Inspection on 14/04/05 for Willows Nursing Home, Blacon

This inspection was carried out on 14th April 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 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 Nursing Home, Blacon 29/05/09

Willows Nursing Home, Blacon 01/05/07

Willows Nursing Home, Blacon 18/10/05

Willows Nursing Home, Blacon 08/12/04

Willows Nursing Home, Blacon 07/06/04

Willows Nursing Home, Blacon 12/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE WILLOWS NURSING HOME Treborth Road Blacon Chester CH1 5RP Lead Inspector Wendy Smith Unannounced 14 April 2005 09:30 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 NURSING HOME BLACON Version 1.10 Page 3 SERVICE INFORMATION Name of service WILLOWS NURSING HOME BLACON Address TREBORTH ROAD, BLACON, CHESTER, CHESHIRE CH1 5RP 01244 374023 01244 379228 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) MR MOHAMMED HUSSAIN MRS VIVIENNE HAYNES CARE HOME 73 Category(ies) of OP Old Age (23) registration, with number DE(E) Dementia - over 65 (50) of places DE Dementia (5) WILLOWS NURSING HOME BLACON Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Maximum of 73 persons accommodated aged 65 years and above. 2 Within the maximum of 73 service users, 50 individuals in the DE(E) dementia category may be accommodated. 3 Within the maximum of 50 individuals in the DE(E) category five persons in the DE category, under 65 years of age may be accommodated. 4 No more then 23 persons may be accommodated in the OP category. 5 Bedroom numbers 8, 27, 64 and 65 only may be used to accommodate two persons. 6 The staffing proposals submitted by Mr Naveed Hussain as part of the application to vary the homes registration numbers and categories, dated 31st March 2004 must be complied with at all times. Date of last inspection 8th December 2004 Brief Description of the Service: Willows Nursing Home is a single storey building situated in the Blacon district of Chester. The home provides nursing care to twenty-three older people whose needs are due to physical frailty, and fifty people who have dementia. The home is part of a small group of homes owned by the registered providers.An extension to the home was completed in 2004 and provides 26 new bedrooms, two lounges, a dining room, and other communal facilities. Work is ongoing to improve facilities in the original part of the home. Extensive work has been carried out to landscape the grounds of the home. All rooms and areas, including the gardens, are spacious and are accessible to wheelchair users. The home provides 65 single bedrooms, 26 of which have en-suite facilities, and four bedrooms which may be shared by two people. Two of these rooms have en-suite facilities, including a shower.The home is conveniently situated for local shops and other communal facilities in Blacon. There is regular public transport into Chester city centre. WILLOWS NURSING HOME BLACON Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place over a period of eight hours. It was carried out by two inspectors who agreed the format of the inspection with the manager. The inspection was carried out using a process of cross referencing the documentation of identified service users following discussion with them, and following the delivery of care and support to them. Staff records were inspected. A tour of the building, including all communal areas and a number of bedrooms, was completed. Six service users and four relatives contributed their experience of living in and visiting the home. Seven of the staff on duty were spoken with. What the service does well: What has improved since the last inspection? Several bedrooms have been refurbished since the last inspection and new furniture has been fitted in the dining room. A visitors’ room, a relaxation therapy room and a hairdressing salon have been completed. Fourteen care staff have enrolled for NVQ level 2 qualification in care. WILLOWS NURSING HOME BLACON Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. WILLOWS NURSING HOME BLACON Version 1.10 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 NURSING HOME BLACON Version 1.10 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) 1 and 3 The home’s Statement of Purpose and Service Users’ Guide do not inform the reader that transitional care is provided at this home. therefore the information provided does not fully assist those who need to make a choice to live at the home. Records kept at the home did not provide evidence that, before moving into the home, all service users had received a full needs assessment. Without a proper assessment the home could not demonstrate that all service users’ care needs would be met. EVIDENCE: Care documents relating to a number of service users were examined. These showed that the people most recently admitted to the home had been admitted under ‘transitional care’ arrangements with the local Primary Care Trust. There was no consistency in the pre-admission assessment documentation for these people and, for two people, no assessments were available. One of the service users admitted under transitional care arrangements with continuing WILLOWS NURSING HOME BLACON Version 1.10 Page 9 care needs was identified as being inappropriately placed, resulting in the disruption of the daily lives of other service users. The home’s Statement of Purpose had not been revised to inform readers that the home provided transitional care or to explain what this means. WILLOWS NURSING HOME BLACON Version 1.10 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, 8 and 10 Most service users had a plan of care providing details of their needs. There was a delay in producing care plans for recently admitted service users, and this needs to be addressed to ensure that the health care needs of all service users are identified and planned for. Service users’ health care needs were met in full. Observation of staff practices showed that, for the most part, service users’ privacy and dignity were upheld. EVIDENCE: A number of care plans were examined. All plans had a comprehensive range of assessment documents but these had not yet been completed in full for several service users, and plans were not yet in place for more recently admitted service users. Care plans identified behaviours associated with the mental health needs of service users. Where identified risks to the individual service user or other service users were recorded in the care plan, it was not supported by a risk assessment or risk management plan. WILLOWS NURSING HOME BLACON Version 1.10 Page 11 Discussion with two service users and a relative confirmed that a number of events recorded about one service user’s behaviour were not being managed by a risk assessment or risk management plan. The frequency of admissions of service users for transitional care was creating a significant amount of extra work in compiling care plans for these service users. This was discussed with the home manager and she explained that additional hours were going to be allocated to a part time administrator so that the manager would have more time to be involved with care plans. Relatives visiting the home said that they had been involved in the care planning process. Evidence from care plans, and from conversations with service users and their relatives, indicated that the health needs of service users were met. At the time of the inspection, all bedrooms were singly occupied and 26 rooms have en-suite facilities. Personal care is carried out in the privacy of the bedroom. During the inspection, we observed that service users with challenging behaviour were treated with patience, dignity and respect by the staff. Visitors spoken with confirmed that they were very happy with the way in which their relatives were cared for. A letter received from the family of a recently deceased resident commented that ‘staff were able to see past her dementia and see the strong, fun-loving person within’. Linen trolleys in the corridors contained some personal items belonging to service users which should be kept in their rooms. The manager acknowledged that this was not acceptable and addressed this issue with the staff in a positive manner. WILLOWS NURSING HOME BLACON Version 1.10 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) 12,13 and 15 Service users are supported to exercise choice in their lifestyle and to meet their social needs. Families and friends are welcomed into the home at any reasonable time. Service users have a good choice of meals in pleasing surroundings. EVIDENCE: Service users were seen to be free to move around within the home and gardens, and a good choice of sitting areas was available. Staff were observed spending social time with service users. There were a number of visitors to the home throughout the day. They were made welcome and were clearly comfortable in approaching the home manager and discussing any issues with her. The home provides three full meals a day. The manager said that approximately 14 service users choose to have a cooked breakfast. The main meal is at lunchtime and a choice of two main dishes is available. In addition to this, individual choices are accommodated. Most service users choose soup and sandwiches for their evening meal, but a light cooked meal is also available. WILLOWS NURSING HOME BLACON Version 1.10 Page 13 Night staff have access to all food supplies and are able to make a snack for any service user who requests this during the night. Service users are weighed on a regular basis and nutritional supplements are provided for any service users who need them. Service users spoken with said that they were satisfied with the meals provided and confirmed that choices were available. WILLOWS NURSING HOME BLACON Version 1.10 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) 18 Policies, procedures and staff training are in place to protect service users from abuse. Managers at the home need to monitor and report the incidents of physical confrontation between service users and report these under the adult protection procedures when necessary to improve the protection of service users. EVIDENCE: The home has an Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets. Staff had received training regarding Adult Protection. Care records identified that physical incidents between service users sometimes occur. These should be dealt with appropriately and reported where necessary under adult protection procedures and should not be accepted as part of community living. WILLOWS NURSING HOME BLACON Version 1.10 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 and 26 Service users live in a safe and well-maintained home, which is clean and hygienic. There is a commitment to improving the standard of accommodation for the benefit of service users. EVIDENCE: Willows is a single storey building and all rooms and areas, including the gardens, are spacious and are accessible to wheelchair users. All communal areas and some of the bedrooms were seen during this inspection. An extension to the home was completed in 2004 and provides 26 new bedrooms, two lounges, a dining room, and additional bathing facilities. A number of other bedrooms have been refurbished and plans are in place to bring the remaining rooms up to the same standard. The dining room has been fitted with new furniture since the last inspection. The home employs a maintenance person who carries out routine maintenance work and decorating. A new fire alarm system and nurse call system was installed in all areas in 2004. WILLOWS NURSING HOME BLACON Version 1.10 Page 16 All communal areas of the home were found to be clean. A small number of bedrooms had an odour problem. This was discussed with the home manager, and it was evident that this problem was being addressed and was due to individual behaviour of service users rather than any lack of cleaning. A new laundry was built in 2004 and provides a very good facility for the home. WILLOWS NURSING HOME BLACON Version 1.10 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 and 28 The numbers and skill mix of staff are adequate to meet service users’ needs. More staff need to achieve NVQ 2 qualification and the home is working towards this. EVIDENCE: On the day of the inspection there were registered nurses and care assistants on duty in sufficient numbers to meet the needs of service users. Inspection of staff rotas provided evidence that these levels were maintained at all times. Any shortfalls are covered by agency staff and, whenever possible, the same staff are supplied to the home by the agency to ensure continuity of care. The manager said that the home had joined the Cheshire Consortium of care homes, and 14 care assistants have enrolled to commence working towards NVQ level 2 or 3 qualification in the near future. WILLOWS NURSING HOME BLACON Version 1.10 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 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) 31 The home is well run and is managed on a day to day basis by a person who is fit to be in charge. EVIDENCE: The home has a very experienced and competent manager who is a registered nurse and is registered with the Commission for Social Care Inspection. She has held this post for several years, during which time significant improvements to all aspects of the home have been observed. WILLOWS NURSING HOME BLACON Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x x x x x x x WILLOWS NURSING HOME BLACON Version 1.10 Page 20 no 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 1 Regulation 4 Requirement The statement of purpose must be reviewed to ensure that it includes details of transitional care. The home must maintain a record to demonstrate that each service user has had a full needs assessment prior to admission to the home. A plan of care must be in place for each service user, supported by a risk assessment and risk management plan when necessary. Timescale for action 31/6/05 2. 3 14(1) 17(1)(a) Schedule3 15 30/4/05 3. 7 30/4/05 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. Refer to Standard 10 18 Good Practice Recommendations Service users personal items should be kept in their own rooms. All incidents of physical aggression between service users should be clearly documented to enable the manager to decide if further action needs to be taken. WILLOWS NURSING HOME BLACON Version 1.10 Page 21 Commission for Social Care Inspection Unit D, off Rudheath Way Gadbrook Park Northwich Cheshire, CW9 7LT 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 NURSING HOME BLACON Version 1.10 Page 22 - 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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