Inspection on 12/09/06 for Willows Edge

This inspection was carried out on 12th September 2006.

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 Edge 18/09/08

Willows Edge 07/11/05

Willows Edge 06/06/05

Willows Edge 13/12/04

Willows Edge 19/07/04

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

CARE HOMES FOR OLDER PEOPLE Willows Edge Willows Edge Hutton Close Shaw Newbury Berkshire RG14 1HJ Lead Inspector Sandra Grainge Unannounced Inspection 12th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willows Edge DS0000031418.V306133.R02.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 Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows Edge Address Willows Edge Hutton Close Shaw Newbury Berkshire RG14 1HJ 01635 45252 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) West Berkshire Council Mrs Patricia Rose Rolfe Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Willows Edge is owned and operated by West Berkshire Council. The home is located in Shaw, near Newbury, and provides specialist residential care for elderly persons with a diagnosis of dementia. Accommodation is on three floors with access via a lift. Thirty-five single bedrooms are used for long-stay care and one single bedroom is available for respite for individuals with mental frailty. The home provides day-care for one existing non-resident; this service is not available to new service users. The home has a number of specialist adaptations to meet the needs of its mentally frail residents. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key report contains information collected during an unannounced site visit to Willows Edge made during a weekday by a locum inspector. Information held in the Service file pre- informed the inspection together with data provided by the Registered Manager. Prior to the visit Service User views had been sought in a survey “Have your say about”. No forms were returned to CSCI; the Manager explained that no Service User had been capable of responding to the survey. A tour was made of the premises and during the visit care practice was observed; Service Users were clearly pleased with the care that they were receiving and they related well to the staff who were observed to treat them with kindness and respect. Relatives who were visiting in the home spoke to the inspector and expressed satisfaction with the care that was being given. A visiting healthcare professional was willing to comment and considered that Service Users receive good care. Records were inspected and the Inspector spoke to staff members. What the service does well: What has improved since the last inspection? Service Users receive a more consistent level of understanding and care from staff who are permanently employed to work in the home. This is because additional staff have been recruited and less agency staff are employed. In addition, more staff are trained to give care; the level of staff who are NVQ trained has risen to 70 . Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 6 The financial records have been improved and receipts are now given to the relatives. New arrangements are about to be implemented for those without next of kin, so that everyone is able to have an available personal allowance. Service Users had fallen in the home less frequently since the new Manager has undertaken to monitor their falls and introduce a safety alarm device. . 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 Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5, Quality in this outcome area is good. Service Users and their relatives had information about the service prior to admission; it had assisted them to make a choice about the home. This judgement has been made using available evidence including a visit to this service EVIDENCE: A statement of Purpose is available for Willows Edge and there is a Service Users’ guide. Each individual has a written contract of terms and conditions. Most Service Users could not remember coming to the home and so were unable to comment on the admission arrangements; a gentleman who was receiving respite care was able to say that he had been given information about the home and assistance to plan his visit. Relatives informed the Inspector that they had been given details of what the home was able to offer and a trial visit had been arranged when possible. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 9 A comprehensive assessment of need is carried out prior to the admission of a new resident. The assessed needs are addressed in each individual’s plan of care. The manager was able to demonstrate that the service has the capacity and skilled staff to meet the assessed needs of those who are entering the home. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10, Quality in this outcome area is excellent. Each Service User’s health, social and personal care needs are planned and met. Their medication is stored and administered safely. They are treated with respectfully with kindness by the staff. This judgement has been made using available evidence including a visit to this service EVIDENCE: Each Service user has an individual plan of care. The plan is followed by care staff and is updated regularly. The new Manger has monitored the number of falls sustained by Service Users in the building and when a risk is identified has introduced the use of a bedroom alarm mat that alerts staff when an “at risk” Service User is moving about during the night. Staff have been able to respond quickly to the alert and consequently the incidence of falls has decreased. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 11 Service Users are referred for professional nursing and medical advice when necessary and the care staff work closely with the community nursing service. One of these nurses was planning to give a training session to care staff during the morning; she outlined her arrangements for nursing care in the home and finds the staff give good care. Equipment necessary for the prevention of pressure sores is provided; a special mattress was delivered during the inspection time. Three medication errors had been reported during the past year; the Manager has improved the system following her investigation and a pharmacist’s inspection. All senior care staff are being trained to be responsible for the ordering and administration of medication to Service Users. No Service User is currently capable of administering their own medication. Special arrangements are in place to care for one individual who can aggressively refuse to take medication. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. Routine in Willows Edge is flexible to suit the needs of the Service Users. Activities are provided and all are invited to become involved. The activities organiser works with each individual. There are frequent visitors to the home and they are welcomed. This judgement has been made using available evidence including a visit to this service EVIDENCE: During the morning the activities Organiser was holding a quiz to encourage Service Users to enjoy and reminisce. Shared activities are displayed on the notice boards and those individuals who do not wish to participate are given opportunity to choose what they would like to do. One relative commentated that he thought this work was “brilliant”. There were many visitors to the home during the day, they were welcomed and encouraged to come frequently. There are places for Service Users to receive visitors in private. A volunteer worker offers to spend time with anyone does not have a visitor. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 13 The Manager has reorganised the arrangements for Service Users’ finances so that everyone has the opportunity to have personal spending money. Lunch is set attractively in various dining rooms in the home. The Manager has chosen bright, light tableware and colours in response to Service Users’ preference. A “healthy food” menu is made available; good-sized portions of appetising lunch were enjoyed and staff assist those who need help to eat. They skilfully encouraged a Service User who has diabetes to eat sufficient. Fresh fruit is offered and staff are aware of Service User individual preferences. Individual arrangements are made for one person to eat separately where she chooses, this allows her to wander and eat when she wants. During hot weather additional drinks are given, records are kept of fluid intake and Service Users’ weight is regularly monitored. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Service Users are protected by properly recruited and vetted staff who are trained to know how to protect vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaint procedure was displayed in the home. Each Service User had a copy on file; although they were largely unaware of how to make a complaint their relatives knew how to do this. There was evidence that the Manager and staff had received concerns and complaints made on behalf of Service Users and had managed these speedily to the satisfaction of the complainants. No complaint had been received by CSCI. New arrangements are operation for management of Service Users’ personal financial affairs. Receipts are now given to next of kin who provide personal allowances and the Manager is making arrangements to have cash available for those who do not have a relative to assist them. Staff are trained in awareness of abuse and no allegations of abuse had been made. In situations when Service Users are violent or aggressive staff know that physical intervention is a last resort and there must be agreed management plans in place. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is adequate. Work is in progress on the building to comply with the requirements of the fire authority; arrangements are to provide better evacuation procedures for Service Users in the event of fire. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are issues concerning the fire safety arrangements for Service Users who live in the building. These were brought to light when the new Manager sought advice from the local Fire Officer following a fire in one of the lounges. Major work was needed and is in progress; workmen were in the building during the visit. There is available outdoor garden space and the home is spacious although it is necessary for wheelchairs to be stored in the entrance area; however, this does not pose a safety hazard to Service Users. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 16 Although three bedrooms do not meet the national minimum size standard they are sufficiently large to meet the needs of the Service Users who occupy them. The bathrooms and wcs are spacious but there are some unprotected pipes and metal tags on pipes in the ground floor bathroom. The flooring in the same bathroom is not closely fitted to the pipes and there are holes where it is difficult to clean. This forms a hazard to Service Users who are at risk of injury or infection. All bedrooms are single and the furnishings are suitable. To assist Service Users the doors in the home are colour coded and each bedroom is individually identified with a photo or picture chosen by the occupant. Specialist beds are provided when needed; one of these was delivered during the visit. When it is appropriate washable flooring is fitted in bedrooms. Grab rails and other aids are fitted throughout the building. The home is clean and pleasant. A new member of the cleaning staff told the Inspector that she liked working in the home even though it is hard work. She was vigorously cleaning a lounge settee where a Service User had secreted a store of biscuits. The laundry is of a good size and is fitted with equipment that meets infection control standards. Service Users’ clothes are all labelled; one of the relatives told the Inspector that staff kindly label clothing for his wife as he is unable to do this. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. Service Users are given care by trained staff who are sensitive to their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new Manager has altered the staffing rotas in order to meet the needs of Service Users. Almost no agency staff are employed following her recruitment of new staff. In addition, the ratio of staff with NVQ training has risen to 70 . A recently employed cleaner said that she likes the work- “much better working in the home than local rumour had led her to believe.” In addition to cleaning well she displayed awareness of her role in relation to the needs of the Service Users. There was evidence in the staff files to show that Service Users have been protected by management adherence to a thorough recruitment procedure for new staff. A training programme was in place and the staff working in the home during the visit demonstrated that they have the skill to provide care for Service Users. In particular they were skilled when assisting at lunchtime. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 18 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, 35, 36, 37, and 38 Quality in this outcome area is good. Service Users live in a home that is well managed and operated to make a safe environment for them and the staff who provide their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new Manager holds the Registered Manager’s award. She was able to demonstrate that she has the skill, experience and motivation to provide a positive environment in which the Service Users can be safe, happy and receive good care. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 19 Although Service Users had not been able to respond to the CSCI survey and give their views on the home it was very apparent that they both liked and respected the Manager. During the Inspector’s tour of the home Service Users responded positively to her and the other staff; one gentleman told the Inspector that the Manager was “my best partner”. The relatives who spoke to the inspector were also very clear that they felt that the home was managed in the best interests of the Service Users. A quality assurance system is in place; a copy of a survey about satisfaction with food was displayed on the notice board. Also displayed was information from the Department of Health about care to be taken during very hot weather and there was evidence in the home that this had been implemented. The Registered Individual has sent regulation reports to CSCI. The accounting and financial procedures for the organisation were not inspected on this occasion though it was noted that the Manager now gives receipts to relatives and new arrangements were being made for every Service User to have cash available from their personal allowance. Records for the safety and welfare of Service Users and staff were available. Work was in progress to complete fire safety work to protect and evacuate Service Users and the Manager is required to notify CSCI when the Fire Officer is satisfied with the standard achieved. Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 2 3 2 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Willows Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 21 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. 1 Standard OP38 Regulation 23, (4) Requirement Inform CSCI when the Fire Officer is satisfied with the work currently in progress to comply with fire safety regulations. Send a plan for action to be taken following a Health and Safety risk assessment of the pipe work and flooring of the bathrooms and toilets. Timescale for action 25/10/06 2 OP19 23(2) 25/10/06 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 Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Oxford Hub Office Burgner House Oxford Business Park Cowley, Oxford OX4 2SU 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 Edge DS0000031418.V306133.R02.S.doc Version 5.2 Page 23 - 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. 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