Inspection on 07/11/05 for Willows Edge

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 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 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 Stephen Webb Unannounced Inspection 7th November 2005 10:15 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 DS0000031418.V264269.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. DS0000031418.V264269.R01.S.doc Version 5.0 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 DS0000031418.V264269.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 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. An experienced new Manager, Patricia Rolfe, has recently been appointed. DS0000031418.V264269.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out on 7/11/05, between 10.15am and 4.15pm. The inspection included discussion with the manager, examination of records, limited discussion with a small group of residents and examination of communal areas of the home, and a small sample of bedrooms. The inspector also had lunch with residents. The newly appointed manager is undertaking her induction training and has begun to identify areas of priority for her initial attention. The manager demonstrates a thorough understanding of the needs of the residents and of some of the ways in which the service might be further improved. During the inspection, the fire alarm sounded owing to a false alarm in the kitchen. The staff drilled according to the procedure and the brigade attended promptly. No evacuation outside was necessary, but staff ensured that the indicated zone was clear of residents. A possible fault on the fire alarm panel, indicated in the course of the false alarm, was addressed by an immediate call to the contractors who attended during the inspection to remedy the problem. What the service does well: What has improved since the last inspection? DS0000031418.V264269.R01.S.doc Version 5.0 Page 6 Improvements have been made in the medication management systems following advice from the CSCI Regional Pharmacist Advisor. The home now has a permanent manager appointed who is undertaking her induction and identifying her initial priorities within the home. An increased focus was evident on involving those residents who wish to, in daily tasks about the home, to maintain their sense of self-worth and of contributing to the home. The manager is seeking to raise the profile of the home, within the local community and bring in appropriate community-based activities to the home. A local school is coming to do a carol service and the manager is seeking local input, and possible commercial sponsorship for improvements to the garden. Additional new staff have been recruited to the home to reduce the previous dependency on excessive agency staffing. What they could do better: The new manager has already identified a number of priorities to be addressed over the next year. • • • • • to carry out a medication review for all residents to improve the quality of information recorded in the complaints log to enable effective monitoring to provide improved signage and colour differentiation in the home to brighten some areas, and improve orientation. to make improvements to the garden facilities and accessibility to review staffing levels, rotas and deployment and the issue of effective use of the home’s allocated care hours A review of the care planning system is also planned. There is a need to undertake a further cycle of quality assurance questionnaires to relevant parties and to produce a summary report of the findings, and also to produce an annual development plan for 2006/7. A proper auditable system needs to be set up to record details of any resident’s monies handled by the home. This issue had already been identified by the new manager. 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. DS0000031418.V264269.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 DS0000031418.V264269.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): None. EVIDENCE: None of the standards in this section were examined on this occasion, but Standard 3 was examined at the previous inspection and found to be met. Standard 6 was not applicable. DS0000031418.V264269.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): 8, 9, 10 Resident’s health care needs are met effectively, and the manager is planning to make further improvements in this area. None of the current residents is able to manage their own medication. The home’s medication management systems have been improved since the last inspection. Residents gave some indications that they were treated with respect and given due privacy. This was backed up by feedback from the manager and the inspector’s observations of staff interaction with residents. EVIDENCE: The health needs of residents are addressed within individual care plans and individual records sheets for district nurse contact, chiropody etc. The care plans are to be further developed in the near future. Amongst the activities provided to residents are some designed to promote physical health, mental awareness, positive sense of self worth and emotional health. DS0000031418.V264269.R01.S.doc Version 5.0 Page 10 None of the residents currently has any pressure sore areas. The new manager is considering setting up a formal pressure sore monitoring system, given the level of risk for this client group. Individuals receive any necessary support from external professionals such as GP’s district nurses, CPN’s etc. as required. Since the visit by the CSCI’s Regional Pharmacist Advisor, improvements have been made in some areas of medication management, particularly around individualised, named stock of PRN (when required), medication. A second drugs trolley has also been obtained to address storage issues. The home has a detailed medication policy/procedure in place. There have also been two pharmacy audits of the unit, by the medication provider, since the previous inspection, which have been satisfactory. The new manager is also planning to arrange medication reviews for each resident in the near future. Feedback from a small number of service users indicated they felt they were treated with respect and had their privacy. All residents have single bedrooms, and staff were observed to knock on doors before entering bedrooms. Personal care support is provided behind closed doors and by the minimum number of staff necessary for the particular task, based on risk assessment. There is a resident’s phone available outside the dining room, though few of the current residents would be able to use it. Individuals do sometimes receive calls from family on this phone. During lunch, staff were observed sitting down next to residents when needing to support them, and giving this support at the resident’s own pace, which is good practice. DS0000031418.V264269.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): 13, 14 Resident can maintain contact with family, and visiting is open and unrestricted. They also have opportunities to go out within the local community on a regular basis. Residents are supported to make choices within their daily lives. EVIDENCE: The home has no restrictions on visiting times, and residents can see visitors in private in the visitor’s room or the resident’s bedroom as well as in one of the communal areas. The manager is considering enabling staff to support resident’s family links through writing letters with, or on behalf of residents to their families. The new manager is seeking to raise the profile of the home in the local community, and involve local volunteers, school-children etc. in the home. A carol concert by local school-children had been organised. The activities co-ordinator regularly takes out individuals and small groups of residents into the community, to local shops, cafes activities etc. During the inspection, three residents went out to a “Singing For The Brain” session, and one reported that she had very much enjoyed it, when she returned smiling and singing, to the dining room for her lunch. DS0000031418.V264269.R01.S.doc Version 5.0 Page 12 As already noted, there is a public pay-phone outside the dining room, which is available to residents and visitors, and accepts incoming calls as well. Residents are supported to make choices whenever possible in their day-today lives. For example, there are two main choices at lunchtime which are posted on a large white-board. During lunch, one resident changed her mind about her main course from the one she had chosen earlier, and this was immediately respected by the staff member. Residents who choose to, are being enabled to take some part in day-to-day activities such as dusting, laying and clearing tables etc. Residents can also choose whether they wish to take part in activities or events. DS0000031418.V264269.R01.S.doc Version 5.0 Page 13 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, 18 Records indicated that the concerns of residents and others are appropriately addressed, though it was not possible to verify this from resident’s feedback. Residents are protected from abuse through proper procedures and policies, and the staff receive appropriate training on the protection of vulnerable adults. EVIDENCE: The home has a written complaints procedure in place. One new complaint was recorded since the previous inspection, the details of which were present in the confidential complaints file. The matter had been addressed appropriately. However the complaint had not been entered in the complaints log. The manager addressed this during the inspection, and also plans to improve the format of the log to include more summary detail, regarding the action taken and the outcome in response to any complaints. None of the residents spoken to made any comment about complaints or expressed any concerns about their care in the home. The home has an appropriate vulnerable adults protection procedure in place and also operates within the local multi-agency protocol. A course ‘flyer’ was present regarding an upcoming adult protection training course as part of the foundation training for newer staff. The manager was going to ensure that all of the newer staff were able to attend. DS0000031418.V264269.R01.S.doc Version 5.0 Page 14 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 Residents live in a safe, well-maintained environment. The newly appointed manager has a range of plans for further improvement of the premises, which will enhance the environment and help to improve orientation for residents. EVIDENCE: On this occasion the communal areas were examined, together with a small sample of the bedrooms. The communal areas were homely and pleasantly decorated and furnished. The home offers a choice of two main lounges, one with a conservatory, and two dining areas. There are bedrooms on all three floors and all three are served by a passenger lift. The home was clean and free of unpleasant odours, and had a relaxed atmosphere. Previously required repairs to some bedroom ceilings had been addressed. The bedrooms examined contained individual items to personalise them. DS0000031418.V264269.R01.S.doc Version 5.0 Page 15 The manager is planning various improvements to the garden, including the provision of raised beds and sensory planting, which will enhance the available facilities for the residents. There are also plans to introduce more colour in areas of the home to brighten them up and also assist with orientation for the residents. Additional signage of specific rooms and individualised labelling of bedroom doors is also planned. The manager also wants to brighten up the bathrooms to make them more user-friendly. DS0000031418.V264269.R01.S.doc Version 5.0 Page 16 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, 29 Resident’s needs are addressed well by the available staff, but there remains some concern regarding staffing levels/deployment, which the newly appointed manager is actively reviewing. Residents are protected by the recruitment and vetting system used when new staff are employed at the home. EVIDENCE: In response to a previous inspection requirement, a review of staffing levels was to be undertaken by another unit manager. The new manager should incorporate this review in her upcoming staffing review. A copy of this previous report should be provided to the inspector. The manager has identified a number of staffing issues around rotas and staff distribution which she intends to explore. There is an issue where full-time posts have been recruited to at only twenty hours, with the consequent loss to the unit, of the remaining seventeen care hours of the post. This issue will require further exploration, as it may well be a factor in the previously identified staffing level concerns. The manager should report the outcome of her discussions and overall staffing review to the inspector. DS0000031418.V264269.R01.S.doc Version 5.0 Page 17 Two new staff had commenced employment in the unit since the previous inspection. Examination of the recruitment records indicated a thorough vetting process. Two further staff had been appointed but were yet to commence work as CRB checks were still awaited. Other required records were in place. DS0000031418.V264269.R01.S.doc Version 5.0 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): 33, 35 Further evidence is required of the ongoing consultation process with residents, relatives and other parties, to better demonstrate the extent to which the views of relevant people are considered in the running of the home. The current lack of a recording/auditing system for resident’s monies held temporarily by the home, could compromise the financial interests of residents. The newly appointed manager is aware of the issue and plans to address this as a matter of urgency. EVIDENCE: An internal quality audit had been carried out prior to the recently appointed manager coming into post. There had also been a round of quality assurance questionnaires to residents/relatives in October and November of 2004, and a later consultation around possible improvements to the garden. A copy of the summary report of the quality assurance survey was provided to the inspector. DS0000031418.V264269.R01.S.doc Version 5.0 Page 19 A further round of quality assurance surveys is now also due together with a summary report of the findings. The quality assurance review should feed into the annual development plan for the ensuing year, together with any issues from CSCI inspections, complaints, Regulation 26 reports, internal audits etc. and should inform the budget planning for the following year. A copy of the annual development plan for 2006-7 should be provided to the inspector. The unit does not manage resident’s monies but does hold small amounts of residents money provided by relatives for specific purposes, such as hairdressing costs. The monies are secured in individual named envelopes in a locked cash box but no proper written record is in place. A written in/out/balance book should be maintained with signatures/initials to account for resident’s monies, and receipts should be retained for any expenditure by or on behalf of residents. The manager had already identified this and is planning an appropriate system. DS0000031418.V264269.R01.S.doc Version 5.0 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X X DS0000031418.V264269.R01.S.doc Version 5.0 Page 21 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 OP27 Regulation 18 Requirement A copy of the staffing review previously undertaken by another unit manager should be provided to the inspector. This requirement remains outstanding from the previous inspection. The manager should supply a copy of her full review of staffing levels and deployment to the inspector. A further round of quality assurance surveys of relevant parties should be carried out and the resulting summary report copied to the inspector. Notify the inspector when an appropriate recording system has been established for resident’s monies. Timescale for action 10/12/05 2 OP27 18 10/02/06 3 OP33 24 10/03/06 4 OP35 17 10/12/05 DS0000031418.V264269.R01.S.doc Version 5.0 Page 22 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 Refer to Standard OP33 Good Practice Recommendations A copy of the annual development plan for the home, for 2006/7, should be provided to the inspector. DS0000031418.V264269.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks 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. 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