Inspection on 17/06/05 for Willowmead

This inspection was carried out on 17th June 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 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

Willowmead 03/05/07

Willowmead 07/11/05

Willowmead 10/01/05

Willowmead 30/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Willowmead Summer Road East Molesey Surrey KT8 9LR Lead Inspector Miss Marianne Barham Announced Inspection 17 June 2005 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. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willowmead Address Summer Road, East Molesey, Surrey. KT8 9LR 020 8398 8664 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) Mrs Marion Davies Mrs Marion Davies CRH (PC) 12 Category(ies) of Old age, not falling within any other category registration, with number (OP) 12. of places Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be over 65. One person to be accommodated may be under the age of 65. Date of last inspection 10 January 2005 Brief Description of the Service: Willowmead is a semi-detached home located in the village of East Molesey. The property backs onto the river and has a well maintained, attractive rear garden that is accessible to the service users. There is parking to the front of the property. The home is owned and managed by Mrs Marion Davies and provides accommodation and care to twelve older people. There are three separate communal lounges, a dining room and a large, homely kitchen on the ground floor. All bedrooms are single occupancy with most having en-suite facilities and there is a good standard of aids and adaptations throughout the home. The majority of bedrooms are on the ground floor. A stairlift is available to access rooms on the first floor, though three steps have to be negotiated at the top of the stairs, for which hand rails have been fitted to aid access. There is a flat consisting of a bedroom, a lounge and a bathroom on the top floor, this is reached by stairs. The home also has a large self contained function room and its own vehicles to access facilities in the local community and beyond. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried at 10.00am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of four and a half hours and was the first inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The registered proprietor and manager Mrs Marion Davies was present and a total of ten service users, four staff members and one visiting relative were spoken with during this inspection. Comment cards were received from all service users and several relatives prior to this inspection, all of which were complimentary about the care and services received at the home. What the service does well: There is a calm, relaxed atmosphere in the home and it is decorated and furnished to a high standard throughout. Service users bedrooms are large, comfortable and attractive, all service users spoken with commented on this. The home offers a wide range of activities to service users based on their own interests and preferences. Visitors are made to feel welcome by the home and this was reflected in the comment cards received and conversation with service users. Service users are able to bring their pet cats and dogs with them when they move in to the home and are supported by the staff team to look after them. This helps remove some of the anxiety service users feel when they move in to a care home. Service users spoken with all stated that they were happy living in the home and all praised the staff team and the manager for the high standard of care received. Staff members spoken with were happy working in the home and felt that they received a good standard of training, supervision and support from the manager. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 6 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. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 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 Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 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) 2 and4 Service users have a written statement of the terms and conditions with the home and they can be sure that the home is able to meet their needs. EVIDENCE: Each service user has a contract stating their terms and conditions of residence at the home. These are in line with the guidance from the Office of Fair Trading and have been signed, either by the service user or a representative. This meets a requirement made at the last inspection on 10th January 2005. The home has recently introduced an admissions checklist for bedrooms and facilities in the home to make sure that facilities required from the preadmission assessment of the service user are in place. As good practice this checklist has been carried out for existing service users as well to ensure their needs continue to be met. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 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 standard(s) 7, 10 and 11 Each service user has an individual plan of their health, personal and social care needs, their privacy is respected and they can be sure that at the time of their death they and their families will be treated with care and sensitivity in the home. EVIDENCE: Care plans were examined and found to be comprehensive and clearly written. All aspects of the service users needs were recorded with good instructions for care staff to follow in meeting those needs. The care plans were not signed by, the service users and a recommendation has been made to address this. Staff members were observed to treat service users with respect and carry out care duties in a dignified manner throughout the inspection. Service users and their families spoken with praised the staff team for their caring and respectful treatment of service users. The home has a policy and procedure in place for the care of a dying and death of a service user. Staff are made aware of the policy at induction and updated at team meetings. This meets a requirement made at the last inspection. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 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 standard(s) 12 and 15 Service users experience a lifestyle in the home that reflects their individual interests and preferences. They receive a balanced, nutritious diet that takes account of their dietary needs and tastes. EVIDENCE: The home offers a wide range of activities to service users, including trips to places of interest, entertainers at the home, dog walking and games, puzzles and crossword sessions. Service users are able to choose whether they take part in activities. The home has links with the local church and service users are supported to attend services if they wish. They also access a local day centre that offers activities such as cooking, music and singing lessons. Menus at the home are rotated two weekly and offer a good range of nutritious meals. Service users are consulted about meal preferences and are able to choose what they have to eat. The home employs a cook and an assistant and all meals are home made. The tables in the dining room were nicely laid and service users were observed to be having a lunch of soup and crusty bread that looked appetising. Service users spoken with were complimentary about the food and confirmed that they had a choice of the meals they ate. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 11 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) 18 Service users at the home are protected from abuse. EVIDENCE: The home has a comprehensive policy and procedure in place for the protection of vulnerable adults and a whistle blowing policy. Staff members are made aware of these at induction and through team meetings. The home also has a copy of the Surrey Multi-Agency Procedures and the manager and five of the staff team have attended the training run by Surrey. The remainder of the team have received in house training by the manager who has been trained to deliver this. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 12 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 clean, safe, well-maintained and pleasant and service users bedrooms are comfortable and they are able have their own possessions in them. EVIDENCE: The home is immaculately presented throughout, with comfortable furnishings and attractive décor. There is ample communal space for service users and their visitors to sit and relax. Most of the bedrooms are on the ground floor with the majority being en-suite. Those not en-suite have full bathrooms next door to them. Bedrooms on the first floor are reached by stairs or a stair lift, however, there are three steps at the top of the stairs to negotiate, for which a rail has been fitted. Service users bedrooms are of a good size, pleasantly decorated and furnished and personalised with their own belongings. Service users spoken with stated they were very happy with their rooms and the standard of the home. The home is very clean and tidy throughout. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 13 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 service users needs are met by, the number and skill mix of the staff team and service users are supported by the homes recruitment policy, however, all staff need to have CRB checks carried out. EVIDENCE: Staffing rosters were examined. These show that the numbers and skill mix of the staff team meet the needs of the service users and exceed recommendations of the Residential Forum. Many of the staff team have worked at the home for a number of years and this is reflected in their knowledge and skills. Staff spoken with felt that they received sufficient training and supervision to carry out their duties competently. Staff personnel records were examined for a number of staff members. These were found to contain identifying documents, application forms, work histories, references, and Police checks. None of the records contained Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) checks. The manager explained that she had taken the CRB forms to the local Police station and had been advised that the Police check was sufficient. An inspector at a previous inspection confirmed that the Police checks were sufficient. CRB and POVA checks have since become compulsory in July 2004 and a requirement has been made that all staff members undergo these checks. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 14 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) 37 and 38 The policies, procedures and record keeping in the home safeguard the rights and best interests of service users and their health, safety and welfare is protected. EVIDENCE: The home has a comprehensive list of policies and procedures. The staff team are made aware of these at induction and through team meetings and individual supervision. Copies of the most used policies and procedures are kept centrally in the kitchen so that all staff members have access to them. Records examined were found to accurately maintained and regularly reviewed and updated. The home carries out a health and safety audit quarterly and there is a programme of routine maintenance and repairs in place. Fire equipment, alarms etc are checked quarterly with alarm tests weekly and evacuations monthly. All members of staff have received training on health and safety issues and are updated annually. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 15 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 3 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 4 x x x x 4 x 4 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x x 3 3 Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 16 NO 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 29 Regulation 19 (4) (b) Schedule 2 Requirement A check by the Criminal Records Bureau (CRB) must be undertaken for all members of staff working at the home. Timescale for action 17/09/05 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 7 Good Practice Recommendations It is recommended that care plans are signed by the service user or their representative to demonstrate their involvement in the process. Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 17 Commission for Social Care Inspection The Wharf Abbey Mill business Park Eashing Surrey GU7 2QN 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 Willowmead H58 H09 s13831 Willowmead v223817 170605 Stage 4 ann.doc Version 1.30 Page 18 - 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. 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