Inspection on 26/05/05 for Willows Residential Home

This inspection was carried out on 26th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willows Residential Home 08/12/08

Willows Residential Home 04/01/07

Willows Residential Home 13/01/06

Willows Residential Home 17/01/05

Willows Residential Home 29/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Willows Residential Home Corders Farm, Bury Road Lawshall Bury St Edmunds, Suffolk IP29 4PJ Lead Inspector Claire Hutton Unannounced 12 April 2005 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 Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Willows Residential Home Address Corders Farm, Bury Raod, Lawshall, Bury St Edmunds, Suffolk, IP29 4PJ 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) 01284 830665 01284 830892 margaretholtuk@yahoo.co.uk 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 I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17/01/05 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 I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over 4.5 hours on a weekday afternoon. Following the last inspection in January 2005, one comment card from a relative expressed ‘niggles’ about lack of communication with the home. This expression of dissatisfaction was followed up at this inspection but the inspector could not find any evidence to support these individual concerns. The individual relative remains anonymous and the home are now fully aware of the concerns and will continue to strive to communicate well with all relatives. A tour of the accommodation was made. Three care staff and the manager were spoken with in private. Time was spent with residents including two discussions in private. Care records, drug records, communication books, rota’s and staff recruitment records were examined. What the service does well: What has improved since the last inspection? What they could do better: As previously stated this is a well run home that is well managed. This report has no requirements however makes two recommendations. Firstly, to have a list of sample initials and signatures of staff relating to the admission of drugs. The second is relating to the rota and this should show who the senior is in charge on each shift. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 6 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 Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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 Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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, 4, standard 6 was not applicable. People who are new to the home can be assured their needs will be assessed and a plan of care provided therefore they can be confident that the home can meet their needs. EVIDENCE: Two new residents to the home were spoken with. Both were generally happy with the home and care provided but especially like their individual rooms. In both cases, their relatives had found the home and they had transferred from other care facilities. Assessment of need and care plans were in place along with evidence of recent reviews to ensure that the home could meet the needs. The homes diary showed dates of when individuals, relatives and social workers were due to visit the home to see what the home had on offer for potential relatives. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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 standard(s) 7, 8, 9, 10 People who use this service can be assured their health care needs will be taken seriously, because health is monitored and recorded by care staff and appropriate referral made to other health professionals. EVIDENCE: Care plans for new residents were seen. These showed the individual health care needs had been documented. Access to specialist care was documented. The district nurse tendered and treated pressure ulcers and catheter care. Additional specialist equipment such as mattresses and cushions had been provided. The GP visits every other Thursday. A recent change was imminent relating to the medication dispensed to the home this would now be dispensed from the GP’s surgery. The manager has planned and will continue to monitor this change. Drugs records had been appropriately completed. The residents spoken to felt that their health care was well taken of care of and that they had access to the doctor when they needed it. The inspector monitored the call bells that rang throughout the afternoon and noted that all call bells were attended to promptly. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 10 One resident had expressed dissatisfaction with the approach of the night staff. The manager was aware of this and had been actively resolving the matter with all involved. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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 standard(s) 12, 13 & 15 People who use this service will be provided with many social options and meals that meet their needs. EVIDENCE: Upon arrival the lunch was well under way with most residents eating in the dining room. Two residents spoken with said that the food was always lovely and there was plenty of it, especially nice tasty teatime meals. In the kitchen was a display of home made cakes. In the lounge was a board with large cards placed upon it. A member of staff explained a game of ‘play your cards right’ had been played that morning. The same member of staff was also responsible for ensuring appropriate activities were available each day. Such things included keep fit most days and reading individual books or newspapers, past recent events had included a poem reading evening and an Easter parade that was put on by a local drama group. A planned event is a VE Day party celebration. Another member of staff runs the home shop on a Monday and also did individual shopping in Bury St Edmunds once a week. Relatives are said to be able to visit at any time. During the inspection relatives were seen visiting and were made very welcome by staff and were very comfortable in chatting to their relative and staff alike. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 12 The diary showed that the vicar visited on regular basis to give communion to the resident at the home and that individuals went out to attend their chosen church. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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 standard(s) 16 The home had an appropriate complaint procedure in place therefore people can be confident that complaints will be taken seriously. EVIDENCE: As stated in the summary one comment card received back after the last inspection expressed ‘niggles’ about staff communication. The matter of communication was discussed with the manager and staff members and all were clear on the method used to keep relatives informed by keeping in touch based upon individual requests. In addition, there was a process where by relatives could contribute to reviews and the care planning process. The home had a book in which they noted all communication in, including incoming telephone communication. Therefore, no part of these concerns could be upheld. However, by raising the matter with the home and staff they will be more aware. The home and staff cooperated well throughout these matters. The home had an appropriate complaints procedure displayed within the home however it needed to read CSCI (Commission for Social Care Inspection) and not NCSC (Nation care Standards Commission). Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 People who use this service will have an environment that is well maintained and provides excellent personal and communal provision. In addition, the home will provide appropriate equipment to meet the needs of the residents. EVIDENCE: The accommodation is well maintained and provides a welcoming and warm atmosphere. It was evident on observation that residents were able to use the home as their own. Communal facilities included large spacious lounge and dining room that enables residents to move around freely. There were sufficient toilets close to the lounge area. The home had a range of aids and adaptations and equipment designed to meet the needs of residents to assist them in personal care mobility. There was also plans to develop an accessible shower for resident as currently there was no bathing facility on the first floor. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 15 The laundry room had appropriate equipment including a sluice washing machine. Two residents spoken with especially liked their individual rooms and had their personal possessions around them. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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 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, 28, 29, 30 People who use this service can be confident that there will be sufficient staff on duty that are appropriately recruited, supervised and trained. EVIDENCE: The rota was examined and showed that each day there was one senior carer and two care staff on at all times of the waking day. At night there were two waking carers. The manager worked Monday to Friday 9am to 5pm but did do the occasional weekends to cover staff sickness but was not generally part of the care rota. In addition, there were two domestic staff who worked over 7 days a week, the home also employed a cook and a kitchen assistant 7 days a weeks. The manager was not aware of the Residential Forum Guidance to assess the dependency levels of the residents and therefore know the minimum staffing levels expected. Following the inspection information was sent to the manager. No new staff had been recruited since the last inspection but the records of the last person recruited that had gaps was re-examined, these records showed that two references had been taken up and enhanced CRB had been provide. There was also evidence of supervision, TOPPS and appropriate induction. Staff spoken with were all aware of TOPPS and NVQ, one person was responsible for training and was an assessor. Another member of staff was pleased to be doing NVQ3. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 17 Two residents spoken to said that they felt that the care staff were very kind and considerate, one resident believed that there was not always sufficient staff first thing in the morning and felt that they were sometimes stretched. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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) 32, 33, 34 People who use the Willows can be assured that it is appropriately managed. EVIDENCE: The manager engaged very well with the inspector and positively welcomed the inspection process. Staff spoken to liked the manager and said her style was open and that she was always available to listen to new ideas and support them with new initiatives. One resident said that she found the manager to be very good at her job. Another member of staff claimed that communication between all staff was excellent and she could not see how it could be improved and that the home was run in the best interest of the residents. Following the inspection the responsible individual, Noel Rodgers was spoken with on the telephone. He confirmed the homes financial viability and the tight control and reconciliation of finances monthly, these documents were available for inspection if needed. This offer was politely declined at this time. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 19 Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 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. 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 x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 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 3 3 3 x x x x Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 21 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 Regulation None Requirement Timescale for action 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 9 16 Good Practice Recommendations A list of staff intials and signatures should be kept to correctly indentify individuals responsible for medication administration. The complaints procedure should read CSCI Commision for Social Care Inspection and not the NCSC the National Care Standards Commission. Willows Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 22 Commission for Social Care Inspection St Vincents House Cutler Street Ipswich IP1 1UQ 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 Residential Home I54 I04 S24528 Willows V220894 050412 Stage4.doc Version 1.20 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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