Inspection on 07/11/05 for Willows Court

This inspection was carried out on 7th November 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 Court 07/01/10

Willows Court 24/06/09

Willows Court 14/01/09

Willows Court 18/02/08

Willows Court 09/05/07

Willows Court 18/05/06

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 Paula Dutton Unannounced Inspection 7th November 2005 10:30 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.V263460.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 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 Mrs Amanda Cooke 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.V263460.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category PD or PD(E) may be admitted into the home when there are 24 persons of category PD or PD(E) already accommodated. No one falling within category MD(E) or DE(E) may be admitted into the home when there are 18 persons of category MD(E) or DE(E) already accommodated. Rooms 21/22/23 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 the home. 08/08/05 Date of last inspection Brief Description of the Service: Willows Court Residential Home offers care services to a maximum of 29 residents. The home is a modern property situated in a quiet residential area of Wigston town. The property can be accessed by main road routes and bus services. There is ample parking available on the road outside the home. Accommodation is offered on the ground and first floor levels. A passenger shaft lift offers access for those with limited mobility. This year the home was sold to BestCare Limited who are registered with the Commission for Social Care Inspection. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of four hours. The manager was available throughout the inspection and one of the new owners was available for half of the inspection. Two health care professionals were interviewed. One member of staff briefly discussed the needs of a resident. Observation took place of residents in communal areas. One relative expressed their views to the inspector. One resident’s bedroom was viewed. Further information was gathered by selecting three residents’ record files for viewing care plans, assessments, daily notes, risk assessments and administration of medication. This method of gathering information is known as ‘case tracking’. This report should be read along side the previous inspection report. What the service does well: Overall this is a well managed service. There was clear indication that the manager and her senior team are accessible and approachable. This is a strength within the service. Some comments were made by residents: • • • • • • ‘It’s very nice living here’ ‘Staff are very good’ ‘Staff are very approachable’ ‘I can ring the bell at night and I don’t have to wait long’ ‘I can ask for anything. Staff say for you to ask at any time’ ‘I can walk short distances but staff fetch a wheelchair when I want it’ Some comments were made by health professionals: • ‘Staff are very helpful and respond promptly to residents’ needs. Staff understand instructions given including participating in assessments such as for continence. A strength in the home is that staff know the needs of the residents. The manager is readily available and assists the staff in helping residents. ‘The manager is always available and the carers are good. Carers have a reasonable level of understanding of health care needs. Carers are good at promoting residents drinking enough. Generally residents are clean and presentable. There has been an improvement in the home in both the level of cleanliness and the atmosphere since the new owners took over’ • Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 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. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Information is exchanged between potential residents and the manager of the home to ensure all parties can make an informed decision about moving to the home. EVIDENCE: The manager stated there have been no new admissions recently. The manager stated assessments are gained prior including those assessments completed by outside professionals such as social workers. Evidence was seen of an assessment completed by the home for a resident when moving into the home. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Overall residents’ health care needs are met. EVIDENCE: Three residents’ record files showed a care plan listed the actions to be taken by the staff team to meet the residents’ needs. Two visiting health professionals stated the staff team demonstrated a working knowledge of health care needs and issues of older people. The manager stated staff had recently received refresher training in moving and handling. Two residents were observed being assisted by staff to move through the home. A resident was observed when assisted by a member of staff to be lowered gently into a chair whilst taking weight under the resident’s armpit. The manager stated this was not how the home expected to assist people with Parkinsons Disease affecting their mobility. The manager stated advice would be sought from a Parkinsons Nurse and a review through an Occupational Therapist would be sought for another resident. Discussion took place with the manager about pressure area management. Two residents had developed pressure sores whilst living at the home. Advice Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 10 and assessment from a health professional is gained after a sore is identified. The agreed to review this process with the health professionals coming into the home with a view to promoting preventative measures. One example was identified of a bed bound resident who had not developed pressure sores over a two year period to the usual pressure areas. This positive outcome is evidence of good practice. The manager stated internal training for the management of pressures areas had taken place eight months ago but the home would seek refresher training from a health professional. There are no reclining chairs used in the home at present. A discussion took place about the use of reclining chairs following a risk assessment demonstrating safe and appropriate use. The manager stated the home would consider use of a reclining chair where a resident was unsafe in an ordinary chair. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): There were no standards inspected from this section on this occasion. EVIDENCE: Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents’ rights and safety are promoted and protected. EVIDENCE: The manager stated there had been no complaints received since the last inspection. A relative confirmed that the manager is very approachable and he felt able to make a complaint should he need to do so. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25, 26 Overall residents live in a safe and homely environment. EVIDENCE: There is a programme of renewal and maintenance provided by the owners. The outside of the premises was being painted on the day of inspection. A partial tour of the premises took place with the owner and manager. One resident’s bedroom was viewed. Generally all communal areas were accessible and clean. Discussion took place with the manager about maintaining hygiene levels in toilets. A commitment was made by the organisation to introduce a programme of deep cleaning to ensure all toilets are maintained to a good standard of cleanliness. A visiting District Nurse commented to the inspector that the levels of cleanliness have improved since the new owners took over. The owner and manager stated the blue carpet in the dining room which is frequently stained through spillages will be replaced over the next three months with a non slip flooring cover. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 14 The manager and owner explained to the inspector that hot water is supplied by two separate boilers. After lunchtime one half of the premises did not have hot water supplied. The high usage of hot water during the morning accounted for the absence of hot water at this time of day. The manager and owner agreed this was not ideal as some residents may need to use their own rooms for a wash but would have to use a communal bathroom to the other end of the building. The boiler supplying hot water at the other end of the building offered water at a temperature of 43.8 degrees centigrade. The owner stated the effectiveness of the hot water supply would be reviewed and a renewal programme may include the purchasing of a boiler if necessary within the next year. Observation found there were no window restrictors fitted to windows. The manager and owner stated some windows had restrictors fitted upstairs. The owner stated this would be addressed as a matter of priority to prevent accident and increase security for the premises. A resident’s bedroom did not have a guard on a radiator. The manager and owner stated none of the radiators were guarded but most have temperature controls fitted. The inspector advised the owner should contact the Environmental Health Officer for guidance about guaranteeing low surface temperatures and produce a risk assessment demonstrating the safety needs of those at high risk of falls in bedrooms are addressed. The owner and manager stated a programme of improvement could include planned provision of radiator guards when those most at risk are identified. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 The combined number, skills and training of staff ensures residents needs are met. EVIDENCE: A rota records the number of staff on duty. At the time of inspection there were only 24 residents living at the home. Sufficient staff were on duty to ensure residents’ need were met. The manager stated there is planned training for staff in the British Sign Language. The home feels this will assist staff to meet the communication needs of residents more effectively. This is good practice. A discussion took place with the manager about Dementia Care Mapping and Person Centred Care. The manager stated this is an aspect of training the company would be interested in researching and accessing if appropriate to the home. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 The management of the home is organised and promotes an open culture which welcomes residents’ opinions. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and has operated the home for over seven years. The manager demonstrated a commitment to achieving the National Minimum Standards and promoting continuing improvement. This is good practice. The manager communicated warmly but assertively with staff and demonstrated the ability to make decisions and lead staff in care practices. The manager demonstrated a good knowledge of the needs of residents living at the home. Two visiting health care professionals expressed satisfaction with the support and open approach shown by the manager. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 17 The manager stated she is finishing a National Vocational Qualification level four in Care. The manager stated the company is about to undertake an annual quality audit which will involve consulting residents and their representatives about their satisfaction with the service. The manager stated it would be possible to consult a range of stakeholders including health professionals and to publish the results to attach to the Service Users’ Guide and Statement of Purpose. This is good practice. The owner stated a monitoring report (regulation 26) will be produced each month as required by the Commission for Social Care Inspection. Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X X Willows Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 19 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 Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Court DS0000063757.V263460.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!