Inspection on 15/12/05 for Willows Christian General Nursing Home

This inspection was carried out on 15th December 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

Willows Christian General... 22/05/07

Willows Christian General... 06/06/06

Willows Christian General... 24/05/05

Willows Christian General... 04/01/05

Willows Christian General... 01/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Willows Christian General Nursing Home Warford Park Faulkners Lane Mobberley Cheshire WA16 7AR Lead Inspector Denis Coffey Unannounced Inspection 15th December 2005 09:00 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 Willows Christian General Nursing Home DS0000018825.V264882.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. Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willows Christian General Nursing Home Address Warford Park Faulkners Lane Mobberley Cheshire WA16 7AR 01565 880180 01565 880068 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) Trinity Care Limited Mrs Vanessa Bradley Care Home 60 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (20), Old age, not falling within any other of places category (40), Physical disability (3) Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 60 service users to include: * Up to 40 service users in the category of OP (old age not falling within any other category) * Up to 20 service users in the category of DE(E) (dementia- over 65 years of age) * Up to 2 service users in the category of PD (physical disability over the age of 55) * 1 named service user in the category of DE (dementia under the age of 65 years) to be accommodated in the dementia unit * named service user in the category of PD (physical disability) Links must be maintained with specialist services for advise about the care of the named service user in the category of PD The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection 24th May 2005 2. 3. 4. Date of last inspection Brief Description of the Service: The Willows is a purpose built 60-bedded nursing home, registered for 40 elderly frail residents, and 20 residents with dementia. Three residents under the age of 65 years with a physical disability can also be accommodated at the home. Forty-eight bedrooms have en-suite facilities, and those that do not, have a wash hand basin in the room. There is a choice of lounges. A dining area is provided on the ground floor of the dementia unit, and on the ground and first floor of the unit for older people. The home caters for residents both male and female aged from sixty-five years onwards requiring nursing care. Trained nursing staff are on duty at the home twenty-four hours a day. Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection that took place over a six and a half hour period and included a tour of the premises, an inspection of care, medicine and general records. Residents on all of the units were spoken with and their views sought with regard to the care they receive. Those residents spoken with were positive in their comments about the home in general, the care provided and the support given by the staff. Nine requirements were identified at this inspection. These were in relation to the residents’ care records, medicines, health and safety issues and the premises. Recommendations have been made with regard to personal care, medicines, and the environment. What the service does well: What has improved since the last inspection? The standard of cleanliness on the dementia unit has improved and there was no evidence of unpleasant smells. Residents’ personal money is now kept separate from the home’s amenity and staff fund. Willows Christian General Nursing Home DS0000018825.V264882.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. Willows Christian General Nursing Home DS0000018825.V264882.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 Willows Christian General Nursing Home DS0000018825.V264882.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): 1&2 Information is available for residents to enable them to know that their needs can be met. EVIDENCE: The home has a statement of purpose that informs the residents and their families of the services provided, the range of care needs the home is intended to meet, the arrangements for dealing with complaints, and the number, relevant qualifications and experience of the staff working at the home. Residents are also provided with a written statement of terms and conditions relating to their residency at the home. The Willows does not provide intermediate care so standard 6, identified above does not apply. Willows Christian General Nursing Home DS0000018825.V264882.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): 7, 8 9 10 & 11 Care plans were well documented, but did not address in full all of the identified needs of the residents. The records of medicines needs improving to ensure that residents are administered their medicines as prescribed. EVIDENCE: Four sets of care records were examined at this inspection. All of the records contained nutritional, moving and handling and skin integrity assessments. Plans of care were in place for the identified needs/problems of the residents with the exception of one resident who had an assessment that identified they were at a high risk of developing a pressure sore, but the care plan did not make reference to this risk. Evidence was seen of the care plans being evaluated on a monthly basis. The recorded evaluations for the residents on the dementia unit were not informative in all cases, as they did not identify how the resident was responding to the care being provided. All of the residents are registered with a general practitioner, and records were seen of visits made by the doctor and of other healthcare professionals to the residents. Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 10 The Medicine Administration Record (MAR) sheets for the residents on the elderly frail unit had a number of gaps on them indicating that the residents had not been given their medicines as prescribed. One of the residents was prescribed a medicine that was to be administered rectally, but there was not protocol/procedure for staff to refer to when administering this medicine. There were similar gaps on the MAR sheets of the residents on the dementia unit. One resident was prescribed eye drops that were to be installed four times a day, but the records showed that these were only installed twice a day. The MAR sheet for another resident identified that 0.5mg of a medication was to be given at night, but the container for this medicine had 1.5mg of the medicine in it. There was a tube of ointment in the medicine trolley that did not have the name of the resident for whose use it was intended. Another tube of cream that can only be obtained on prescription was found on the toilet cistern lid in the ensuite of a resident’s bedroom. Medicines subject to stricter controls were examined and found to be correct. Staff were observed to assist the residents in a positive and friendly manner and to address them correctly. Residents spoken with were positive in the comments on how they are treated. At the time of inspection there was one resident who was being nursed in bed and whose physical condition had noticeably deteriorated. Records were seen of the care the resident was receiving, and of their family being informed of the changes in the resident’s condition. See See See See Requirement 1 Requirement 2 Recommendation 1 Recommendation 2 Willows Christian General Nursing Home DS0000018825.V264882.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 14 & 15 Residents are able to make choices in how they live, and are also to receive visitors, enabling them to maintain contact with people who are significant in their lives. EVIDENCE: Residents spoken with said that they are able to exercise choice in their daily lives, and three sets of visitors spoken with said that they were made to feel welcome when visiting and were kept informed. They described the care given as ‘first class’. The menus were varied, and residents said that the standard of food provided was good and that they have a choice of food at mealtimes. Willows Christian General Nursing Home DS0000018825.V264882.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 & 17 There is information available to residents, and visitors to the home on how to make complaints and how these will be dealt with. EVIDENCE: There have been three complaints recorded as being received at the home since the last inspection, one of which was partially substantiated; the other two were not substantiated. Records were seen of a representative of the company investigating the complaints. The home’s complaints procedure was on display, and information on how to make a complaint and to who was included in the service users’ guide. Residents can exercise their right to vote. Willows Christian General Nursing Home DS0000018825.V264882.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): 19, 21, 22, 24 25 & 26 The home provides a comfortable and clean environment for the residents to live in. Satisfactory policies and procedures were in place regarding the risks of cross infection, but staff need to be more aware of good practice in this area, so the risk of cross infection is minimised. EVIDENCE: The home provides adequate communal space for the number of residents accommodated. Residents bedrooms were comfortably furnished and most had been well personalised by the residents or their families. The hard surface flooring in one bedroom on the dementia unit had noticeable black marks on it and this will require replacing if it does not respond to cleaning. Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 14 The home provides sufficient baths and toilets in all areas of the home accommodating residents, and a number of residents’ bedrooms are supplied with the ensuite facilities of a toilet and wash hand basin. All of the remaining bedrooms have wash hand basins in them. The bath in one of the bathrooms on the elderly care unit had a sign on it “do not use”. This bathroom was being used to store two mobile hoists and a linen trolley. Pressure relieving mattresses were on the beds of residents identified as being at risk of developing a pressure sore, and mobile hoists were provided on both units for the movement of residents who are unable to do this independently. Handrails were in place in the corridors and grab rails were located within close proximity to the toilets. Disposable continence equipment is used at the home and machines were provided for the destruction and disposal of these products. Hand washing facilities were provided in these areas. It was observed that one of the nursing staff on duty had nail extensions fitted to their fingernails. This practice is unhygienic and could lead to cross infection occurring when delivering personal care to the residents. Staff are unable to open the windows in the lounge on the dementia unit, as the pole for opening the windows was broken. This means that the ventilation to this room is limited to a door leading onto the garden that was not being opened due to the cold weather. See See See See Requirement 3 Requirement 4 Requirement 5 Recommendation 3 Willows Christian General Nursing Home DS0000018825.V264882.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): 28 & 29 Recruitment procedures are not thorough enough to ensure that the residents are protected from any possible harm. Training is provided to enable staff to develop and maintain their skills in the delivery of care. EVIDENCE: 45 of the care staff employed at the home have achieved an NVQ level 2 in care, and a further five staff have just completed this training and were awaiting confirmation that they had been successful in this. New staff undergo a two-day induction-training programme following which they work alongside an experienced member of staff for a day. An induction programme is also in place for agency staff working at the home. At the time of this inspection five new staff were undergoing an induction course. The areas covered in this included adult protection, infection control, safe moving and handling practices and fire safety. These staff members were recruited abroad, and interviewed in their home country by representatives of the company. An examination of their personnel records was made. There were no application forms in two of the files, no interview records and no record of the weekly contracted hours. Satisfactory references were in place, but there was no evidence that a protection of vulnerable adults or Criminal Records Bureau checks had been made. The home manager was informed that these staff could not work at the home until the necessary checks had taken place. See Requirement 6 See Recommendation 4 Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 16 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): 31, 35, 36 & 38 The health,safety and welfare of residents and staff is generally well managed but there are areas where this could be improved upon. EVIDENCE: The home manager is a trained nurse and has been in post for some time. Staff spoken with said that they are supported in their role and that the manager is approachable and listens to their opinions. Residents’ money held by the home is deposited in non-interest bearing accounts. The home keeps a £50 to £100 ‘float for each resident, from which the cost of hairdressing, chiropody and newspapers are paid for, and receipts are obtained for all such expenditure. Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 17 Records were seen of the staff receiving supervisory meetings with their manager/senior. The night staffs were up to date, and the manager was aware of the need to ensure that this was the case with the day staff. She said that she was planning to do this in the New Year. A fire risk assessment was carried out on the premises in March 2005, and records were seen of the fire alarm and emergency lighting systems being tested on a weekly basis. Records were also seen of a visual inspection of the fire extinguishers being carried out weekly. Fire drills were recorded as last taking place in November and December 2005, but there were some staff that have not undertaken this training within the past twelve months. A total of eleven bedroom doors on the elderly care unit were found to be wedged/propped open. As these doors are designated as fire doors they must be kept closed at all times unless they are fitted with an approved door hold open device. Satisfactory service reports were seen for the following equipment: • • • • The passenger lift in June 2005 Fire extinguishers in August 2005 Landlords Gas Safety in February 2004 Portable electrical appliances in May 2005 See Requirement 7 See Requirement 8 See Requirement 9 Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X 3 3 X X 2 2 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 X 2 Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Timescale for action Suitable plans of care must be in 24/01/06 place that address all of the identified needs/problems of the residents accommodated at the home. The residents medicine 24/01/06 administration sheets must be filled in accurately at all times, and medicines must be stored securely and properly labelled. Suitable provision must be made 24/01/06 for storage for the purposes of the home. The bedroom flooring identified 31/01/06 in the body of the report must be thoroughly cleaned. If this does not respond to cleaning, new floor covering must be supplied and fitted. Staff practices must be amended 24/01/06 to reduce the risk of cross infection occurring. An enhanced Criminal Records 24/01/06 Bureau disclosure must be obtained for all staff employed at the home. Requirement 2 OP9 13 3 OP21 23 4 OP24 16 5 6 OP26 OP29 13 19 Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 20 7 OP38 23 8 9 OP38 OP38 23 23 Adequate arrangements must be 24/01/06 made for the provision of fire safety training for all staff employed at the home. All designated fire doors must be 24/01/06 kept closed unless fitted with an approved door hold open device. Arrangements must be made for 24/01/06 a satisfactory gas safety certificate to be obtained for the home, and for this to be maintained. 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. 2. 3. Refer to Standard OP7 OP9 OP25 Good Practice Recommendations Care plan evaluations should more accurately reflect the residents’ response to the care given. A protocol for the administration of rectal medicines should be devised for use by staff at the home. Arrangements should be made for natural ventilation of the lounge on the dementia unit. Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Willows Christian General Nursing Home DS0000018825.V264882.R01.S.doc Version 5.0 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!