from extra activity hours so that those residents who wanted to go out and needed a member of staff with them could do so. The recommendation that the amount of hours provided for activities should continue to be monitored remains. This should take into account the social needs of residents. Some of the residents were playing skittles in the upstairs dining room. The activities person engaged with individuals and the group. They encouraged participation. They also provided a commentary on what was happening for those residents who had a visual impairment. The member of staff responsible for activities talked later in the day about what they provided. They explained that activities were planned according to each resident’s concentration levels, achievable outcomes and enjoyment. They also took the groupwork to different sitting rooms so al had access. One resident had accessed games on the computer. The activities co-ordinator had taken a group of residents to a local pottery to make items for a member of the organisation who was retiring. They said they visited some residents who did not like groups in their bedrooms to talk about various subjects they were interested in. They said they trimmed some residents’ nails and would take the opportunity to chat with those residents. They would take residents to a local coffee shop, to the pub or for a cream tea. Sometimes residents would like to take a walk with the activities co-ordinator around the immediate locality. All of the calendar celebrations were recognised, for example, Halloween or Salisbury Carnival. Some residents who were originally from overseas could access some local facilities, for example, the Polish church. The activities co-ordinator keeps a record of all activities undertaken recording who participated. In a survey form one resident wrote: “I join in [with activities] when I can.” “Bingo parties, darts sing-a-longs.” Another resident said they would like the home to “Organise more outings if possible.” Most of the residents spoken with described activities they liked to join in with. One resident said they liked bingo and skittles but these did not take place everyday. Another resident talked about the regular visits of the hairdresser and how they liked to walk in the garden. They said that there were activities on most days with people coming in to entertain them. One resident said that staff were too busy to take them out but they did go out regularly with their relative. One resident said they went into Salisbury on the bus at least once a week. They said that staff would provide them with an early breakfast so they could catch the bus in time. Mrs Crothers had announced to the residents meeting that she planned to organise at least 2 half day outings each month. Mrs Crothers said that a nearby home had the use of a minibus which could be shared amongst the 4 homes in the organisation in the area. There were photographs of some of the Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 15 activities displayed around the home. A car wash had been organised the previous weekend to raise money for activities. Residents were encouraged to retain contact with families and visitors were encouraged. There was a small servery where residents or their families could make a drink. The home provided a range of meals on the menus. There were 2 choices for lunch and the evening meal. Breakfast was a range of cereals, toast and porridge. The menus were not dated so it was not possible to determine how often they were reviewed and changed. Mrs Crothers said that the daily menu choices were going to be written on a blackboard by each dining room so it was easier for residents to read. In a survey form one of the residents wrote about the meals: “sometimes too much for [my] liking but plenty of choice.” Another wrote: “The meals are simple and tasty.” Another resident wrote: “Nice food and always a selection. Sometime people put food on the floor so cleaners have to clean it up.” One of the relatives wrote: “Scrambled eggs, soup or similar would be a nice alternative to be on offer permanently (to order on demand) if residents are feeling unwell, off their food or just don’t fancy the set menu.” There was a bowl of apples on each of the dining room tables for residents to help themselves. On the second day there were also apples in a bowl on the tables. One of the residents was asked how they liked to have fresh fruit available. They said that the apples had not been eaten by any of the residents as they were hard. They went on to say that bananas or softer fruit were more popular. One of the residents said that staff came round to ask what they wanted to eat for the next 2 days. During lunch it was noted that staff in the first floor dining room were asking residents which of the 2 choices they wanted. Some of the residents had difficulty constructing how the meal might look and taste. The inspector advised the staff that other homes in the organisation showed residents the two choices at the table. This enabled residents to have a much better idea as to whether they liked what saw and could make a more informed choice. Staff provided sensitive care and attention to one resident who required support with eating and drinking. All of the residents were given juice or water with their meal. Some of the residents were taken to the dining tables and left in wheelchairs rather than transfer to a dining room chair. This meant that some of the arms of the wheelchairs did not go under the tables so these residents could not get near enough to the meal. The explanation given by staff was that the residents were not safe in a dining room chair as they fell forward. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 16 The minutes of the residents meetings showed that the meals had been discussed with residents. Wanting more roasts and vegetables cooked for longer was suggested by residents had been actioned. The home had started the system: Resident of the Day. This system ensures that the keyworker and other staff involved in the resident’s care, focus on certain aspects of their care and support. This may be a review of their care plan, a deep clean of their room, discussions about appointments or activities they want to be involved in. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 17 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that residents are able to make complaints about the service. Records showed that Mrs Crothers takes all complaints seriously. Complainants are informed of the outcome of investigations and any actions taken. Residents spoken with were confident in telling staff if they were unhappy about anything. Staff were confident in using the Safeguarding Adults procedure. EVIDENCE: The home follows the organisation’s complaints procedure. Mrs Crothers sends a monthly return to the organisation on complaints and compliments. Mrs Crothers kept a log of all complaints showing details of the investigation and outcome letters to complainants. The log also showed what action had been taken to address complaints that had been upheld. One of the residents wrote in a survey form: “[Staff listen] most of the time. I would try [talking to] one or two people depending what the problem was.” Another resident wrote that they would use the “Complaints form or tell someone.” One of the relatives wrote: “I don’t know of a set procedure in place but feel sure that should I have reason to complain the matter would reach the correct ears.” Most of the residents spoken with said they could talk to staff if they wanted to make a complaint or discuss issues they were not Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 18 happy with. One resident said they had no complaints and were very happy but they would go to the manager if there was anything to discuss. Some of the staff were asked about the procedure of reporting any allegations of abuse to the local Safeguarding Adults procedure. All were confident in using the procedure. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 19 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): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Significant efforts are being made to improve the quality and comfort of the environment for residents. Mrs Crothers has implemented new cleaning schedules and the improved cleanliness of the home is apparent. EVIDENCE: All the bedrooms are single room accommodation. Residents had been able to bring some possessions to personalise their rooms. Mrs Crothers said that all of the bedrooms were gradually being redecorated by the handyman. Residents had chosen colour schemes. Curtains were being replaced throughout the home. The building is gradually being upgraded. Mrs Crothers said that she planned to have some of the flooring in the toilets and bathrooms replaced in the next financial year. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 20 In a survey form one resident said about their environment: “Sometimes my room smells, the carpet smells of urine.” Another resident wrote: “Lovely flowers and cleaners are always cleaning.” One of the relatives wrote: “Obviously there are unavoidable ‘off days’ but the problem is never permanent.” Action had been taken to address the requirement that all areas of the home are cleaned to infection control standards. This included particular attention to those areas not immediately visible. It was noted early in the inspection that the undersides of toilet surrounds and raised toilet seats were cleaned to a high standard. Mrs Crothers had allocated different tasks and areas to cleaning schedules. These were required to be filled out daily to show which areas had been cleaned. There were 4 housekeepers each allocated to an area and a set of tasks. Action had also been taken to address the requirement that infection control guidance is always followed when cleaning and returning commode pots to residents. Commode pots ceased to be soaked communally. Pots were individually emptied, cleaned and sterilized then returned directly to the resident. All pots were numbered according to bedrooms to assist with this. Disposable protective clothing and gloves were available to staff when needed. There were no offensive odours detected at any time during the inspection. Residents could easily access the grounds to the rear of the property. The laundry area was well ordered with systems for dealing with soiled or infected items. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some increase in support staff hours enables care staff to concentrate on care. It is the experience of some residents and relatives that the home is short staffed at times. A robust recruitment process was in place. Dementia care training is increasing. All staff are expected to undertake mandatory training. Residents were very positive about their good relationships with staff. EVIDENCE: The care staffing rota provided for 4 care staff and a care leader during the mornings with 3 care staff and a care leader in the afternoons and evenings. There were 3 waking night staff. The recommendation that the staffing levels continue to be monitored remains. This monitoring should take into consideration the residents’ dependency levels and other duties that staff are expected to carry out. Support staffing levels had been increased so that care staff were not expected to do domestic work as well as care. Care leaders had been given 7 hours each week between them to carry out their delegated administrative duties. All care leaders were responsible for different areas, for example, medication or the rota. In a survey form one of the residents ticked that staff were always available “except at night.” Another resident wrote: “They help whenever needed; they Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 22 are wonderful. Sometimes at night you don’t see them.” One resident said: “an excellent care home. Very helpful and caring staff. [staff listen] most of the time. The home does try and look after and care for the people that live there they work to a good standard.” Another resident said “they help me when they can.” Another resident said: “feel that the carers are very friendly and willing to help at all times. Good mixture of staff.” One of the relatives wrote: “Willowcroft facilities, accommodation and all the staff deserve nothing but praise. As a family we have been delighted with the standards and level of care (and affection) offered to my [relative]. More carers on shift for meal times.” All of those residents spoken with made very positive comments about their keyworkers. Two residents said that at times the home was short staffed. There was a robust recruitment process in place. All potential staff are required to fill out an application form, attend an interview and provide evidence of qualifications, training and medical fitness. All the information and documents required by regulation were in place. No staff commenced duties without a check on the Protection of Vulnerable Adults list. Mrs Crothers said that she was awaiting Criminal Records Bureau certificates for 2 newly appointed staff. She went on to say that she intended to build up a group of bank staff to cover for holidays and sickness. All new staff have a period of induction. One of the new staff was shadowing a more experienced member of staff during the inspection. Some progress had been made to address the requirement that a programme of varied dementia training was available to staff. This training should include outsourced training and seminars from specialist dementia providers and experts. Age concern was booked to provide training to all the organisation’s homes in the area in depression in old age. It was reported that one staff was qualified to train staff in dementia care. One of the staff said they had completed training in dementia care. They said they had also trained in moving and handling, first aid, diabetes and Safeguarding Adults procedures. Recent training had included infection control, tissue viability, health and safety, symptoms of heart failure and the Primary Care Trusts guidance on when to call a healthcare professional. This was described as an ‘early warning system’. Mrs Crothers said that one of the staff was in the process of putting all the staff training records into a new computer programme. This would highlight when updated mandatory training needed to be completed. All staff, not just care, had access to dementia training and other training pertinent to their role. Much of the training is provided by the organisation with lists of future training available to staff. The staff also have access to the organisation’s e-learning packages. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 23 Mrs Crothers said that she had started to collect a resource library of relevant articles and books related to the needs of the current residents and the ageing process. In a survey form one of the staff wrote: “I am unable to do NVQ 3 as not in senior position.” Another staff wrote that they would like “to improve teamwork”. Another said they would like: “having more staff on duty so that more quality time can be spent with residents.” Mrs Crothers had arranged for one of the chefs whose first language was not English to undertake their food hygiene certificate in French. Staff engaged with residents. Staff were seen to spend time chatting with residents as they went about their work. All staff knocked on bedroom doors before being invited in. Residents confirmed that staff were respectful of their private space. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 24 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): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Crothers has many years experience of providing care both as a registered provider and in care homes. She is clear about how she wants the home to develop. The home is run in the best interests of the residents. Systems are in place to ensure any money held on residents’ behalf is properly managed. EVIDENCE: Mrs Crothers was registered as the manager in July 2007. She has had many years experience of providing care to older people as a provider, manager and carer. The organisation was to interview Mrs Crothers for the position of manager the day after the inspection. This is more than 2 months after having Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 25 proposed her to the Commission as the manager to be registered. There was evidence that she had commenced induction into the role of manager on the 10th April 2007. Mrs Crothers was completing the NVQ Level 4 in care management and was to do the Registered Managers Award. Residents meetings were regularly held with minutes kept and published on various notice boards around the home. A representative of the organisation had carried out a quality audit of the home. Questionnaires had been sent to residents and relatives. The findings had fed into the audit and an action plan established. One of the care staff said they had monthly supervision. They said there was a format for recording what was discussed and that they could contribute to the agenda. The organisation has developed safe systems for the holding of any small amounts of monies residents wish to keep in the safe. Records and receipts are kept of all transactions. Only senior staff have access to the safe. All staff are required to undertaken regular updated training in moving and handling, fire safety, first aid, food hygiene and infection control. Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 26 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 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 X X 3 Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement The Registered person will ensure that a pressure area risk assessment is completed for all residents. This requirement is outstanding from the 3 previous inspections. However some progress had been made and a further timescale has been agreed as Mrs Crothers was new to post. The assessment must inform the care plan. 2. OP7 15 The Registered person will ensure nutritional risk assessments are in place to fully monitor service users dietary needs. This requirement is outstanding from the last 2 inspections. However a further timescale has been agreed as Mrs Crothers was new to post. These assessments must relate to the care plan. 3. OP3 14 The person registered must ensure that an appropriate preadmission assessment document DS0000028288.V346567.R01.S.doc Timescale for action 04/09/07 04/09/07 04/09/07 Willowcroft Version 5.2 Page 28 is in place in order to gain sufficient information from potential residents and their carers so that a care plan can be established. This requirement is outstanding from the last inspection. However a new timescale has been agreed as Mrs Crothers was new to post and the organisation was piloting a new format. 4. OP7 15 The person registered must ensure that all care needs are recorded in residents care plans, including guidance to staff on meeting those needs and how progress is monitored. This requirement is outstanding from the last inspection. However a new timescale had been agreed as Mrs Crothers was new to post. Care plans must identify where indicated how diabetes is managed and monitored. 04/09/07 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 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 DS0000028288.V346567.R01.S.doc Version 5.2 Page 29 2. OP27 Willowcroft staffing levels ensuring that the staffing levels are appropriate to meeting the needs of the service users dependency levels. The review should also include tasks and other duties that staff are expected to carry out. 3 4 OP37 OP15 Separate entries on body maps should be dated for monitoring purposes. Consideration should be given to allowing some residents to see the meal choices at the table rather than trying to remember what they had ordered the day before. Other homes in the organisation enable residents to choose at the table. Unused or unwanted medication should be entered into the disposal log at the time it becomes discontinued. Prepackaged medication should be returned in its packaging and blister packs should be returned unopened. Consideration should be given as to whether it is appropriate to leave some residents in wheelchairs at the dining room, particularly when the resident cannot reach the meal due to the arms of the chair not fitting under the table. All written documents should be signed and dated for monitoring purposes. 5 OP9 6 OP14 7 OP37 Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Willowcroft DS0000028288.V346567.R01.S.doc Version 5.2 Page 31 - 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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