Inspection on 06/06/05 for Willows Edge

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 Edge 18/09/08

Willows Edge 12/09/06

Willows Edge 07/11/05

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 Hutton Close Shaw Newbury Berkshire RG14 1HJ Lead Inspector Steve Webb Unannounced 6 June 2005 @ 10:15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willows Edge Address Hutton Close Shaw Newbury Berkshire RG14 1HJ 01635 45252 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) West Berkshire Council Vacant Care Home 36 Category(ies) of Dementia over the age of 65 years - DE(E) registration, with number of places WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13/12/04 Brief Description of the Service: Willows Edge is a home, located in Shaw, near Newbury, which provides specialist residential care to elderly persons with diagnoses of dementia. The home is on three floors with a lift, and has thirty five single bedrooms which are long-stay, and one single bedroom which is used for respite for individuals with mental frailty. The home also provides three day-care places for non-residents, but this facility is not separately provisioned, nor staffed, and any day-care service users are integrated with the residents group. The home has a number of specialist adaptations to meet the needs of its mentally frail residents. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out between 10.15am and 4.15pm on 6/6/05. The inspection included discussion with the acting manager and staff, examination of files, records and policies, a tour of the unit and some conversation with about eight of the residents. The inspector also had lunch with residents. The inspection was a positive one, though the shortfalls in staffing levels were evident at various times during the afternoon. Feedback from several residents, was generally positive, though some said there were not enough staff at times. Staff were said to be kind and helpful, but did not have much time to chat. Feedback on the food and the choices available was positive. What the service does well: What has improved since the last inspection? The majority of the previous inspection requirements had either been addressed, or were in progress. There are plans to improve the access, design and function of the garden for residents. Care staffing levels had been increased to some degree, as had domestic hours. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 6 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 H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 standard(s) 3, 6 Service users are assessed appropriately prior to moving into the home, initially for a six-week trial period. Standard 6 is not applicable, as the home does not provide intermediate care. EVIDENCE: Standard 6 is not applicable, as the home does not provide intermediate care. The home has a standard procedure for referrals which entails obtaining the care manager’s assessment, together with any psychiatric assessment, (if available), initially. If the prospective resident is living at home, they are invited to visit the unit for the day for assessment. If they are in hospital or another unit, they are visited there to complete this stage of the process. At this stage a brief Trial Visit record is completed, and a copy of the user guide is given to the prospective resident or their representative. These assessment documents are used to inform the decision on whether a place is offered, together with any additional information obtained from family. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 9 If a place is offered, it is initially on a six-week trial period, and Past History and Likes and Dislikes forms are sent to the person’s family to assist in planning for their admission. Family are encouraged to bring in some of the resident’s small personal items ahead of their move to make them feel more at home. A Task Plan (initial care plan) is completed to inform staff of individual care needs. A review is held after six weeks to confirm permanency. At this stage. additional personal items including small items of furniture, may also be provided by family to make the resident’s bedroom more personalised. A standard risk assessment format is completed where applicable to help identify specific areas of additional need, including a moving and handling assessment. Once the placement has been confirmed, a more detailed service-user, (care) plan is completed by a Link Worker (senior), in consultation with the resident’s keyworker. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 standard(s) 7, 9 Service user needs are detailed within an individual care plan as required. The home’s medication practices protect the service users, for the most part, though clarity is being sought on the handling of some PRN medication. EVIDENCE: Once a placement is confirmed as permanent, the service user plan is reviewed on a monthly basis, by a link worker, and this is recorded on a care plan review sheet. Examples of this process were seen during sampling of service user records. The old care plans are reportedly shredded, when a new, updated one is produced on computer. Care plans are dated and signed by their author. The home is beginning to get the care plan countersigned by the resident or their representative, after discussion at annual reviews. This is good practice and consideration should be given to seeking such countersignature whenever any significant changes to a care plan become necessary between reviews. None of the current residents are able to hold their own medication. All are held and administered by staff. The home uses the monitored dosage system for the majority of medication, though advice has been sought from the CSCI WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 11 regional pharmacist advisor regarding the present system for storage and administration of some PRN medication. All medication administered is recorded on MAR (medication administration record) sheets, and initialled by the person administering. All staff receive in-house medication training and shadow a more experienced staff member within the unit for two weeks before administering alone, as well as completing a medication checklist as part of induction. The home has a detailed written medication procedure which was reviewed in 2004, and is in the process of being reviewed again. The quantities of medication received into the home are recorded on MAR sheets as part of the medication audit trail. Monthly returns sheets are also completed for all medication returned to the pharmacist. A controlled drugs register was in use appropriately for two prescribed medications. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 standard(s) 12, 15 The home’s ability to meet the social and recreational needs of residents is enhanced by the employment of an activities co-ordinator, for thirty hours per week. However, the care staffing levels, although recently improved, still limit the ability of care staff to provide significant activities input or individual emotional support, particularly in the afternoons and evenings. Service users are provided with an appropriately varied and nutritious diet, including daily choice, within pleasant dining facilities, at appropriate times. EVIDENCE: The home employs an activities co-ordinator from 10am to 4.00pm, Monday to Friday, whose role is to lead on the provision of individual and group activities with the residents. It was reported that she provided the majority of the planned activities for residents. She was observed interacting with individuals, both individually and in small groups, on activities during the inspection. A weekly activities planner is posted of the scheduled activities provided and these are retained for the record. The care staff, offer additional activity input, from time-to-time, which is recorded within care records activity record sheets on individual files. If the current care staff levels were increased there would be improved opportunities for care staff to provide additional personal emotional support and activity WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 13 input. Given the levels of dementia and the need for regular staff input this would benefit the residents. Another aspect which could be improved upon, was the absence of suitable facilities where a resident or small group could be assisted, by staff to engage in limited cooking activities. Some residents are enabled to help with vegetable preparation at times, but opportunities were acknowledged to be limited. The main kitchen is not really appropriate for resident use, but there are two littleused kitchenettes, one of which could be adapted simply to provide a facility for residents to engage in baking and cooking activities. One senior staff member has a particular interest in reminiscence work and is developing subject-based sets of reminiscence materials to use with residents, which will be an excellent resource as long as the staff have sufficient time available to make effective use of them. The home has also established a sensory room, but this is little used at present owing to the need for staff training in its effective use. There is flexibility in the timing of residents going to bed and getting up according to their preference. Breakfast is available from 8.00am until 10.30am, although lunch and tea are more fixed. Choices are available at all meals. Staff were observed offering the teatime options to residents during the inspection, and the day’s menu is written up on a whiteboard in the dining room. Meals can be kept hot, by arrangement, if a resident is out over a mealtime. The home has recently employed a contracted-in catering company to provide meals, and although there have been some initial problems with staffing consistency, the system now appeared to be stabilising. Feedback obtained from residents by the home, indicated they were broadly happy with the new caterers, and this was also reflected in the feedback to the inspector. The home had used a questionnaire about meals to obtain residents views, at the end of 2004, as part of the quality assurance system, and there was a plan to revisit this after a suitable settling-in period. The acting manager indicated that a positive relationship was developing with the caterers, through regular meetings to discuss any issues. The residents usually dine in one of the two dining rooms, which are attractively furnished and decorated, providing a pleasant dining environment. Flexibility is also evident in other areas of care such as preferred bathing times, wherever possible, though staffing limitations in the afternoons would be likely to impact upon this. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 standard(s) 16 The available evidence suggests that the home works to resolve complaints appropriately, and refers them through the available stages of the procedure appropriately, when agreement is not reached about their resolution. EVIDENCE: An appropriate complaints procedure was in place, which was displayed in the home’s entrance hall. Copies of complaints forms were also available in the comments and suggestions book, on a table in the entrance hall. There were two recent complaints, one of which had been resolved at stage one and a second, which had been referred on through further stages of the procedure for resolution. The home appeared to have responded appropriately to the findings of the investigating officer, at stage two, on the second complaint and the recommendations made had reportedly been actioned. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 standard(s) 19, 26 The premises were, for the most part attractively decorated, homely, and well Maintained. Some works in response to previous requirements still needed to be actioned, though these were within the previous deadlines. The home was found to be clean and staff respond promptly to address unpleasant odours when they arose. EVIDENCE: The various communal areas of the building are attractively decorated, well furnished, and homely. The entrance hall is light airy and very welcoming. Some of the bedrooms were also inspected and were satisfactorily decorated and personalised to varying degrees. The previous requirement to make good the decoration of the ceilings of four of the top floor bedrooms had yet to be actioned, although the job had reportedly been priced-up and the requirement remained within the original deadline at the time of this inspection. The same was true of the requirement to replace the defective sluices, which had been checked, but no date for their replacement could be provided. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 16 Plans to improve the usability and effectiveness of the main garden area were in the process of being drawn up in consultation with residents. This previous requirement was also still within the original deadline at the time of inspection. The inspector should be notified when these required works have been completed. Staff regularly shampoo the carpets, when necessary and this was observed during the inspection. Staff were observed to respond promptly to address unpleasant odours when they arose. One of the baths was out of order, necessitating residents using the facilities on other floors until it is replaced. This is not really appropriate, and the budget for a replacement item had reportedly been agreed. This should be provided as soon as possible and the inspector notified of its installation. As noted earlier, consideration should be given to the conversion of one of the kitchenettes to a facility where service users can be assisted with cooking and baking activities. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30 The range and complexity of needs of service users are not fully met by the current staffing levels, particularly at certain times of day, given the layout of the building. Further consideration of increasing care staffing levels is needed. The permanent care-staff receive a good range of training to equip them to do their job, though the high levels of agency staff do not have access to much of this training. EVIDENCE: Recruitment continues to be a problem for this unit. No new care staff had been recruited since the previous inspection in December 2004. A recent planned recruitment drive did not take place, but it was reported that this is about to happen. The home is also taking a stand in the local Kennet Centre to publicise the home and try to engage recruits. There had also been some informal expressions of interest which are to be followed up. Consideration is being given to a regular fortnightly or monthly recruitment advert. There have also been some reported issue with the Authority’s personnel department’s processes. There were 265 vacant day care hours out of an allocated 597, all of which are now covered by agency staff. The unit has changed agency and the acting manager felt that they were now getting more consistent and suitable staff provided by their agency. Up to four of the agency staff are working full weeks, with others regularly doing individual shifts. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 18 There is one vacant senior officer post out of four, though an applicant is being processed. Domestic hours have been increased since the last inspection. Although some increase in day care staffing had been agreed following the previous inspection, the high level of needs of the resident group, together with the physical layout of the building mean that there are still insufficient staff to fully meet the range of complex needs of the resident group. On weekday afternoons, between 1.30pm and 3.30pm daily there remains only five care staff on duty and this situation continues until 9.00pm, Monday to Friday. In the inspector’s opinion this remains insufficient on health and safety grounds as well as in terms of fully meeting the needs of the residents. It was evident during the inspection that the call bells are in regular use and that some residents in particular needed frequent reassurance and staff attention to enable them to remain calm and not become agitated. Several residents require two staff to assist with toileting/transferring etc. and this could leave areas of the building short of staff. During the inspection two separate contractors had to wait several minutes to get in and out of the unit, because no staff were available to attend to them. It was also evident that the duties of the seniors took them away from direct care input for significant periods (meetings, handovers, medication rounds, etc), and with one of these posts vacant, the direct care support from senior staff was reported to be limited. Further re-consideration of the care staffing levels is needed. Some staff already had NVQ level 2 and a further two staff had recently completed this, with two more in the process of their level 2. One of the senior staff is undertaking the in-house assessor modules. There was a collective spreadsheet of staff training received, plus individual training records in personnel files, together with copies of certificates. Some recent training had still not been entered on these records, and they should be brought up to date through supervision. Permanent staff were booked on a wide range of appropriate upcoming training over the ensuing months, including care planning, 1st aid, dealing with difficult behaviour, moving and handling, communication skills, recording skills, complaints, infection control, diabetes and introduction to dementia. However, the high levels of agency care staff do not have access to much of this training. Care staff training on the use of the sensory room equipment would also be beneficial. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The health and safety of service users and staff are promoted through the training provided and the regular servicing of equipment. EVIDENCE: Most of the required servicing could be evidenced through certification, though some could not be located at the time of the inspection. Missing certificates were copied to the inspector immediately after the inspection. Clarification is required that identified remedial electrical works were carried out. The home has regular fire drills for staff including during their initial induction. Accident/incident records are maintained on a computerised system, and are monitored by the Regulation 26 monitoring visitor and acting manager. Copies of incident or accident records are also printed out and placed on the resident’s file as required. Health and safety related training is provided to staff on a rolling programme. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 2 WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement Timescale for action 6/8/05 2. 12/27 18 The recommendations of the regional pharmacist advisor must be actioned, with regard to PRN medication. The daytime care staffing levels 6/9/05 require further review, to more effectively address the complex needs of the service users for whom the home now provides. 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. Refer to Standard 12 12 38 Good Practice Recommendations Consider the provision of staff training on the appropriate use of the sensory room equipment. Consider the adaptation of one of the kitchenettes as a facility where residents can be supported in cooking and baking activities. Please clarify that the identified remedial electrical works have been carried out. WILLOWS EDGE H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA 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 H52-H01 31418 Willows Edge V228939 060605 Stage 4.doc Version 1.30 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. 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