CARE HOMES FOR OLDER PEOPLE
Willows Residential Home Corders Farm, Bury Road Lawshall Bury St Edmunds Suffolk IP29 4PJ Lead Inspector
Claire Hutton Unannounced Inspection 13th January 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 Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 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 Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Willows Residential Home Address Corders Farm, Bury Road Lawshall Bury St Edmunds Suffolk IP29 4PJ 01284 830665 01284 830892 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) Extrafriend Limited Mrs Margaret Holt Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 26th May 2005 Brief Description of the Service: ‘Willows’ is a large detached building set it its own grounds in the village of Lawshall, a rural location, approximately eight miles south of Bury St Edmunds. The property, originally a farm, was extended during 2004 to provide additional bedroom and communal facilities. As a result the number of registered beds at Willows increased from seventeen to twenty-five. Apart from one larger shared bedroom on the first floor, the remaining bedrooms were singly occupied, and all bedrooms in the home had en-suite facilities. The accommodation, located on two floors, includes a shaft lift, and a staircase, connecting the two floor levels. The home is set in pleasant gardens, which include patio seating areas, lawns, flower beds, and a pond. There is off road car-parking at the front of the home. ‘Willows’ is owned by Extrafriend Limited. The Registered Manager is Mrs Margaret Holt, and the Responsible Individual is Mr Noel Rogers, who is frequently present at the home. Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over three and a half hours on a weekday in January 2006. The registered manager was not present and two senior carers facilitated the visit. Feedback was given to the registered manager by telephone on the next working day. The purpose of this visit was to assess the key standards not examined at the visit in May 2005. Therefore this report would benefit form being read alongside the May report to enable all key standards to be viewed. Two residents were met and spoken with, all staff on the roster were seen, and two staff were spoken with privately. A tour of all communal areas was undertaken along with five bedrooms. Records examined included rosters, assessment, care plans, training, residents finances and policies. What the service does well: What has improved since the last inspection? What they could do better:
There were two areas for future development that were discussed with the manager. She agreed to address both matters.
Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 6 Firstly the environment, in relation to radiators there was one area of the home that was not heating sufficiently and residents were concerned about the temperatures. In addition the bedrooms should have individual thermostats for residents to control the temperature. The windows on the first floor must have restrictors upon them to prevent the possibility of residents falling. The laundry fire door was propped open and the wash hand basin was not accessible for staff to wash their hands with no paper towels in place. Secondly records, it was advised that the records relating to residents finances be tightened up to show a clear audit trail for all transactions. Also the tool currently used for assessing residents care needs before they come to the home must be revised to demonstrate how the manager made the judgement that the home can meet the prospective residents needs and what those needs are. Finally, the care plans could be improved by having an element that shows how the home provide care support to the district nurses treatment of residents. 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 Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 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 Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 6 does not apply People who use this service cannot be assured that the home knows their needs before they enter the home. EVIDENCE: Two lots of assessment information were examined. An assessment completed by the manager on a recently new resident was looked at. This is believed to have been completed before the resident moved into the home, but was more about gathering information with a risk assessment evaluation sheet attached. The format did not include the eleven elements of care needs that are set out in the standard such as: personal care, mobility, continence, history of falls, mental state and cognition etc. The senior carer explained that the care plan is then developed once the person arrives. The assessment did not have a signature of the person who completed it nor was it dated. Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Residents can expect to have a plan of care that sets out their individual needs. EVIDENCE: Care plans for two residents were examined. The format developed was based around twelve elements of daily living such as hygiene, dressing, eating and drinking and stated the support required by care staff. The daily notes made by care staff were of good quality and clearly showed the care given on that day. In one case the district nurse had been enlisted in the care of a resident. A pressure-relieving mattress was placed upon the bed and a hospital bed was on order. The district nurse had visited on occasions and their instructions were in the daily notes. The care required because of the district nursing intervention was quite specific in this particular case. Therefore the care plan must include an element around how the home support the district nurses treatment. The two residents spoken with were very happy with the way the staff cared for them. Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 10 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 and 14 People who use this service can expect social opportunities and to choose a lifestyle that is suited to them. EVIDENCE: The care plans set out the recreational and spiritual needs of each resident. In addition the care staff confirmed that each day – usually in a morning now there was a social activity arranged in the communal lounge for any resident who wished to join in. On the day a quiz had taken place and the hairdresser was visiting and was taking various residents to have their hair done in a salon area within the home. One resident spoke of their interests in painting and clocks. The care staff were aware of these hobbies and had promoted these activities for that individual. One resident said there was plenty to do at the home with the sing-a-longs and quizzes organised. and also that they were kept up to date with a daily paper and the television. Both residents spoke of having visitors come to see them and that they were happy with these arrangements. They also spoke of visits out to relatives. The care staff confirmed other activities that were mentioned on notice boards, such as communion, the local church involvement and a local social club called ‘nip in’. Residents confirmed that they were satisfied with the freedom they had to choose when to get up and when to retire to bed. They were also satisfied around their personal arrangements in dealing with their finances.
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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. People who use this service can expect that complaints and matters of protection will be taken seriously. EVIDENCE: The home had an appropriate complaints procedure displayed within the home. The home subscribe to the local policy and procedure developed by Suffolk Social Services on protection of vulnerable adults (POVA) The policy was available to care staff and the senior carer was able to locate the referrals forms should such a matter arise. The senior also confirmed that staff were aware of POVA matters as this was covered in their induction and further on NVQ training. Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 12 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, 25 and 26 The Willows provides a good quality environment for residents, but there is scope to improve on some aspects of safety. EVIDENCE: A tour of all communal areas and five bedrooms was undertaken with a the help of a senior carer. All areas of the home were beautifully clean and well maintained as were the grounds and gardens. One resident spoken with stated that the heating in their room did not work efficiently and they needed a separate heater in the room. The room was visited and indeed there was a separate plug-in heater in the room. This was discussed with the manager and she agreed to resolve the matter. In the new extension all bedrooms have individual thermostats that enable the resident to individually control the heating in their own rooms, but in the existing part of the home this was not the case. Again this matter was discussed with the manager and she will look at a timescale for upgrading these radiators. Whilst looking around the home it was evident that the handy man was in the process of installing radiator covers to prevent the possibility of residents burning
Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 13 themselves on the radiators. This is a positive move. Whilst upstairs it was noted that the windows do not have any restriction upon their opening to prevent any resident from falling. The laundry room is well equipped and quite well designed. There were two suitable washing machines in place – one of which had a sluice program and alginate bags were used. There was also a commode cleaner. Staff had propped open the fire door and had placed a clothes bin in front of the wash hand basin which prevented staff from cleansing their hands before leaving the laundry room. There was evidence to show that staff probably did not cleanse their hands routinely in the laundry room, as there was no paper towels or dispenser there. The manager agreed to address these matters with staff. There were a number of specialist beds in place for use by residents and the home has a specialist ‘Parker’ bath. The temperature of this bath was taken using the temperature gauge on the bath. This was just within the upper limits and recorded 45°c. Therefore, the manager was recommended to keep a monitoring eye on the temperature levels and adjust if it got any higher. Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 14 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 and 30 The Willows provides sufficient well trained staff to meet the needs of residents. EVIDENCE: All the care staff that were on the roster were seen on duty. There were three care staff working, two staff in the kitchen and the handy man. The roster examined showed that there was consistently three staff on duty through out the working day one of which was a senior and at night there was two care staff. The roster also showed the kitchen staff, domestic staff and the handyman and gardener as needed. Residents said how good the cleaners and the gardener were. Residents spoken with also said that care staff are very busy and believed that they may be short staffed. However, upon examining the roster it was evident there had been a period of staff sickness, but the shifts were covered by existing care staff and no agency was used. The home currently have vacancies for a kitchen assistant and a cleaner. New staff had been recruited. Recruitment records were not examined as the manager was not present at this inspection. Three staff were on their induction training and the senior explained that all staff had recently been trained in manual handling, fire, health and safety and food hygiene – records were sampled to confirm. Two more staff were said to have just finished their NVQ 2 and another had just finished their NVQ 3. The senior explained that as well as having all staff trained in basic first aid the home also has three people trained as appointed first aides.
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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): 32,35 and 38 The Willows is appropriately managed, but there are further developments to be made in promoting health and safety and welfare of the residents. EVIDENCE: The manager of the home welcomes the regulation process and views the inspection as development for the home. Feedback was given via the telephone and the manager gave an undertaking to address the requirements made in this report. Staff who work with the manager view her management style positively and like the open way she works. Residents finances were examined. The home holds personal money for residents and allows them access when they need it. The money is kept safe and in individual amounts. There was not a totally clear audit trail in place and the process should be tightened up, just in case there was a discrepancy. It is suggested that those handling the money should sign and keep a running
Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 16 balance. When a resident is given cash they should sign to say they have received it. In relation to health and safety this has been addressed through two sections in the report – environment and staff training. There is adequate training in place, but there are some outstanding environmental controls that must be put in place. Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 17 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 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 2 X X 2 Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 18 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 OP3 Regulation 14 (1)(a) Requirement New residents are admitted only on the basis of a full assessment undertaken by people trained to do so. Where needed care plans must include an element of how the care provided by the home supports the district nurse treatment. The heating, lighting, water supply and ventilation of service users’ accommodation must meet the relevant environmental health and safety requirements and the needs of individual service users. Safe guards must be in place to protect the financial interests of the residents. Timescale for action 10/03/06 2 OP7 15(1) 17(1)(a) 10/03/06 3 OP38OP25 13(4) 10/03/06 4 OP35 17(2) 10/03/06 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 Good Practice Recommendations
DS0000024528.V277770.R01.S.doc Version 5.1 Page 19 Willows Residential Home 1. 2. Standard OP3 OP25 Assessments should be signed and dated. The manager should monitor the temperature of the Parker bath to ensure this does not get any hotter, before being adjusted. Willows Residential Home DS0000024528.V277770.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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