This inspection was carried out on 17th March 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Willowdene Care Home Lizard Lane Sedgefield Stockton On Tees TS21 3ET Lead Inspector
Mr Peter Bentley Unannounced Inspection 17th March 2006 1:00 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 Willowdene Care Home DS0000059169.V275585.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. Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Willowdene Care Home Address Lizard Lane Sedgefield Stockton On Tees TS21 3ET 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) 01740 623644 Maria Mallaband Care Homes Limited Mrs Lynne Margaret Smith Care Home 48 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (36) of places Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: Willowdene provides residential care services for up to 36 persons in the category of OP (older persons) and for up to 12 persons in the category of DE(E) (Dementia Elderly) residing in the Maple Suite. The Home is a modern two story building with the benefit of a lift between the floors along with a single floor annex known as the Maple Suite. The home is situated on the B 1278, about half way between Sedgefield and Fishburn, and lies within its own grounds. Although situated in a rather isolated position, with no shops or other amenities close to the home, there are frequent buses to local villages and major towns and cities in the area ( eg Durham, Sunderland) with a bus stop immediately outside the home. Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced Inspection took place over a five hour period. At the time of the Inspection the manager was on annual leave. The staff member in charge of the home did not have access to some of the documentation and records needed, and as a result it was not possible to look at everything that was planned during the Inspection. During the inspection some files of residents were looked at, talks took place with staff members dispensing medication, the procedure followed by the staff member giving out medication was watched, talks took place with the cook and menus and other records examined. A discussion took place with one of the residents who was involved with the residents committee. There were shorter talks with other members of staff and some residents during the teatime meal. What the service does well: What has improved since the last inspection?
Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 6 Since the last recent inspection there was clear evidence of some developments at the home which need to be acknowledged. There was reference in the last report to concerns about an unresolved problem between the day and night staff teams. During this inspection it became clear from talking to a number of staff that the atmosphere was now much improved and any problem which had been there in the past now no longer existed. In the view of the staff the reason for this change appeared to be connected to recent changes in the staff who were employed at the home. The last report referred to the need to develop a working supervision policy. There was evidence on this inspection that an appropriate supervision policy for staff was now in place. 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. Willowdene Care Home DS0000059169.V275585.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 Willowdene Care Home DS0000059169.V275585.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): None of the above standards were looked at on this inspection. EVIDENCE: Willowdene Care Home DS0000059169.V275585.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): Standards 8,9 Standard 8 Residents health care needs were met. Standard 9 Although some evidence was seen that the homes procedures were protecting residents there was also evidence that they are not always fully doing so. It is important that the homes manager undertakes a review of all aspects of medication safe storage (including the safe storage of oxygen bottles and whether the current location is appropriate), and the giving of medication to residents. In particular the following aspects of procedure need to be immediately checked : that there is no danger of residents being given the wrong medicines from the medicines trolley and that the door to the drugs room in Willowdene is locked when, during the dispensing of medicines, the staff member concerned is not in the immediate vicinity of the room. These measures will ensure that residents only take the medicines prescribed for them and are protected from the opportunity to gain access to medicines inappropriately, and their safety will be further ensured by the appropriate storage of oxygen cylinders.
Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 10 EVIDENCE: Standard 8 A random selection of three residents files were looked at. It was clear that health needs have been met, one resident having seen the doctor on the morning of the inspection and there was evidence that another resident was being carefully monitored by the staff every fifteen minutes because of an ongoing health issue. Standard 9 Talks took place with the staff members administering medications. The giving out of medication to residents was observed on four occasions with three different staff members ( once briefly at the start of the inspection, and three times at teatime) on both floors of Willowdene and in the Maple suite. A senior staff member stated that no resident was ‘self medicating’. All the persons dispensing medication said they were aware of the homes drugs protocol. One said that she had taken a course in the administration of drugs ( level 2) and another said that she had finished a drugs administration course in November 2005. It was not possible to see written evidence of these qualifications at the time of the Inspection as access to staff files was not possible because of the absence of the manager on annual leave. During the first observation (at the very start of the inspection) is was noted that the person dispensing the medication was giving the medication in a plastic cup to another staff member to give to the resident. It was noted that there was an occasion when two cups, with medication already in them, were on the top of the trolley waiting to be picked up by two different staff members. There was a danger that the wrong cup could have been picked up and hence the wrong medication given to a resident. In addition during the teatime administration of medication on the ground floor of Willowdene it was noted that when the staff member giving out medication was away from the room, and out of eyesight of it, the door to the medicine room remained open and unlocked. The trolley had been properly locked but there were ‘blister packs’ of medication on top of the trolley unprotected. The person dispensing the drugs was at the time giving medication to a resident in the residents room some distance away from the medicine room. It was noted that the oxygen bottles stored in the Willowdene medicine room were not secured although the end of a chain was hanging loose nearby. It was also noted that in the weekly audit checks ( which were up to date) a ‘no’ was recorded against the question ‘are there any unsecured gas cylinders?’.
Willowdene Care Home DS0000059169.V275585.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): Standard 15 Residents received a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: Standard 15 Talks took place with the cook at the home. The menu of food available at the home was looked at. The cook was in the process of completing new menu cards with an improved variety of food on them. He was enthusiastic about this - it having been part of his course work on a ‘focus on food’ course. The cook said that there was a need to produce new menus because the old ones ‘did not give enough detail’, ‘they contained examples of too many things on too often’, and ‘there was no hot choice on the Sunday teatime meal’. Records were seen that documented what meals and drinks each resident had taken on any one day. Evidence was seen in the kitchen of recording that indicated that the cook was taking a real interest in fortifying food where appropriate for residents and that he had a good understanding of the individual needs ( and recent weight loss/gain) of residents.
Willowdene Care Home DS0000059169.V275585.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): Standard 18 It was not possible to assess this standard because required documents were not available as the manager was on annual leave. EVIDENCE: Willowdene Care Home DS0000059169.V275585.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): None of the above standards were considered at this inspection. EVIDENCE: Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 14 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): Standard 27 The needs of residents is met by the numbers and skill mix of staff on duty. It is strongly recommended that ways to minimise the possibility of only two care staff being on duty on the upper floor of Willowdene (during the daytime) be examined. EVIDENCE: Standard 27 Talks took place with the senior staff on duty and the duty rota was looked at. From these discussions it was apparent that the normal staffing during the daytime was three carers on duty in the upstairs of Willowdene together with a senior and carer on the ground floor and a senior and carer in the Maple Suite. This was confirmed by information on the staff rota. There was concern expressed by some of the staff that if only two staff are on duty on the upper floor of Willowdene there was a danger that the staff there became very heavily pressed in meeting the needs of residents adequately. It was also noted that Willowdene has quite a high rate of staff sickness and that this was apparently contributing to the difficulty. Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 15 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): Standard 35,38 Standard 35 The homes manager was on leave at the time of the inspection and relevant records relating to this standard were not available. Standard 38 (part) This standard could not be examined in full because of the lack of access to appropriate records. It was however possible to partly consider standard 38. Immediate attention must be given to ensure that all senior staff who are likely to be in overall charge of the home ( in the absence of the manager and deputy manager) are fully aware of their responsibility and the actions they must take should there be an outbreak of fire at the home. In particular the fire service must be called immediately. EVIDENCE:
Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 16 In the absence of the homes manager questions were asked of the senior staff concerning their actions should a fire break out at the home and separately should a resident be suddenly taken seriously ill. Whilst in the main the responses were satisfactory one of the responses to the question about an outbreak of fire was not as clear as it should have been regarding the need to immediately dial ‘999’. (The response from the staff member was that attempts would be made to ‘get the fire under control’). Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 9.4 Regulation 13.2 Requirement It is required that the home checks to make sure that the procedure used for the administration of medication follows recognised practice and removes any possibility that residents may by mistake be given the wrong medication. It is required that secondary dispensing must cease. It is required that the door to the medicines room on the ground floor of Willowdene is always locked when the staff member giving medicines to residents is not in the room or in the immediate vicinity of it. It is required that the home review whether the current location of oxygen bottles is appropriate and ensures they are securely stored. It is required that senior staff are 30/03/06 made fully aware of the procedure (as advised by the Fire and Rescue Authority) to follow should there be an outbreak of fire at the home.
DS0000059169.V275585.R01.S.doc Version 5.1 Page 19 Timescale for action 30/03/06 2 38.2 23(4) Willowdene Care Home RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willowdene Care Home DS0000059169.V275585.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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