Inspection on 24/05/05 for Willows Christian General Nursing Home

This inspection was carried out on 24th May 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

Willows Christian General... 22/05/07

Willows Christian General... 06/06/06

Willows Christian General... 15/12/05

Willows Christian General... 04/01/05

Willows Christian General... 01/07/04

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Chirnside House

Keer Sands Residential Home

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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 24 May 2005 09:00 th 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. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willows Christian General Nursing Home Address Warford Park Faulkners Lane Mobberley Cheshire WA16 7AR 01565 880180 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) Trinity Care plc Mrs Vanessa Bradley Care Home 60 Category(ies) of OP Old age (40) registration, with number DE(E) Dementia over the age of 65 (20) of places PD Physical disability (1) PD Physical disability 55 years and over (2) Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 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 PD (physical disability). 2. 3. 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. Date of last inspection 4th January 2005 Brief Description of the Service: The Willows is a purposebuilt 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 F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and included a tour of the home as well as inspection of care records. The inspectors spoke with ten of the residents, three sets of visitors and seven members of staff. What the service does well: 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. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 6 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 Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 7 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) 3 & 5 Full assessments of needs are carried out before residents move in, so they know their needs can be met at the home. Prospective residents are able to visit the home before deciding to move in. EVIDENCE: Residents’ care records show that assessments of their care needs were carried out before they moved into the home. Their needs are reviewed regularly to make sure that all care needs are included. The care plans show clearly what staff need to do to meet each resident’s needs. One of the residents spoken with told the inspector that they and a member of their family had visited the home prior to making the decision about taking up residency there. The Willows does not provide intermediate care so standard 6, identified above, does not apply. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 8 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, 8, 9, & 10 Care plans are thorough to make sure that all residents’ care needs are met effectively. Staff make sure that residents’ dignity and privacy are respected at all times. Although the medicines generally are managed well, improvements need to be made to the records to ensure that rsidents receive their medicines as prescribed. EVIDENCE: The care files of three residents on the older people’s unit, and two residents on the dementia unit, were checked at this inspection. They all contained plans of care to meet all the identified needs/problems of the residents, and were regularly reviewed. Assessments were in place on the residents’ nutritional needs, and their risk of developing a pressure sore. Where there was a noted decline in the residents’ health and wellbeing, their plans of care were reviewed more frequently. All of the residents are registered with a general practitioner, and the care records contained a record of when their doctors visited. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 9 Pressure relieving mattresses were fitted to the beds of residents identified as being at risk of developing a pressure sore, and the home has a number of height adjustable beds for those residents who require nursing care whilst in bed. The home manager said that an order had been placed to increase the number of these beds. The management of medicines was examined on for both floors of the older peoples unit. There were numerous gaps in the residents’ medicine administration record (MAR) sheets, plus one of the MAR sheets showed that the medicine had not been given according to the prescribed directions, and one medicine was still being used even though it was passed the date when it should have been used. The home has a ‘homely’ remedies policy that identifies specific medicines the trained nurses can administer to residents over a twenty-four hour period that do not require prescribing by a doctor. There was a record seen of the residents’ doctor signing agreement for this. A random sample of medicines was checked for stock reconciliation and was found to be correct. Medicines subject to stricter control measures were examined. The records for these were well maintained, and the stock levels were correct. Staff were seen interacting appropriately with residents, knocking when entering rooms. Six residents needed support with eating, and staff were seen to sit and talk with them during lunch. See Requirement 1 Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.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, 13 & 15 Social activities and meals are well managed, providing variety and interest for people living at the home. EVIDENCE: The list of activities for May was on display on a notice board. Activities on offer included a visit to Marbury Park for bird watching and lunch, a trip to Delamere Forest followed by a fish and chip lunch, and entertainers providing entertainment twice in the month. On the day of inspection a group of six residents, accompanied by staff, spent the morning at the Blue Planet Aquarium near Chester. Family members visiting at the time of inspection were spoken with. They said they felt welcomed at the home and that staff at the home kept them informed when visiting. The menus on display appeared varied and nutritious. Residents were complimentary in their remarks about the standard of food provided. Lunch on the day of inspection was a choice between meat and potato pie or salmon fish cakes and parsley sauce, both of which were served with creamed potatoes and vegetables. The dessert was fruit crumble and custard and fruit salad. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 11 Staff on the dementia unit said that the kitchen staff had been asked not to provide the unit with fruit salad. However this was served on the day and residents were seen with fruit still in their mouths some 1½ hours later. The evening meal was to be minestrone soup, cottage pie or assorted sandwiches followed by rice pudding or fresh fruit. See Recommendation 1 Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 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 standard(s) 16, 17 & 18 There is information available to guide residents and relatives on how to make a complaint and who to make it to. There are procedures and guidance available for staff to ensure that residents are protected from abuse, harm and poor practice. EVIDENCE: One complaint has been received at the home since the last inspection and was currently being investigated. The home has its own adult protection policy and a copy of the Department of Health’s document ‘No Secrets’. This document contains guidance that identifies the different forms abuse can take and how to report this. Records were seen that showed the care and ancillary staff have received training on adult protection. One member of staff spoken with showed a good knowledge of adult protection procedures and felt confident that she knew how to report suspected abuse. Family members generally manage residents’ financial affairs. There were three exceptions to this where one resident’s finances were managed by social services, another by their solicitor, and the third by the Court of Protection. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 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 standard(s) 19,22, 24 & 26 The home provides comfortable and safe spaces for the residents to live in. Bedrooms were carpeted and comfortably furnished, many with items residents had brought into the home with them. EVIDENCE: A call alarm system is in place throughout the home enabling residents to call for help if needed. There were handrails in the corridors and grab rails close to toilets to help people move around as independently as possible. The older people’s unit was clean and tidy and free from unpleasant smells, but there were areas on the dementia unit where this was not the case. Three of the bedrooms smelt of urine and there was a stale smell in the dining room. Staff on the unit said that the smell in the dining room was due to poor ventilation of this area. Although there are windows that can be opened in the dining room, they are above the patio door and cannot be reached without using a window pole, which was broken. See Requirement 2 Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 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 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 29 & 30 There are enough staff rostered to be on duty to meet the needs of the residents at all times, apart from the domestic cover on the dementia unit. Recruitment procedures include thorough checks of new staff, ensuring that the residents are protected from any possible harm. EVIDENCE: The staffing rotas showed that, apart from two occasions recently, adequate staffing levels were being provided. On two occasions a member of staff had reported sick for work before the start of their shift. When this had happened, the day staff stayed on duty until the residents had been got ready for bed and were settled for the night. Staff on the dementia unit told the inspector that a member of the housekeeping staff is not always allocated for the number of hours required when the domestic on the unit is not on duty. The personnel files seen of new staff employed at the home contained completed application forms, two satisfactory written references, completed health declaration forms, and satisfactory enhanced Criminal Records Bureau disclosures On the day of inspection three of the trained nurses employed at the home were on training about the administration of liquid medicines. Records were seen of eight members of staff having undertaken food hygiene training, and twelve staff had done safe moving and handling training since January 2005. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 15 Five of the care staff were currently undertaking training leading to an NVQ level 2 in care, and one member of staff who is a trained nurse in her country of origin has recently completed an adaptation course enabling her to become a registered nurse in the United Kingdom. Induction records were seen of new staff that included them signing to confirm that they had received a copy of the staff handbook. See Requirement 3 Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 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 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) 33, 35 & 38 The home is well managed and residents’ views are taken into account so they have an influence in how the home is run. The practices in the home ensure that that residents are safe and their welfare is promoted. EVIDENCE: A satisfaction survey has recently been sent out to the families/representatives of the residents living in the older people’s unit. A representative of the company that runs the home visits each month, unannounced to check on how the home is being run. Individual records for residents’ personal allowances are kept on computer and these were recorded appropriately. However, a donation made to the home had been deposited in the residents account, and a record was seen of this money being withdrawn to fund a social event. It would be safer and more accountable for all money held at the home for service users to be placed in an account that does not include money obtained from other sources. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 17 The fire alarm and emergency lighting systems were tested each week and a Five fire drills weekly visual inspection was made of the fire extinguishers. have been carried out at the home since the last inspection, and 22 members of staff have received fire safety training so far this year. A list of emergency telephone numbers is kept with the fire logbook, e.g. the local hospital, fire alarm engineers, utility companies, electrician and plumber. The manager had completed a fire risk assessment in March 2005. The home manager reviews the accident records to identify if there are any patterns to accidents to residents, or particular areas of risk. Most of the 101` recorded accidents that had happened between 1 March and the day of the inspection were due to falls/trips. Falls risk assessments had been carried out for residents. Appropriate risk assessments were also in place for those residents that had rails fitted to their beds to stop them falling out. Products subject to the Control of Substances Hazardous to Health regulations were stored securely. See Recommendation 2 and 3 Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x 3 x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x 2 x x 3 Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 19 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 9 Regulation 13 Requirement Timescale for action 30/06/05 2. 26 16 3. 27 16 & 18 The residents medicine administration sheets must be filled in accurately at all times, and medicines with a limited life span must be used within the dates identified. Rooms where there is an 30/06/05 unpleasant smell must be cleaned thoroughly and adequate ventilation must be provided for the dining room on the dementia unit. Enough domestic staff must be 30/06/05 employed to ensure that the home is kept clean at all times. 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. Refer to Standard 15 35 Good Practice Recommendations Care staff members views about the suitability of particular foods for some of the residents should be taken into account by the kitchen staff. Arrangements should be made for all money held at the home for service users to be placed in an account that does not include money obtained from other sources. F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 20 Willows Christian General Nursing Home 3. 38 It would be advisable to carry out a risk assessment of the premises in relation to identifying areas of the home where residents may be more vulnerable to falling or tripping. Willows Christian General Nursing Home F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich Cheshire 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 F51 F01 S18825 The Willows V228550 240505 Stage 4.doc Version 1.30 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. 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