Inspection on 22/05/07 for Willows Christian General Nursing Home

This inspection was carried out on 22nd May 2007.

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

Willows Christian General... 06/06/06

Willows Christian General... 15/12/05

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 22 May 2007 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.V334225.R01.S.doc Version 5.2 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.V334225.R01.S.doc Version 5.2 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 thewillows@trinitycare.co.uk 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 Homes Limited Mrs Vanessa Bradley Care Home 60 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (40), of places Physical disability (3) Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 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) * 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 6th June 2006 2. 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. 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 for the residents. There are dining rooms 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 people aged from sixty-five years onwards who need nursing care. Trained nursing staff are on duty at the home twenty-four hours a day. The weekly fee payable at the home ranges from £755 to £850. The manager provided this information before this inspection visit took place. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on the 4 April 2007 and was carried out by Denis Coffey and Gill Matthewson, CSCI inspectors. During the visit, the inspectors toured the building, looked at care and general records, and spoke with staff and people who live at the home. People who live at the home were positive in their comments about the care they received, the support provided by the staff and the services provided by the home. CSCI comment cards were sent out before this visit to people living at the home. Those returned reflected the same opinions as those given by people spoken with. The views of people about the home are included in this report. What the service does well: People are given information about the home and have their needs assessed so they can make a decision about whether their needs can be met at the home. Records of people’s health and social care needs were informative, and were reviewed regularly to make sure that their needs were being met properly. Medicine records were accurate so it could be seen that people were receiving their medicines as prescribed. Staff were seen to care for people sensitively so that their privacy and dignity were respected. There were activities available so that people had the chance to socialise and people spoken with said that the standard of food at the home was good, with choices available. Complaints are managed well with records kept of what was being done in response so that people can be confident their concerns will be listened to and acted upon. The home is well maintained so that people live in a comfortable, homely, clean and fresh surroundings. There were enough staff on duty to meet the needs of people living at the home, and training is arranged to enable staff to maintain and improve their knowledge and skills. Health and safety in the home is taken seriously so that people living there stay safe and well. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 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.V334225.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with information, and have their needs assessed before moving into the home to enable them decide if their needs can be met. EVIDENCE: There is a statement of purpose that outlines the services provided at the home. People spoken with said that they had the necessary information to make up their minds about whether or not to move into the home. Prior to this visit CSCI comment cards were sent to the home for people to fill in, some of which were returned. People returning these said that they had received a statement of terms that identified the weekly fee payable, and the services covered by the fee. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 9 The care records of two people who had moved into the home since the last inspection were checked. Both contained an assessment of need that had been completed by the deputy home manager before the people concerned had moved into the home. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Thorough detailed and informative care records are kept to make sure that all the care needs of people who live at the home are met in the best way for them. EVIDENCE: On the dementia care unit, three people were observed for a two hour period by one of the inspectors, the final hour being when they were served lunch. During that time, the inspector observed people’s state of wellbeing, whether they were taking part in any activity or interaction with others, and the quality of interactions with staff. Overall, people were observed to be either in a positive or passive state, with no sign of being distressed or withdrawn. People were seen doing things such as eating, drinking or reading the paper as well as talking with or responding to staff. Interactions with staff were good; staff approaches were respectful and cheerful, pleasant and polite. They showed genuine affection, care and concern for people, and maintained a relaxed atmosphere. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 11 Following these observations, the people’s care records were examined. These contained all the information necessary to help staff provide the appropriate care for each individual. They showed that people were referred to other health care services as necessary, for example, GPs, chiropodist and optician. Care plans were reviewed regularly with the person and their family. The care records of three people who live in the unit for elderly frail people were also examined. These were found to contain detailed plans of care for all of their identified needs/problems, and were evaluated regularly. A daily record is made about each person’s the health and welfare and these were seen to be informative. Arrangements for the medicines were checked on both units. Medicines were found to be correctly stored, and records were well maintained of medicines given to people who live in the home. A number of people on the elderly frail unit were prescribed strong pain relief medication, and a check of these found the stock balances to be correct. Staff were seen to knock on bedroom and bathroom doors before entering and were heard to address people appropriately. Two people spoken with said that their privacy and dignity was respected. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are helped in making decisions, to enable them to make their own choices about their daily lives. EVIDENCE: An activities organiser is employed at the home who produces a monthly programme of social and leisure activities for the people who live at the home to join in if they wish. The programme is displayed around the home. At the time of the inspection visit, this person was on holiday and there appeared to be no structured arrangements for staff to involve people who live in the home in activities. This was discussed with the manager and a suggestion made that this aspect of care be looked into. People spoken with said that their interests are well catered for. There is a ‘quiet’ room that is used as a prayer room by some of the people living at the home. Clergy from the local churches conduct monthly services at the home. There are policies for the home that contain information on various cultural and religious beliefs. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 13 Time was spent observing people’s daily life and staff care practices were seen to be carried out in a patient and friendly manner. Staff were heard to ask people questions about what they wanted rather than making decisions for them. Visitors can call at the home at any reasonable time and people who live there can choose where they see their visitors. Menus appeared varied and nutritious in content. A choice is offered at all meals and people spoken with said that the standard of food provided was very good. People on the dementia unit were observed having their lunch. The unit manager supervised the lunch serving and those people who could express a choice were asked what they would like from the range of food sent from the kitchen. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure so people know how to make their concerns known and staff are receiving training so they know what to do to protect people from possible harm or abuse. EVIDENCE: There have been two recorded complaints received at the home since the last inspection, both of which have been dealt with in line with the complaints policy and procedure for the home. Comment cards received from people living at the home confirmed that they know how to make their concerns known. There are policies and procedures in place for staff that identify their roles and responsibilities in relation to protecting vulnerable adults. All of the nurses who work at the home have recently done training about dementia care that included information about protecting people from abuse. The care staff are due to receive similar training, and the manager said when this is completed all of the staff will undertake more comprehensive training about safeguarding adults from harm and abuse. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained with good facilities so that people who live there have comfortable, clean surroundings. EVIDENCE: There have been some alterations made at the home since the last inspection. Ensuite facilities have been installed in one of the bedrooms on the dementia unit. A lounge on the first floor of the unit for older frail people has been converted into two single bedrooms. A former bedroom on this floor is now a small lounge with kitchenette where visitors can make drinks, and where the activities organiser can do activities with smaller numbers of people. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 16 All of the communal rooms on the dementia unit have been redecorated and fitted with new carpets recently. New easy chairs and dining room suites have also been provided. The ground floor of the unit for older frail people has also been redecorated and had new carpets fitted. However, the first floor corridor needs redecoration as the walls were scuffed in places and the wallpaper border noticeably torn. The carpet in this corridor was stained and there was a gap in the carpet where work had been carried out on the two new bedrooms. A requirement for this work to be done would have been made but, following this inspection visit, a representative of the company that owns the home has confirmed that this work is due to be carried out in the near future. There are sufficient bathrooms and toilets in the home to meet the needs of the people living there. These rooms are close to the communal and bedroom areas. A number of bedrooms were visited at this inspection and were seen to be comfortably furnished and personalised, reflecting the tastes and interests of people occupying those rooms. All areas of the home were visited and found to be clean, tidy and free from unpleasant smells. One person said that there was an ‘excellent standard of cleanliness throughout’. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive training to enable them to meet the needs of people living at the home. Recruitment procedures are thorough to make sure that people are protected from possible harm or poor practice. EVIDENCE: There is a team of nurses and care assistants who provide the care for people living at the home. The staff rotas seen showed that there are enough staff on duty to meet people’s needs. One person spoken with said the staff “love their work and it shows”, and another said “staff are friendly, and nothing is to much trouble for them”. Forty five percent of the care staff have achieved an NVQ level 2 in care. Staff training records showed the following training had taken place since the last inspection: protection of vulnerable adults, dementia care, nutrition, diabetes, challenging behaviour and food hygiene. One of the nurses employed at the home has completed a trainers’ course in safe moving and handling, and now provides this training for the rest of the staff. This nurse has been given six hours apart from their normal duties to carry out this training, and another member of staff has been nominated to attend the trainers’ course. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 18 The personnel files of four staff were examined at this inspection. All contained completed application forms, two satisfactory references, health declarations and satisfactory Criminal Records Bureau disclosures. Nurses are required to maintain their registration to practice with the Nursing and Midwifery Council, and evidence was seen of the nurses employed at the home complying with this requirement. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in a way that ensures the health and well being of people living at the home. EVIDENCE: During the course of this inspection the manager demonstrated a sound awareness of the needs of the people living at the home. She displayed a positive approach to her responsibilities, and staff spoken with said that they felt well supported by her. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 20 Unannounced visits are carried out monthly at the home by a representative of the company that owns it and a record of their findings/observations is left at the home. The home manager checks care plans and the premises every two months, and the deputy manager checks medicines and accidents records every month. The personal money of people living at the home is ‘pooled’ in a current bank account. Individual accounts are maintained on the home’s computer enabling people to have access to the current state of their finances. Signatures are obtained for any cash withdrawals, and receipts were in place for all purchases made. Maintenance records showed that equipment was regularly checked and maintained. Water temperatures were routinely checked to reduce the risk of scalding. Seven fire drills have been held so far this year, two of which involved the night staff. Satisfactory risk assessments were in place for the use of bed rails. Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 30 X 3 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Willows Christian General Nursing Home DS0000018825.V334225.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V334225.R01.S.doc Version 5.2 Page 24 - 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. 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