Inspection on 19/09/07 for Willows The

This inspection was carried out on 19th September 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 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 The 14/09/09

Willows The 17/09/08

Willows The 28/09/06

Willows The 01/02/06

Willows The 08/12/05

Willows The 22/11/04

Willows The 14/07/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Willows The The Willows Bridlington Road Burton Fleming East Yorkshire YO25 3PE Lead Inspector George Skinn Key Unannounced Inspection 19th September 2007 09:30 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 The DS0000029969.V351291.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 The DS0000029969.V351291.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows The Address The Willows Bridlington Road Burton Fleming East Yorkshire YO25 3PE 01262 470217 01262 470217 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) Hexon Limited Amanda Jayne Warkup Care Home 33 Category(ies) of Dementia (33), Old age, not falling within any registration, with number other category (33) of places Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE The maximum number of service users who can be accommodated is: 33 19th February 2007 2. Date of last inspection Brief Description of the Service: The Willows is a two-storey building offering personal care and accommodation to 33 older people who may have a dementia. A two storey extension has been added to the main building and provides pleasant airy en suite rooms. The home provides communal dining and lounge space and gardens to the rear. There is car parking space to the front of the home. Information about the services available at The Willows is provided to prospective service users and their families in the form of a brochure. The home’s statement of purpose is available at the home along with the most recent inspection report. The range of charges the home makes is between: Private £375 EMI private £400 Local Authority Funding High Dependency £363. Additional charges are made for hairdressing (£4.50 - £13) and chiropody (£12). Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a pre inspection questionnaire; Comment cards returned from service users, relatives and staff A visit to the home carried out by one inspector. A site visit was carried out which lasted 8 hours. Service users, relatives and staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home The Manager was available to assist throughout the day. What the service does well: What has improved since the last inspection? What they could do better: The home must make sure that they have all proper information relating to the care needs of the service users to help them care for them properly. The home should make sure that all the service user can comfortably sit the dining room. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 6 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 The DS0000029969.V351291.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 The DS0000029969.V351291.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): 3 People who use this service experience adequate quality outcomes in this area. Not all of the service users have their needs assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of the service users’ files indicated that both the home and the placing authority had carried out an assessment prior to admission. Evidence was seen that a newly admitted service user had no records of assessments being undertaken prior to admission and there were no copies of an assessment undertaken by the placing authority. The manager stated that she had assessed the service user prior to admission but no written evidence was available to confirm this. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use this service experience adequate quality outcomes in this area. Not all of the service users have a plan of care. Service users have access to health care professional when required. Service users are protected by the home’s policies and procedures for handling medication. Service users are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of service users’ care plans was looked at. All the care plans contained relevant and up to date information. There was evidence of risk assessment being undertaken regarding falls, diet and tissue viability. Following the last key inspection the home were required to undertake risk assessments around the use of bed rails; this had been done and the proper guidance was being used when assign the condition and use of bed rails. There Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 10 was evidence of service users or their relatives agreeing the plan of care and being involved with reviews. There was evidenced of consultation with health care professionals including GPs and Community Psychiatric Nurses (CPNs) being consulted on a regular basis. The area of social activities and interests was poorly recoded and did not give a full picture of service users’ needs in this area. One recently admitted service user was committed to caring for his partner and still undertook a lot of caring tasks within the home as they had been admitted together; this was not recorded in his care plan. His partner did not have any record of her needs or plan of care albeit they had been admitted some weeks earlier. This information only became apparent following discussion with the manager. Evidence was available through interview which indicated that the staff were aware of the two service users’ needs despite the lack of written information. The manager stated that she had been on holiday and the records had not been formulated or completed as she saw this as her task. It was suggested that she delegate this task to her deputy or senior staff as this would ensure that the record would have been completed in her absence. Observation made during the site visit indicated that the staff are trained appropriately and observe safe practice when handling medication. Medication continues to be stored in line with legislation and records were up to date. Observation made during the site visit indicated that the staff respect service users’ dignity and their right to privacy is upheld. Interaction between staff and service users was respectful and staff used appropriate terms of address. Service users commented on being satisfied with the service offered by the home comments included “the staff are very kind” “my key worker is very good she gets me my shopping and takes me out” “the staff cant do enough for you and they are always jolly”. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use this service experience adequate quality outcomes in this area. Service users can lead a life style of their own choosing. Service users maintain contact with relatives and friends Service users are provided with a wholesome and varied diet, however this not provided a pleasing, or conducive environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation made during the site visit indicates that the service users are provided with social activities which matches their individual interests and cultural expectations. The home provides activities for the service users in house and outside entertainment is sought. There is a dedicated member of staff who organises activities and she has devised a program for the service users to participate in. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 12 During the site visit many relatives were visiting the service users, they commented on being made welcome at the home and were able to visit at any reasonable time. Observation made during the site visit indicate the service users can lead a lifestyle of their own choosing. Service users were seen to be using their own rooms and moving around the home pursuing personal interests and pastimes, those service users interviewed commented positively comments included “I can come and go as I please” “there are no restrictions I can get up and go to bed when I want” “I like the way the staff are there if you need them, it makes me feel safe”. The home continue to provide the service users with a well-balanced wholesome diet. Again comments were positive these included “the foods really good” “there is always plenty of choice”. The home caters for service users’ special diets including diabetic, low fat and soft diets. The dinning room was very cramped and could not accommodate all of the service users if they all wanted to eat their meal in there. The service users did comment on this; one said he felt as though they were packed in like cattle, one was concerned that if he got into any difficulties in the dining room staff could not deal with this safely or effectively. Staff also commented on their concerns about the safety of the service users if anyone should get into difficulties and their ability to deal with these situations effectively. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 19 People who use this service experience good quality outcomes in this area. Service users know who to complain to and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is clear and accessible to service users, visitors and staff. All those spoken with confirmed they would feel happy to bring up any concerns with the manager. Relatives confirmed that they knew about the complaints procedure and those who had brought up concerns were generally satisfied with how they were handled. The adult protection policy is clear and all staff have received training in this area. All staff are issued with a quick reference guide issued by the local authority. One complaint had been received since the last inspection. This had been dealt with correctly. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use this service experience good quality outcomes in this area. Service users live in safe well-maintained environment. Service users live in home which is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and tidy all areas, both communal and private, were comfortable, warm and well maintained, there were no malodours. The staff are provided with lifting and moving equipment. The home has aids and adaptations for the service users to lead an independent lifestyle. Following the last key inspection the fire doors have been repaired and now comply with fire safety regulations. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 15 The manager was advised to contact the fire officer with regard to the locking of the front door with keypad to obtain their advice on using this devise on a fire door. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use this service experience good quality outcomes in this area Service users are cared for by staff in sufficient number and are trained to meet their needs. Service users are protected by the homes recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence of induction training and mandatory training was seen. Staff receive regular, relevant supervision. Those spoken with found this to be useful. Staff have received all mandatory training. External training is also arranged where appropriate. This ensures that well-trained, motivated staff that are valued by the organisation always attend service users. Staff rotas showed that sufficient staff are on duty at any time. This was observed to be the case on the day of the inspection. Currently 50 of care staff have achieved a qualification in care at NVQ level 2 or above. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 17 Following the last key inspection the home were required to improve the way staff are recruited to protect the service users. Staff files looked at during this site indicates that all relevant checks are completed prior to staff commencing work at the home. Staff files contained copies of Criminal Records Bureau (CRB) checks and references. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use this service experience good quality outcomes in this area Service users live in a home which run by someone who is fit to do so. Service users live in a home which is run in their best interests. Service users financial interests are safeguarded This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has achieved the Registered Managers Award. She has many years experience. She is assisted in her role by a supportive staff team. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 19 Service users, staff and relatives spoken with feel the manager has an open, inclusive approach and operates an open door policy. Relatives, staff and service users were observed freely approaching her during the day. The home has a very happy and homely atmosphere. Staff spoken to confirmed that they feel well supported by the manager to help them achieve good outcomes for service users. They have regular supervision when training needs and progress are discussed. Quality assurance within the service is carried out. This has been further developed to ensure that the views of all who have an interest can be taken into account when developing the service. All safety certificates were up to date. Service users monies are handled safely and receipts are kept for all transactions. The manager has developed risk assessment for the use of bedrails in line with current legislation and guidance. Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 X 3 X X 3 Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 Requirement Timescale for action 30/03/08 2 OP7 3 OP15 4 OP19 12, 13, 14 The registered person must & 15 ensure there is copy of an assessment for those service users who have been placed at the home by the local authority. This will help the staff care for the service user appropriately. 15 The register person must ensure there is care plan in place for all service users living at the home. This will help the staff care for the service user appropriately. 16, 17 & The registered person must 18 ensure there is enough space for all of the service users to sit in the dining room comfortably and safely. 16, 17 & The registered person must 23 consult with the fire officer as to the appropriateness of using a keypad devise on the main entrance. This will ensure the safety of the service users. 30/11/07 30/03/08 30/11/07 Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willows The DS0000029969.V351291.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 The DS0000029969.V351291.R01.S.doc Version 5.2 Page 24 - 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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