CARE HOMES FOR OLDER PEOPLE
Willowmead Willowmead Summer Road East Molesey Surrey KT8 9LR Lead Inspector
Marianne Barham Unannounced Inspection 7th November 2005 11:00 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 Willowmead DS0000013831.V252980.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. Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Willowmead Address Willowmead Summer Road East Molesey Surrey KT8 9LR 020 8398 8664 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) Mrs Marion Davies Mrs Marion Davies Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 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 17th June 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 DS0000013831.V252980.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried at 11.00am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of three hours and was the second 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 eight service users and four staff members were spoken with during this inspection. What the service does well: What has improved since the last inspection?
All members of staff have a Criminal Records Bureau check carried out on them meeting a requirement made at the last inspection on 17th June 2005. All care plans are now signed by, the service user or a representative to show that they have been involved in the care planning process, meeting a recommendation made at the last inspection. Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 Page 6 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 DS0000013831.V252980.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 Willowmead DS0000013831.V252980.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): 3 Service users can be sure that the home is able to meet their needs. EVIDENCE: Following the initial enquiry the home sends out a short information request form for prospective service users to complete. This provides background information and contact details to the home. Once a bed becomes available the manager then carries out a more comprehensive assessment that takes into account all areas of the persons needs. Once this is completed a decision is then made as to whether the home is suitable for the person. Some service users, admitted to the home from hospital, also have a health needs assessment carried by the hospital staff. The manager stated that she would not admit a person unless she was sure that their needs could be met. Willowmead DS0000013831.V252980.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): 8 and 9 Service users healthcare needs are met and the home’s policies and procedures for dealing with medicines protect them. EVIDENCE: All service users are registered with a local GP practice. The home has a good relationship with the practice and accesses district nurses and other specialist healthcare professionals through it. Health needs assessments are carried out jointly by, the manager and the district nurse. The service users access an optician in the town and are registered with a local NHS dentist who also carries out domiciliary visits when needed. A chiropodist visits the home every six to eight weeks and sees all service users. The home has a policy and procedure in place for dealing with medicines that is in line with guidance from the Royal Pharmaceutical Society and all staff members who administer medications have read this. The medication is delivered to the home mainly in blister packs from a local pharmacy and six monthly audits are carried out by this pharmacy, with advice provided to the home as needed. A record is kept of returned medicines.
Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 Page 10 The medication administration records were examined and found to be in good order with no errors noted and the medication was seen to be stored securely. Members of staff undertake a distance training course on the safe administration of medicines run by NESCOT college in Epsom and a list of those qualified to administer medication is kept in the medication file. Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 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): 13 and 14 Service users maintain contact with their friends and family and are helped to exercise choice and control over their lives. EVIDENCE: Service users are able to receive visitors at any time without an appointment. Visitors may be seen in the lounge area, the garden room or in the service user’s room. The home actively supports service users to stay in contact with their friends and family through telephone calls, letters and accommodating special occasions such as holding birthday parties. Service users are allowed to bring their pets with them when they move into the home, which alleviates a lot of stress for the individual and provides for a homely atmosphere in the home. All service users spoken with enjoy having the animals around, including those without pets. Service users are encouraged to make choices about their everyday lives by the home and this was confirmed by those spoken with who said that they get up and go to bed when they please, choose how they spend their time and what they have to eat and drink.
Willowmead DS0000013831.V252980.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): 16 Service users and their friends and family can be sure that any complaints they have will be listened to and acted upon. EVIDENCE: The home has a complaints procedure in place, a copy of which is contained in the service users guide given to each service user. The procedure is clearly written and gives information to the reader on the process to follow when making a complaint. The home maintains a complaints and suggestions book for service users and visitors to write in. The home has never received any formal complaints and any concerns that service users or their families have are dealt with as soon as the home is made aware. Service users spoken with confirmed that they had never made a complaint and that they would speak to the manager if they were worried about anything. Willowmead DS0000013831.V252980.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): N/A These standards were not assessed at this inspection. Please see report dated 17th June 2005 for detail on these standards. EVIDENCE: Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 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): 30 The staff team in the home are trained and competent to do their jobs. EVIDENCE: The home has a programme of planned training in place that incorporates mandatory training such as Health & Safety and fire training as well as developmental training such as dementia care and equality and diversity training. The manager has undertaken NVQ assessor and also ‘train the trainer’ training and carries out a lot of the staff teams’ training herself. Individual training records are kept for each member of staff with both the manager and the staff member signing to show the training has taken place. Members of staff spoken with confirmed that they receive training and supervision, all said that they were supported by the manager and felt that they receive a good standard of training that is appropriate to the jobs they do. Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 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): 33 and 35 The home is run in the best interests of service users and their financial interests are protected. EVIDENCE: The home has a business plan in place and quality audits are carried out when formulating the plan. Feedback is sought from service users and their families through regular meetings. These are recorded and any issues raised are addressed with actions taken carried forward to the next meeting. Service users spoken with said that the manager often asked for listened to their views. The home is not involved in service users finances. Any purchases made or services provided that are extra to the fees is invoiced direct to the service user or a representative. Records are kept of all transactions undertaken on behalf of service users and receipts kept as proof of purchase.
Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 Page 16 Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 Willowmead DS0000013831.V252980.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office 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 DS0000013831.V252980.R01.S.doc Version 5.0 Page 20 - 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!
