Inspection on 18/02/08 for Willows Court

This inspection was carried out on 18th February 2008.

CSCI found this care home to be providing an Adequate service.

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 Court 07/01/10

Willows Court 24/06/09

Willows Court 14/01/09

Willows Court 09/05/07

Willows Court 18/05/06

Willows Court 07/11/05

Willows Court 08/08/05

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Willows Court 107 Leicester Road Wigston Leicestershire LE18 1NS Lead Inspector Linda Clarke Unannounced Inspection 18th February 2008 08:45 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 Court DS0000063757.V356676.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 Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows Court Address 107 Leicester Road Wigston Leicestershire LE18 1NS 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) 0116 2880223 0116 2880223 BestCare Limited Position Vacant Care Home 29 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18), Old age, not falling within any other category (29), Physical disability (24), Physical disability over 65 years of age (24) Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. No one falling within category PD or PD(E) may be admitted into Willows Court when there are 24 persons of category PD or PD(E) already accommodated in the home No one falling within category MD(E) or DE(E) may be admitted into Willows Court when there are 18 persons of category MD(E) or DE(E) already accommodated in the home Rooms 21, 22 and 23, within Willows Court are not to be used for residents who fall within categories PD or PD(E) No one under 55 years falling within category PD may be admitted into Willows Court No one falling within category OP may be admitted into Willows Court where there are 29 persons of category OP already accommodated within the home To be able to admit the named person of category PD named in variation application number V32221 dated 15th May 2006 The maximum number of persons accommodated within Willows Court is 29 9th May 2007 Date of last inspection Brief Description of the Service: Willows Court Residential Home offers care to a maximum of 29 people. The home is a modern property situated in a quiet residential area of Wigston town and is accessible by main road routes and bus services. Accommodation is over three levels with the majority of bedrooms being on the first and lower ground floors. All levels of the home are accessible by a passenger lift. There are two lounges and a dining area with a conservatory attached. Smoking is only permitted in the conservatory area. There are six shared rooms with en-suite facilities. Eric the cat lives at the home and the rear garden contains a duck pond. Information as to the current fees is available by contacting the home. Additional charges are made for chiropody, hairdressing, toiletries and newspapers. The home’s ‘Statement of Purpose’ and ‘Residents Guide’ is available from the manager and a copy of the most recent Inspection Report is kept in the entrance to the home. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection process consisted of pre-planning the inspection, which included reviewing the Previous Inspection Reports, which included a Random Inspection and a Pharmacy Inspection. We (Commission for Social Care Inspection) sent surveys to nineteen people who use the service of which eleven were completed and returned, twenty were sent to care staff, none were returned and nine surveys were sent to health care professionals, which included General Practitioners, District Nurses and Specialist Nurses of which one was completed and returned. The unannounced site visit commenced on the 18th February 2008, and took place between 08:45 and 17:30. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Willows Court. Three people accessing services were selected, with a range of individual needs, including those with Dementia. Discussions were held with two people who reside at the home and two visiting relatives. Discussions were also held with care staff. What the service does well: What has improved since the last inspection? Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 6 Information to people who are considering moving into the home is available and contains up to date information about the services offered at Willows Court. Records, which record whether people who are using the service have received their medication, are now signed. A number of bedrooms and communal areas have been decorated, and have had new carpets and flooring fitted. Newly recruited staff do not commence employment without the appropriate pre-employment checks, which includes an Enhanced Criminal Record (CRB) disclosure, staff that have worked at the home for a while have had another CRB check undertaken. People, who use the service, their relatives and other interested parties such as health care professionals, have the opportunity once a year to complete a survey. The survey is sent out by the owners of Willows Court to ascertain the views as to the service it provides. The information received is then collated and a report produced detailing the outcome of the process, and includes an action plan as to how the service will continue to improve. What they could do better: The production of written information available to people that use the service could be improved if the presentation of the information was accessible to people with specialist needs, such as a sensory impairment or Dementia. People who are to potentially move into the home, need to have a detailed assessment undertaken, which should include all aspects of their care, with particular attention to specialist areas of care such as Dementia. A detailed assessment may need to include information from relatives and friends as well as professionals. Assessments should also include information as to the person’s life, social history, work history, hobbies and interests. Detailed assessments can then be used to develop a comprehensive care plan, which will support the individual to maximise their independence and live the lifestyle they choose. Care plans need to focus on the abilities of the individual, and how they wish to be supported and spend their day. People residing at the home should have the opportunity to participate in recreational pursuits, hobbies and interests, which reflect their lifestyle choices, both within the home and within the community. The quality of care people living at the home experience is dependent upon the quality and number of staff available to support them. If individuals are to be supported to live the life they choose, additional staff will need to be Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 7 employed, and staff will need training in specialist areas, relevant to the needs of people they care for, such as Dementia Care. Willows Court requires significant improvements to its décor and furnishings to create a homely and well-maintained home suitable for those in residence. Staff need the opportunity to regularly discuss both individually and collectively their role in providing care and support to people who use the service. Staff supervisions and meetings will provide staff with an opportunity to discuss their work, and identify any areas where training is required. 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 Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 8 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 Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 9 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 and 3. Standard 6 is not applicable, as the service does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People considering moving into the home have access to information about the services provided, and will have an assessment of their needs undertaken prior to moving in. EVIDENCE: Information available to people who are considering moving into Willows Court has been updated, detailing the services offered by the home, enabling individuals to consider whether the home will fit their lifestyle. People residing at the home have a copy of the information in their bedroom. The Manager should consider how written information is presented and its ease of reference for those who may have difficulty in understanding information due to their health needs, such as Dementia or sight impairment. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 10 People using the service where funded by Social Services are provided with an Individual Placement Agreement, outlining the terms and conditions of occupancy. There was no evidence of a contract on the file of a service user whose file was viewed who funded their own care. People who are considering moving into Willows Court where funded by Social Services receive a comprehensive assessment of their needs undertaken by a Social Worker. People who fund their own care and those funded by Social Services will have an assessment of their needs undertaken by a representative of Willows Court. The records of three people residing at the home were viewed, the assessments carried out by the home were brief, and did not provide clear and detailed information as to the needs of the people that have specific needs such as Dementia or memory loss. The content of assessment forms has been reviewed, and a new assessment form has been developed which will increase the level of information gathered. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service have access to health care services, but are not supported by care plans that record all aspects of the care and support they require or their choices and preferences as to how their care is delivered. EVIDENCE: The care plans and records of three people residing at the home were viewed, which included one person who had recently moved in. Care plans were very brief in their content and did not detail all aspects of support and care required by the individual, in particular those with additional care needs due to health conditions such as Dementia. Care plans in some instances advised that an individual may become distressed and disorientated, but there was no information as to how staff could recognise this or state ways, which were effective in offering reassurance to the individual. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 12 People who use the service need to be confident that their care plan covers all aspects of the help and support they require, including specialist areas such as Dementia Care. Individuals preferences, as to daily routines, hobbies and interests, needs to be ascertained during the assessment process and when first moving into the home. The Manager needs to work closely with family and friends and professionals, especially where information cannot be gained from the person. Records evidenced that care plans had been reviewed, however with limited recorded information as to how people living at the home spend their day, the review process is not robust. The records of one person showed that they had fallen eight times in the last seven months, four falls being in the last two months, however the risk assessment which details how the falls of the person are to be managed to ensure minimal risk to the individual had not been reviewed. Records evidenced that people residing at the home have access to health care, which included dentist, general practitioners and hospital appointments. We spoke with two visitors who came to the home to see their relatives, both said that their relative did see health care professionals, and that they were kept informed by the Manager about the health care needs of the person they were visiting. Since the last Key Inspection of Willows Court a Pharmacy Inspection was carried out on 7th December 2007, and a Random Inspection on 17th December 2007. The Pharmacy Inspection highlighted areas of concern with regards to the signing of medication records and the lack of policies and procedures. The Random Inspection noted improvements to the signing of medication records however identified the lack of training some staff responsible for the administration of medication had received. A requirement for staff to access training was set at the Random Inspection with a compliance date of 29th February 2008; this requirement has to date not been met. The medication records of three people, whose records were viewed, showed that staff are signing records when administering medication. Medication was stored within a medicines trolley, accessible only by staff with a key. A majority of people living at Willows Court are unable express their views with regards to the care they receive, including their views as to the promotion of their privacy and dignity. Two people were spoken with who felt that the care they received was okay, and said that staff were always helpful and friendly and knocked on their bedroom and waited for an answer before coming in. We sent out surveys to people who use the service, which were completed by the person themselves or their relative. Information in surveys stated that staff listen and act upon what people who use the service say, and that they are supported and cared for with regards to the care and medical support. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service need to have a wider choice of recreational pursuits and activities within the home and the local community, which reflect their abilities and life style choices. EVIDENCE: People who use the service do not have written records in most instances that detail their hobbies and interests, or recreational interests and lifestyle prior to moving into Willow Court. Greater emphasis needs to be placed on gathering information about an individual’s lifestyle before moving into the home. An activity programme is in place, which details an activity for each day of the week, the Manager advised that since a meeting held last year to which relatives and people using the service were invited various games have been purchased, to include bingo, floor skittles, cards etc. A significant number of people residing at the home are unable to participate in such activities as they are limited by their physical health and conditions, the Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 14 Manager needs to promote links with specialist organisations who offer support in specialist areas, to enable everyone where they so choose to participate in meaningful activities to lead a meaningful and full life. We observed a few people who live at the home reading newspapers and magazines, whilst some participated in a one to one activity with a member of staff. One service user who is able to access the community without assistance said that they visit the local Public House and Shops. One person we spoke with said they had visited the local shops to buy flowers supported by a member of staff and enjoyed playing dominoes and ball games. Information provided to people residing at the home details that Religious Services are held within the home no records of these being held were seen. Additional staffing or an appointment of an Activity Organiser should be considered if people residing at the home are to experience a lifestyle reflective of their preferences, hobbies and interests. Visitors are encouraged to visit the home, one visitor said they are welcomed to visit any time of the day, and this enables them to remain actively involved in the care of their relative. Willows Court manages limited amounts of money on behalf of some of the people using the service, the records and monies of two individuals were viewed, and the amount of money held by the home was consistent with the financial records. One person spoken with said that they manage their own spending money. We spoke with two people who live at Willows Court, who expressed general satisfaction with the meals provided. Both said that sometimes they are asked what they wish to eat the following day, on the day of the visit we observed a member of staff asking people what they wished to eat for their tea time meal. People living at the home and their relatives had expressed their views at a recent meeting, and the home was in the process of addressing the points raised with regards to the meals provided. The dining room could benefit from improvements to make it a more homely and relaxing environment, currently the walls are bland in colour and are without pictures and curtains. Dining tables and chairs are functional and in a poor state of repair and are not comfortable or appropriate for those people who require support whilst seated. The Manager advised that new tables and chairs are to be order in the near future. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 15 We sent out surveys to people who use the service, which were completed by the person themselves or their relative. Views were mixed with regards to their participation in activities, one said that events are only organised on special occasions such as at Christmas or Easter. Comments with regards to the quality and variety of food served at meal times were mixed. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service could be further protected by staff that are trained in recognising potential abuse and by an accessible complaints procedure. EVIDENCE: We sent out surveys to people who use the service, which were completed by the person themselves or their relative. Surveys revealed that people are confident to speak with the Manager if they are unhappy but are unclear as to the formal complaints procedure, and would not know who to speak with if they wished to speak with someone other than the Manager. We were advised that there have been no complaints to the home since the last Inspection, however there is not a clear system currently in place for the recording of concerns and complaints. We were shown the revised Complaints Procedure and form for the recording of complaints and concerns that would be put into practice in the near future. People who use the service and their relatives will need to be advised and given copies of the Complaints Procedure, and staff will need to be given instruction as to how to take and record complaints. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 17 Members of staff were asked as to there understanding of protecting people who use the service from abuse, staff said they would report any concerns to the Manager. There is no clear system for recording the training staff have received and it was difficult to ascertain the number of staff that had undertaken training in ‘safeguarding adults’. All staff are to access this training to ensure that they know the forms in which abuse may occur, and the signs for spotting potential abuse, and their role in reporting it. A Random Inspection was carried out at Willows Court on 17th December 2007; the focus in part was to ensure that all staff had an Enhanced Criminal Record Bureau (CRB) disclosure. Records viewed confirmed that the organisation of which Willows Court is part of have undertaken CRB checks for all staff, and that staff do not commence work until checks have been carried out. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 18 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, 20, 21, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to the décor and furnishings of the home to ensure that the environment is comfortable and pleasant to live in and suited to the needs of the people living there. EVIDENCE: Willows Court is currently in the process of undergoing refurbishment, which includes decorating, the replacing of flooring, curtains and the purchasing of new furniture. Whilst the refurbishment of the home takes place people who use the service should not have their safety, privacy or quality of care affected, however this was not found to be the case. The refurbishment of the home should consider best practice guidance from organisations that provide information as to how the environment can be Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 19 decorated and furnished to improve the quality of life for people with Dementia. The home provides two lounge areas, one to the front of the property and the other to the rear of the property with access into the garden. In addition to the lounges there is a dining room with access to a conservatory. The lounge to the front of the property has been decorated and a new carpet fitted, a majority of the chairs in this room are of good condition. The small tables in the room were damaged and stained. There are insufficient chairs in the room to accommodate the number of people residing at the home and their visitors, who choose to use the room. Throughout the day people residing at the home sat on the poof in order to find seating, it was observed that a visiting relative sat on a small nest of tables so that could be seated, there are insufficient tables for people to rest their drinks and belongings. The window is furnished with net curtain but no curtains. The lounge to the rear of the property has new flooring, the chairs in the room are stained and worn, some having an unpleasant odour. There are no small tables for people to rest their drinks when seated, and the television cabinet is damaged. The dining room has new flooring, the dining tables and chairs are stained and worn, the chairs offer no support to people whilst sitting at the tables, as they do not benefit from arm rests, and have little padding in the way of comfort. Walls and radiators in parts were stained with drink and food spillages. Occasional furniture in the room such as the sideboard cabinet is worn. There were no curtains at the windows. The dining room provides access to the conservatory through sliding doors, when the doors are open; this creates a gap and a potential trip hazard. The conservatory is furnished with blinds that are stained and has chairs that are worn and stained. The garden area has a pond and a family of ducks, which are in residence. The garden is not accessible to people using the service especially those with mobility difficulties. Due to the refurbishment of the home the outside space is being used to place old and unwanted equipment until it is disposed of. Bedrooms are located on the ground, first floor and second floor; access to the first floor is via a passenger lift and a stair lift provides access to the second floor. Bedrooms are in the process of being redecorated, with new carpets being fitted. People who use the service and their visitors confirmed that they had been consulted as to the colour scheme for their room. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 20 There are a number of bedrooms to the rear of the property, which cannot safely be used by people residing at the home without artificial light, this is as a result of the overgrown trees and shrubbery to the rear of the property blocking out the natural light. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 21 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and the training staff receive need to improve to ensure that people who use the service receive the care and support they require. EVIDENCE: There are three members of care staff on duty throughout the day, and two staff on duty at night with an emergency contact person being available. The Manager is available during office hours. Catering and domestic staff are employed. The Manager said they were currently advertising and recruiting for additional care staff, with the intention to increase staffing levels. The layout of the home, means that staff need to be deployed in all areas to ensure that people who live at the home require the support they require, and have the safety and welfare protected. A person residing at the home whilst attempting to sit on a poof in the lounge, lost their balance and slid to the floor, there were no staff available to observe this event. A member of staff spoken with said that had attained a National Vocational Qualification (NVQ) in Care, and had attended various courses since the commencement of their employment, which including training in Dementia care and a risk assessment course. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 22 Staff files of members of staff on duty were viewed; all contained a completed application form and two written references. A Random Inspection was carried out at Willows Court on 17th December 2007; the focus in part was to ensure that all staff had an Enhanced Criminal Record Bureau (CRB) disclosure. Records viewed confirmed that the organisation of which Willows Court is part of have undertaken CRB checks for all staff, and that staff do not commence work until checks have been carried out. Staff files contain certificates of training that staff have attended, and the Manager advised that training will take place over the coming year, a majority of training courses are yet to be booked. A member of staff recently employed advised that as part of their role they were moving and handling people living at the home, but they had not as yet received any training. The Manager said there training would take place later in the month. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 23 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, 36. 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Management of the home provides opportunities for people who use the service to comment on the service they receive, staff however have limited support and opportunity to reflect and improve the care they deliver. EVIDENCE: The Manager of Willows Court has worked in her current capacity since August 2007. They commenced employment at the home in August 2005 and until becoming the Manager held the position of Care Worker and Senior Care Worker. The Manager has attained a National Vocation Qualification in Care at level 2 and 3, and has attended courses on the administration of medication and Dementia Care. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 24 The Manager needs to ensure that they keep up to date with good practice and continuously monitor and develop the service and access training relevant to their role and responsibilities. The Responsible Individual who represents the company for which Willows Court is part of, are required to ensure that the Manager they have appointed submits an application to the Commission of Social Care Inspection to be considered for the position of Registered Manager. The Manager advised that a Management Consultation firm have been employed by Willows Court to evaluate administrative and managerial systems, and to make practice recommendations. Willows Court has a Quality Assurance process, which enables people who live at the home; there relatives and other interested parties, to comment on the service. Surveys are sent out on an annual basis, which upon their return are analysed and used to further develop the service. A report of the most recent findings were viewed, we were advised that the report would be made available to people who use the service and their relatives. Willows Court manages limited amounts of money on behalf of some of the people using the service, the records and monies of two individuals were viewed, and the amount of money held by the home was consistent with the financial records. The Manager advised that staff have not been receiving support and guidance in the form of one to one supervisions; these have now been scheduled with dates set. People who use the service benefit from staff receiving guidance and support, by ensuring that all staff are working to the policies and procedures of the home, and have the opportunity to discuss there work practices and identify areas where additional training is required. Meetings are held for people living at the home and their relatives, enabling additional opportunities for people to comment on the day to day running of Willows Court. Staff meetings are held, these need to be held regularly to ensure that all staff have a clear understanding of there roles and responsibilities and are up to date with any changes which may affect the care and safety of people living in the home. We looked at records in the home, which evidenced that people residing at the home are supported by gas, electrical and fire systems, which are regularly maintained and serviced. Records are in place, which record all accidents and incidents, which affect the welfare and safety of people residing at the home, these records need to be used as part of the review process for the care individuals receive. Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 25 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 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 3 X X 2 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 2 X 3 Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 26 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(1) Requirement Timescale for action 18/06/08 2 OP9 13(2) Care plans need to be comprehensive reflecting all aspects of care, including specialist care such as Dementia, and provide information as to how the person wishes their care to be carried out and to include their preferred daily routines. Care plans to be supported by risk assessments, which are regularly viewed with the involvement of all relevant parties. The Registered Person to ensure 29/02/08 that staff responsible for the administration of medication undertake appropriate training to ensure safe working practices and the promotion of services user health and wellbeing. This requirement is not outstanding, but has been carried over from the Random Inspection of the 14th December 2007. The Registered Person to ensure that service users are consulted about their social interests, and the programme of activities DS0000063757.V356676.R01.S.doc 3 OP12 16(2) 18/06/08 Willows Court Version 5.2 Page 27 4 OP18 13(6) 5 OP19 13(4) (c) 6 OP19 23(2)(0) 7 OP25 23(2)(p) 8 9 OP26 23(2)(d) 18(1) (c) OP30 10 OP31 8 arranged by the home, and put into place activities and events of interest to all service users. The Registered Person to ensure that all staff receive training which provides staff with knowledge as to the types of abuse people who use the service may be exposed to, and the signs for spotting potential abuse and staff role in reporting any suspicions. The Registered Person to undertake a risk assessment of the potential trip hazard created when the doors are open between the dining room and conservatory, and to take steps to ensure the health and safety of people using the service. The Registered Person to ensure that the external grounds are suitable, and well maintained and safe for use. The Registered Person to ensure that there is sufficient natural light in the bedrooms to the rear of the property to ensure the safety and well being of people using the service. The Registered Person to ensure that all areas of the home are kept clean. The Registered Person to ensure that care staff receiving training relevant to their role, and should include moving and handling. The Registered Person to appoint a person to Manage the home, with the intention of submitting an application to the Commission for Social Care Inspection to be considered for the post of Registered Manager. 18/06/08 18/03/08 18/06/08 18/06/08 18/06/08 18/06/08 18/06/08 Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 28 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 4 Refer to Standard OP1 OP3 OP12 OP16 Good Practice Recommendations The service should review the accessibility of its information with consideration given to the needs of people who may live at the home. The assessment process needs to be robust and reflect all areas of care, for which the person is being considered as to their suitability to the home and the meeting of needs. The assessment process to include information as to peoples preferred lifestyle choices, including hobbies and interests. A record should be kept of all complaints and concerns raised by people residing at the home, relatives or other interested stakeholders. This should include the date of and nature of the response made. Efforts should be made to ensure that residents and their relatives are aware of the home’s formal Complaints Procedure. The decoration and furnishing of the home should take into account best practice guidance from organisations who advise as to how the decorating and furnishing of a home can impact and improve the quality of life for people with Dementia. It is recommended that staff meetings take place on a regular basis to ensure that staff are kept up to date in changes in care practices, to ensure that the needs and safety of persons residing at the home are met. 5 6 OP16 OP19 7 OP33 Willows Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Court DS0000063757.V356676.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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