Inspection on 04/01/07 for Willows Residential Home

This inspection was carried out on 4th January 2007.

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 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 Residential Home 08/12/08

Willows Residential Home 13/01/06

Willows Residential Home 26/05/05

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 Sue Jenkins and Claire Hutton Unannounced Inspection 4th January 2007 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.V323167.R01.S.doc Version 5.2 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.V323167.R01.S.doc Version 5.2 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.V323167.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 The home may accommodate persons of either sex, over the age of 65 years, who require care by reason of old age (not to exceed 25 persons) 13th January 2006 Date of last inspection 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, flowerbeds, and a pond. There is off road car-parking at the front of the home. Current fees for this home range from £331.00 to £475.00. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven and a half hours on a weekday. This was a key inspection, which focused on the core standards relating to older people. Sue Jenkins and Claire Hutton carried out the inspection. The report has been written using accumulated evidence gathered prior to and during the inspection, including information from 12 residents ‘Have your say about’ comment cards. Inspectors reviewed the progress of the requirements made at the last inspection on 13th January 2006. Time was spent talking with three residents, three staff and the deputy manager. Additionally a number of records were inspected including those relating to residents care plans, staff personnel and training, medication, quality assurance and polices and procedures. At the first visit to the home an immediate requirement was left relating to excessive hot water temperatures that was a possible risk to residents. Therefore a second visit to the home was conducted on 10th January 2007 whereupon action was seen to have been taken to restrict hot water temperatures therefore presenting less of a risk. What the service does well: What has improved since the last inspection? Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 6 The home has complied with three of the four requirements made following the last inspection on 13th January 2006. Residents are assessed before being admitted to the home. Where needed the care plans include an element of how care provided by the home supports the district nurse treatment. Heating and lighting meets the relevant environmental health and safety requirements. Other developments include the updating of the Statement of purpose and the Service Users Guide. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 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.V323167.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4 Standard 6 does not apply Quality in this outcome area is good. Prospective service users can expect to be provided with information to help them make a decision to move into the home. Service users can expect to have a contract with the home and a needs assessment undertaken before admission to ensure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users guide and statement of purpose had been updated in November 2006 and a copy had been sent to the Commission. It was freely available at the home. This information conforms to regulation. Information relating to three service users was assessed and each person was found to have a contract and terms and conditions signed and in their file. The same three service users files demonstrated that the manager had completed an assessment of need before the person moved into the home and that formed the basis of the care plan that was developed. All three service users had a formal review within six weeks of entering the home. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 9 Of the twelve returned service users survey eleven stated they received enough information about the home before they moved in and had a contract. Two of the three service users spoken with stated they had received enough information and had visited the home before moving in. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. Residents can expect to have care plans that reflect their individual needs. Residents are protected by safe administration and storage of medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three residents were case tracked. Care plans were completed using activities of daily living and were based upon the assessment made. Daily records were informative and District Nurse and GP visits were recorded. The standard recommends a review by care staff of the service users care plan at least once a month. Of two of three care plans examined there was no evidence of a monthly review for the previous consecutive three months. The three residents spoken to were happy with their care. All thirteen of the returned ‘relatives/visitors comment cards’ said they were satisfied with the overall level of care provided. Eight of the twelve residents returned ‘have your say about’ said they always receive the care and support they need. The other four said they usually did. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 11 The GP to the home is instigating daily calcium and vitamin D supplements to the residents. However, this should form part of a larger falls prevention strategy initiative at the home. One inspector observed the administration of drugs at lunchtime. Medication was dispensed; the resident observed taking it by the staff member who then signed the MAR sheet. (Medication administration record) A sample of all staff signatures that administer medicines was evident. Two of the MAR sheets were found to have no code entered when the resident had not taken a medicine. Observations between staff and residents was friendly and appropriate. A comment from a relative of a resident “ I am very grateful to the staff for their genuine caring attitude.” Another comment from a resident’s relative “I am satisfied with the level of care and overall running of the home.” Comments form service users included ‘staff are very sweet’ and ‘the home is warm and comfortable’ and ‘I would recommend the home to anyone’. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Residents can expect social opportunities and to choose a lifestyle that matches their expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans set out the recreational and spiritual needs of each resident. The home has Holy Communion and religious activities at the home. Care staff confirmed there was usually a group activity each day, on the inspection day a quiz had taken place in the lounge facilitated by a carer. One resident was being helped with some knitting. The mobile library visited. One of the carers is also the activities organiser and both staff and residents confirmed there was a monthly themed party. Other activities include knitting, board games, books, tapes, and records and reminiscence group. Care staff also undertook one to one activities such as manicures and foot spas. All the activities were listed on a notice board in the dining area. The home has links with the local primary school and a local organisation. Five of the twelve residents ‘Have your say about’ confirmed there were always activities and five said usually there were activities arranged in which they could take part. Three residents were observed to have visitors during the inspection. One care staff member said the home was looking to do some Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 13 outside trips i.e. to the theatre as the residents had asked about this at a recent residents meeting. The majority of the residents were able bodied with only three residents needing the assistance of two carers at a time. Residents were asked if they wanted to participate in activities, sit in the lounge and what they would like to eat at meal times. The daily menu is displayed in the dining room. The menu for the day: breakfast was cereal, toast and fruit. Lunch was lamb mince, mashed potato and vegetables and for dessert apple sponge and custard or mousse or a banana. For supper cheese, pate and French bread and fruit. The staff confirmed there is only one main meal of the day and one staff member suggested a choice of two would be better. Vegetarian diets are catered for. The lunch was served by the kitchen staff and was hot and well presented. Both staff and residents said the food was ‘good’. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People who use this service can expect that complaints and matters of protection be taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure displayed in the main entrance. There is also a copy in the service users guide which all residents have a copy of. There were no reported complaints in the last year. The Commission has not received any complaints about this service. Six of the twelve returned ‘have your say about’ forms stated they did know how to complain. Two of the twelve stated residents not able to understand and one said they would ask their daughter to do this. The home subscribes to the local policy and procedure developed by Suffolk Social Services on protection of vulnerable adults (POVA). The staff files seen showed that staff had received training in complaints and POVA. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 and 26 Quality in this outcome area is good. People living in the home can expect to live in a clean, comfortable and well-maintained home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the communal areas and nine bedrooms was undertaken, all were found to be clean and tidy and hygienic throughout. Three of the bedrooms had residents own furniture in and one of the rooms was unoccupied. All nine bedrooms seen had en-suite toilet and wash hand basin facilities. Bedrooms had personal possessions such as photographs, pictures and books. Accommodation is on two floors with access via a passenger lift. Willows is well decorated and maintained to a good standard. The communal lounge is large and spacious with a view of the well-kept garden. The dining room is spacious and residents sit with groups of two to six people. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 16 There were two radiators one on the top landing and one in the unoccupied room (15) do not have a radiator cover. There is a laundry room with two washing machines and a dryer. There is a sluice machine for cleaning commode pans. The sluice machine was last serviced 19/12/06. There is a separate ironing room, on inspection day the door was wedged open. There were a number of specialist beds in place for use by residents and the home has a specialist walk in bath. The water temperature at the first visit to the home was 48°C, which is above the recommended 43°C. An immediate requirement notice was left. A second visit to the home was made on 10th January 2007. The hot water was again measured and found to be too high at 46.8°c. The handy man adjusted this down to 43°c whilst the Inspector was at the home. The manager agreed to purchase a new thermometer to ensure accurate readings. The downstairs bath water temperature was 44.2°C. The manager had also set up a system of periodic testing of water temperatures to ensure the future safety of residents. Main corridors/hallways were wheel chair accessible and had grab rails. Wheel chairs were stored tidily under a cupboard. All fire exits were clearly marked and designated. Fire extinguishers had been checked and serviced in March 2006. Some of the bedroom doors were wedged open. Following an inspection by Suffolk County Council Fire Officer on 21/11/2006 the Home has implemented a fire risk assessment with monthly checking of emergency lighting. Further improvements regarding fire doors with selfclosing devices are ongoing and the home must follow the advice from the fire service not to wedge open these doors. The home has a fire risk assessment in place. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. Residents can expect to be supported by sufficient numbers of staff that are well trained and can meet their needs. However not all staff were found to be adequately recruited. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota was seen and this reflected the staff on duty, three carers including one senior, two kitchen staff, two cleaners and the handyman. There are three carers throughout the day and two during the night. Four of the returned relatives/visitors comment cards said there was not always sufficient staff on duty. It was observed that the three carers on duty were calm and carried out their duties well. District Nurse, GP, relatives, library lady all visited as well as the two Commission inspectors. Call bells were answered in a timely manner and carers facilitated activities with residents. In house staff provide sickness cover, no agency staff have been used in the last year. The recruitment process was reviewed and three staff records were seen. Two staff had the necessary checks in place. One staff member appointed November 2006 working at the home did not have evidence of a criminal record bureau check (CRB) or the minimum of a POVA 1st check. At the last inspection recruitment practices were good. Training records were up to date Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 18 and the training includes moving and handling, Parkinson’s disease, dementia care, fire safety, infection control and first aid. There are thirty one care staff and eight staff have completed National vocational Qualification (NVQ) in care level two and one is currently undertaking the course. Three staff have NVQ level three in care. There is a clear commitment from the home to staff training and development both inhouse and by external agencies. Three of staff spoken with said the training was very good and there was lots of variety. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 Quality in this outcome area is good. Residents can expect to live in a home that is managed by an appropriately qualified manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home has been working in the care profession since 1992. She has been the manager of Willows since February 2001. In June 2005 she completed the Registered Managers Award (RMA). The three staff spoken with view her management style positively and say she is approachable, encouraging, easy to talk to and open to new ideas. The home does not act as agent with regard to any residents finances. The home does keep small amounts of personal money for residents and allows them access when they need it. The money is kept in a locked box and in individual envelopes. The balance is recorded and a receipt written for new Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 20 money. However, the resident does not sign to say they have received any money, nor is there a signature of who handled transactions. In relation to staff being appropriately supervised there is always a Senior on duty and in addition there is an on call person in case of emergencies. However, formal supervision records are ad hoc, the deputy manager stated that staff can expect six supervision sessions per year and this was not evident in the record keeping. From inspection of records it was evident that records required by the food standards agency were being kept and monitored including fridge and freezer temperatures of food being served. Other Health and Safety matters relating to bath water temperatures, fire doors and emergency lighting have been addressed in the environment section. Staff meeting and residents meeting minutes were seen. Both meetings seem to happen on ad hoc basis but the minutes are available for all to see and points are actioned accordingly. The home’s certificate of registration and employers liability insurance was seen displayed in the dining room. The home has a quality-auditing tool that was completed. There are also visits to the home by the provider and copies of these reports are regularly sent to the Commission. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 22 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. 2. 3. Standard OP8 OP7 OP29 Regulation 12 (1) (a) 13 (4) (a) 15 (2) (b) 19 (1) (b) schedule 2 Requirement The registered person must develop a falls prevention strategy The registered person must ensure care plans to be reviewed monthly The registered person must operate a thorough recruitment procedure ensuring the protection of service users. Therefore CRB’s must be completed on all staff and as a minimum a POVA 1st check undertaken. The registered person must ensure that the employment policies and procedures adopted by the home such as supervision arrangements are put into practice. Timescale for action 19/02/07 19/02/07 19/02/07 4. OP36 18 (2) 19/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 23 No. 1. 2. 3. 4. Refer to Standard OP15 OP25 OP25 OP36 Good Practice Recommendations There should be a second choice of main meal more widely known and written on the menu board for all to see. The manager should monitor the hot water temperatures and purchase a new thermometer. The uncovered radiator in room 15 should be reviewed and form part of a risk assessment. The manager should ensure staff receive formal supervision at least six times per year. Willows Residential Home DS0000024528.V323167.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000024528.V323167.R01.S.doc Version 5.2 Page 25 - 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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