Inspection on 31/08/05 for Willowcroft

This inspection was carried out on 31st August 2005.

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

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

Other inspections for this house

Willowcroft 22/07/08

Willowcroft 03/09/07

Willowcroft 08/01/07

Willowcroft 23/01/06

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 Announced 31 August 2005 st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Willowcroft Address Odstock Road Salisbury Wiltshire SP5 4JL 01722 323477 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Orders of St John Care Trust, Mrs Diane Bowden Miss Susan Tiller Care Home 42 Category(ies) of DE(E) Dementia - over 65 (21) registration, with number LD(E) Learning Disability - over 65 (1) of places MD(E) Mental Disorder - over 65 (1) OP Old Age (21) Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who may be accommodated at any one time is 42. 2. No more than 21 service users in the category Old Age may be accommodated at any one time. 3. No more than 21 service users with Dementia over the age of 65 years ay be accommodated at any one time. 4. 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. 5. 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. Date of last inspection 15th March 2005 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 D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection commenced at 9.30am and was completed at 3.30pm. The inspector was assisted by Sue Tiller Registered Manager and the care staff. The inspector was able to freely tour the home and visit with many of the Service Users. Care records were inspected, as were medication records. What the service does well: What has improved since the last inspection? What they could do better: The pre admission assessment document should be changed to ensure that all care needs are really assessed. The care plans do not meet the needs of the Service Users and documentation is limited. The electrical sluice should be in full working order to ensure that infection control practices are maintained. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 6 The staffing levels should fully meet the needs of the Service Users. The emergency lighting should be tested monthly ensuring the safety of the Service Users in the event of a fire. 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 D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 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. Service Users and families are encouraged to visit the home prior to admission. EVIDENCE: The Registered Manager conducts a pre admission assessment for each Service Users prior to admission to ensure the home is able to meet the personal care needs and social care needs of the Service Users. The document used to record the assessment is in-fact a long-term care needs assessment and is not suitable to be used as a pre admission assessment as it is complex and may cause more stress to the Service User at what could be considered a very stressful time. The current policy is that this document will be used in the care records for three months and then removed from the care record. All longterm care needs are then transferred to short- term care needs. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 9 Where possible Service Users and families are encouraged to visit the home prior to admission to view the home and meet with staff and other Service Users. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The care records do not fully address all aspects of care providing evidence that all health care needs are fully met. The medication procedures are safe. Personal care is provided in privacy treating the Service User with respect. EVIDENCE: Each Service User is provided with a care plan. However several key documents have been removed from the care plans since the last inspection. The key worker information sheet has been removed, yet when the inspector spoke with Service Users many referred to their key worker. The pressure sore risk assessment has been removed causing a risk to those Service Users who maybe at risk of pressure break down, as there is now no written indicator available. Clear documentation was in place regarding Dr visits but did not link to the daily records. The home is not registered to provide nursing care therefore the Community Nursing Team attends to nursing needs. The Service Users the inspector visited were confident that their health care needs were being met and all were Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 11 registered with a local GP. However due to the standard of care records it is difficult to assess if all care needs are fully met. The Registered Manager has worked hard to improve the medication procedure ensuring now that the medication procedure is fully safe for Service Users. Storage of medication was now satisfactory. Service Users confirmed that any personal care always took place in the privacy of their bedroom or bathroom. This was also observed taking place during the inspection. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 Service Users are supported by the home to maintain links with families and friends. Meals are of a good standard with a varied menu and a daily choice. EVIDENCE: Service Users confirmed with the inspector that they could receive visits from family and friends at anytime. The visitors signing in book was reviewed and confirmed this. The main hot meal of the day was observed, which was well presented. Service Users were all complimentary of the food provided and were able to receive their meals in one of the dining rooms or in the privacy of their bedroom if they wished. The menu was clearly displayed, with a choice available. The kitchen is large and was well organised and clean to a good standard. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 There is a complaints policy and procedure. 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 for Service Users and families to see. All Service Users are provided with a copy of the complaints procedure. The CSCI have recently received two formal complaints, which are currently being investigated. An “Abuse” policy and “Whistle Blowing” are in place. The home has copies of the No Secrets document and care staff understand the local vulnerable adults procedure. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26 The home is generally well maintained providing a safe environment for Service Users to live in. The bedrooms are personalised and homely but the toilet facilities are not. Infection control procedures are not adequate to ensure that Service Users are not at risk of any cross infection occurring. EVIDENCE: Willowcroft is a purpose built home, which is well furnished with domestic furnishings. The home provides good communal areas for Service Users to spend time together and attend group activities. The décor of the home is well maintained apart from the carpet in the main downstairs dining area which was badly stained and will need replacing. A bath hoist seat was broken and will need replacing. The inspector was able to visit many of the bedrooms, which were well furnished and homely. Service Users were seen with many personal items around them. The bedrooms do not have en-suite facilities and the communal toilets could be made more homely. Service Users were satisfied with the accommodation provided. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 15 The home was generally clean throughout apart from one bedroom, which had a strong smell of urine. The bathrooms were clean and infection control measures in place apart from the procedure of cleaning commode pots. The commodes pots were left in the sluice most of the day soaking and would be returned to bedrooms later in the evening. The electrical sluice was not in working order. The whole procedure should be reviewed to reduce any cross infection occurring between Service Users. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home is not able to meet the needs of the Service Users with the current staffing levels in operation. The home’s recruitment practices are satisfactory apart from ensuring that all employees provided proof of identification. EVIDENCE: The staffing levels according to the rotas are 4 carers in the morning shift one of which is the Care Leader for 42 Service Users. The Care Leader is responsible for the morning medication administration round whilst leaving only three carers during this busy period to support and provide personal care to 42 Service Users which is a ratio of 16 Service Users to 1 carer. This staffing level cannot fully meet the needs of the Service Users especially those suffering from Dementia who require more support and guidance with many aspects of daily living. At the time of the inspection 5 carers were available however they seemed busy and rushed. Service Users made comments to the inspector regarding how short of staff the home appeared and that staff were always very busy. Three employment files were reviewed which were all satisfactory apart from one file did not have proof of identification. All employees are CRB checked protecting the Service Users. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 There is leadership from the registered manager. Appropriate health and safety checks are made within the home ensuring Service Users are living in a safe environment apart from the emergency lighting not being checked monthly. EVIDENCE: The Registered Manager has been in post at Willowcroft for approximately a year but has also managed similar homes prior to this post. The Manager has recently completed The Registered Managers Award Level 4. Fire records indicated that weekly testing of the fire alarm was taking place, however the emergency lighting had not been tested for two months. The Staff had received fire training and all fire exits were accessible. Accidents were fully recorded and audited by the Manager regularly. The home is well maintained, ensuring the safety of the Service Users and the staff. Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 3 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 Standard No 16 17 18 Score 3 x 3 3 x x x x x x 2 Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 19 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 OP3 Regulation 14(1,c) 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 easliy be used in consultation with the Service User prior to admission. The Registered person will ensure that the Keyworker document is used as Service Users made references regarding the Key worker relationship. The Registered person will ensure that a pressure area risk assessment is completed for all Service Users. The Registered Person will ensure the daily statement is detailed and in line with the GPs visit. The Registered person will replace the carpet in the downstairs dining room The Registered person will replace the bath hoist seat in the ground floor bathroom near Rm 3. The Registered person will ensure that bedroom carpets are kept clean and odour free at all Timescale for action By 1st November 2005 2. OP7 15 By 1st November 2005 By 1st November 2005 By 1st November 2005 By 1st November 2005 By 1st November By 1st November 2005 Page 20 3. OP7 15 4. OP7 15 5. 6. OP19 OP19 23 23 7. OP26 23 Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 times. 8. 9. 10. OP26 OP26 OP27 23 13 18 The Registered person will ensure the electrical sluice is in working order. The Registered person will change the procedure for dealing with the commode pots. The Registered person will ensure that the staffing levels fully meet the needs of the Service Users at all times. The Registered person will ensure that all employment files contain proof of identification. The Registered person will ensure that the emergency lighting will be tested monthly. By 1st November 2005 By 1st November 2005 By 1st November 2005 By 1st November 2005 By 1st October 2005 11. 12. OP29 OP38 19 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. Refer to Standard Good Practice Recommendations Willowcroft D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 21 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, 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 D51_D01_S28288_Willowcroft_V205137_310805_Stage4.doc Version 1.40 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!