Inspection on 21/12/05 for Willowdene Care Home

This inspection was carried out on 21st December 2005.

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.

Other inspections for this house

Willowdene Care Home 05/02/09

Willowdene Care Home 06/02/07

Willowdene Care Home 17/03/06

Willowdene Care Home 03/11/04

Willowdene Care Home 15/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Willowdene Care Home Lizard Lane Sedgefield Stockton On Tees TS21 3ET Lead Inspector Mr Peter Bentley Unannounced Inspection 21st December 2005 10:00 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.V272281.R01.S.doc Version 5.0 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.V272281.R01.S.doc Version 5.0 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 (12), Old age, not falling within any registration, with number other category (36) of places Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2004 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.V272281.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was meeting the needs of residents well and they benefited from the opportunity to be involved in an extensive range of activities both inside and outside the home. Residents were treated with dignity and respect and given the opportunity to make their own independent choices. Issues that were of concern were the use of non approved door jams, the lack of a working staff supervision policy, the absence of the proper use of a complaints procedure and issues relating to unresolved problems within the staff team. This inspection started on the 21st December 2005 and concluded on January 13th 2006. During this period two visits were made to the home , the first being unannounced. A total time of about eleven hours was spent on the inspection. During this period discussions took place with the manager, and seven other members of staff. Discussions also took place with three residents and three relatives of residents who happened to be visiting. Some records were also examined and the replies on comment cards completed by twenty residents were looked at. A further unannounced Inspection of Willowdene is intended in the next few months and additional standards, not considered at this inspection, will be looked at then. A relative said ”it’s the nicest one (home) I’ve ever been in over the years..the staff are wonderful”. A relative said ”they (the staff) get to know them ( the residents) and talk to them……I’ve been in a lot of homes with (name of resident) and this is the best one I’ve been to”. A resident said ”you can still keep your dignity (here)…you don’t need to lower your standards because you’re living in a home”. What the service does well: Particularly impressive at Willowdene was the opportunity available to residents to be involved in activities both inside and outside the home. This is primarily because of the enthusiasm and commitment of the activities organiser presently in post. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 6 Visiting relatives and friends feel welcome at the home. Residents believed that their dignity and independence were respected. The homes manager was very keen on providing the opportunity for relevant training for the staff and said that between 60 and 70 of staff have now obtained the appropriate qualification for the work they do (the recommended minimum is 50 ). All the above are significant in that they help the residents experience a good quality of life at the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 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.V272281.R01.S.doc Version 5.0 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): Standard 3 A pre-admission assessment is carried out before potential residents are offered a place at the home EVIDENCE: The Manager of the home stated that all pre-admission assessments were undertaken by herself or her deputy. Copies of a letter sent to residents after the pre-admission process were seen on residents files. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 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 7,10 The Individuals care plans are set out in the residents file and were up to date. It was clear that residents were treated with respect and their dignity and privacy respected. EVIDENCE: Standard 7 Entries in the care plans looked at were up to date and seemed comprehensive, referring to health, personal, and social care needs. Standard 10 There was evidence from discussions with staff and residents that the residents dignity and his or hers right to independence and privacy were respected. The replies on the service user comment cards, completed by residents, confirmed this. A resident said “they try and keep you independent…..they like us to try and make our own minds up on certain things …..you can still keep your dignity…you don’t need to lower your standards because you’re in a home”. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 10 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): Standards 12,13,14 There was a comprehensive variety of activities for residents to take part in should they wish. Contact with relatives and friends was made easy for relatives. Relatives felt welcomed at the home. The provision of a post box in the home, looked after by the activities organiser, made it easy for residents to post letters. Generally residents and relatives were happy with lifestyle choices in the home. Residents were encouraged to exercise choices. EVIDENCE: Standards 12 and 14 There was a weekly list of activities available for residents selected from a comprehensive list of options including bingo, ball games, baking, musicalchairs, dominoes, word games, gardening, and watching a video. The home has a pet dog, ‘Dylan’, who visited the residents every two weeks Occasional visits from outside entertainers took place and there was a weekly visit by a hairdresser. Outside bus trips were organised to places, and activities, of interest to the residents (eg theatre nights). Local school children take part in a Christmas service at the home. One of the activities available was Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 11 ‘reminiscing-including giggles’ which gave the residents a chance to talk about their memories and past lives. However one staff member and one resident did feel that there was not enough activity available outside the home. This could indicate that better consultation with staff and residents regarding activities outside of the home was required. Residents files were looked at and discussions took place with residents, relatives and staff. The replies of residents to questions asked on the ‘comment cards’ was considered. The Willowdene ‘activities schedule’ was read. A visiting friend of a resident said ”..(there are ) opportunities to go out.. (she) does play bingo, they go to the operatic, they can go shopping …”. A resident said .. “If you want to go anywhere you just ask the person in charge and they let us go anywhere”. Discussions with the activities organiser confirmed that she was aware of the individual preferences of residents and tried to structure activities to meet their different needs. Standard 13 Discussions took place with residents, relatives and staff. The daily report sheet on residents files was looked at. A relative said …” I always feel welcome”. A resident said ….” They ( referring to relatives)..just come when they want to”. A relative said …” I always find them ( the staff) .. alright.” Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 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 16 Some service users were aware that they could raise matters of concern with the manager but there was no evidence of the service users being encouraged to use a formal complaints procedure. It is important that the home develops its complaints policy and makes it available for use. A written record of complaints must be kept as required by the regulation. It is essential that there is evidence kept by the home of the fair resolution of complaints in a way which residents, relatives, and staff can have confidence in. This helps ensure residents are protected from abuse. EVIDENCE: Standard 16 . The complaints book was looked at and discussions took place with residents relatives and staff. The manager stated : “to be honest we don’t get complaints .. I address the issue in front of them”. The last entry in the complaints book examined was over seven months before the date of this inspection. A staff member said ..”…they ( complaints)..get sorted out ok”, however another member of staff said that she did not believe that the manager treated all the staff equally. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 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): Standards 19,26 In general the residents live in a well maintained safe environment. It is however not acceptable for doors to be wedged open by non approved devices. Doors which are normally required to be closed for fire safety reasons must only be kept open by devices approved in writing by the Fire and Rescue Service. The home was clean, pleasant, and hygienic. EVIDENCE: Standard 19 During a tour of the building a small number of room doors of residents were seen to be wedged open. The manager said that this was because the resident was in the room and wished the door to be open and that an officer from the Fire and Rescue Service had agreed verbally that this was acceptable in the short term. The manager said that in the event of a fire staff would kick away the door jams. The manager was not able to produce written confirmation from the Fire and Rescue Service that this practice was acceptable. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 14 Standard 26 A resident said ..”its run fairly decent …its clean…..its clean that’s the main thing”. A tour of the home confirmed that the home was clean, pleasant and appeared hygienic. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 29,30 Standard 29 There is a good system in place for ensuring staff employed are properly vetted before they commence employment. This ensures that the residents are cared for by staff who are committed to enhancing the quality of life of the residents. Standard 30 There is a culture in the home ( led by the manager) that encourages appropriate attendance at courses by the staff. The manager said that more than 50 of the care staff have a level 2 NVQ qualification (as recommended by the relevant standard). EVIDENCE: Standard 29 There was evidence from the staff files examined that references and other checks were taken up and considered before the person was employed by the home. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 16 Standard 30 There was clear evidence from staff records and from speaking to staff of recent, and relevant, completion of appropriate courses relevant to the work of the staff member. Courses attended by staff included infection control, first aid, fire training, food hygiene, catheter care, and manual handling. The manager said that between 60 and 70 of the care staff are qualified to NVQ level 2 and this was confirmed by another senior staff member. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 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 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): Standards 31,33,36 Standard 31 The home is run and managed by a person able and fit to do so. The manager has demonstrated good leadership on a number of issues relevant to the efficient running of the home for the benefit of residents. Standard 33 It was concerning that there were issues involving how the staff got on with each other and their relationship with the homes manager. These issues needed to be resolved immediately in order that the staff are able to say that they all worked together as a team. Only when this is true for the staff can the home be certain that it is run in the interests of service users. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 18 Standard 36 Although there was evidence of some appraisal and supervision activity there was not the evidence to show that persons working at the home were appropriately supervised as required by the regulation. EVIDENCE: Standards 31 A letter dated 29/10/05 from Care Training Services confirmed that the manager had completed her qualification at level 4 NVQ in management and care as recommended by the standard. Standard 33 Comments from staff included reference to problems relating to ‘staffing issues’, that the manager ‘doesn’t seem to treat all the staff the same’, that there is ‘no consistency’ from the manager, and that ‘although there were a lot of good staff here some don’t deserve to be in a job like this’. There was a belief by some staff that the whole staff group (in particular the day and night staff) were not working together as ‘team’ for the benefit of residents. These matters were discussed with the home manager who was aware of some staffing issues which needed to be resolved. Standard 36 The manager agreed that an appropriate supervision procedure was not yet in operation at the home. She indicated that it was intended that the supervision of the staff team would be shared between herself and her deputy and would result in supervision for each member of staff once per month and in addition an annual appraisal of once per year. Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 1 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 1 X X Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Requirement number 1 of the previous inspection was worded as follows: ‘That the homes registered manager must by the year 2005 have satisfactorily completed the level four National vocational qualifications in management and care’. During the course of this inspection the homes registered manager produced a letter dated 29/10/05 from Care Training Services confirming that she had completed the required qualifications. The outstanding requirement from the previous Inspection is therefore met. 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 16 Regulation 22 Requirement It is required that a complaints procedure as required by the regulation is put into operation and recommended that in particular a record is kept of all complaints made and includes details of the investigation and any action taken. It is required that the home use only devices, approved in writing by the Fire and Rescue Service, to keep doors open that would otherwise be required to be closed by the Fire and Rescue Service. It is required that the registered DS0000059169.V272281.R01.S.doc Timescale for action 31/03/06 2 19.5 23 (4c) 31/12/05 3 32.1;32.4 12(5)(b) 30/04/06 Page 21 Willowdene Care Home Version 5.0 4 36.2;36.3 18 (2) provider and registered manager understand the nature of the culture of disquiet between some members of staff at the home and take action to ensure that all staff work together as a team for the benefit of the service users. It is required that all persons 30/04/06 working at the home are appropriately supervised. It is recommended that the frequency of supervision for care staff is at least six times per year and covers the areas specified in the Standard. 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 12 Good Practice Recommendations It is recommended that the home ensures that all staff and residents are aware of activities (both inside and outside the home) in a way which enables a positive participation by residents in activities that they choose to be involved in. In particular it is recommended that staff work constructively together on this. It is recommended that in addition to the question relating to a residents preference as to a bed time ( as part of the service users plan) the same question is asked as to the residents preferred ‘getting up’ time in the mornings and this is complied with as much as possible. 2 14.1 Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 22 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 © 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 Willowdene Care Home DS0000059169.V272281.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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