Inspection on 28/09/06 for Willows The

This inspection was carried out on 28th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 19/09/07

Willows The 01/02/06

Willows The 08/12/05

Willows The 22/11/04

Willows The 14/07/04

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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 Mrs Rosalind Sanderson Key Unannounced Inspection 28th September 2006 09:00 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 The DS0000029969.V314632.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.V314632.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 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 23 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (23) of places Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: The Willows is a two-storey building offering personal care and accommodation to seventeen older people who may have a dementia. The registration has recently been increased to twenty three. 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 £330 and £390 per week. Additional charges are made for hairdressing (£4.50 - £13) and chiropody (£12). This information was correct at 28/9/06. Willows The DS0000029969.V314632.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 7 service users and 9 relatives. No comments were received from the GPs and Care managers that were surveyed. A visit to the home carried out by one inspector. A site visit was carried out and lasted for five and a half hours. Ten service users, two relatives and four 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. This enabled the inspector to gain an insight of what life is like at The Willows for the people that live there. The Manager was available to assist throughout the day. What the service does well: What has improved since the last inspection? Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 6 Since the last inspection medication systems have been adopted to ensure that medication is handled and administered correctly. 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. Willows The DS0000029969.V314632.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.V314632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 is not applicable Quality in this outcome area is good. Service users can be assured that their assessed needs will be met. This judgement has been made using available evidence including a visit to this service EVIDENCE: Service users records showed that a full needs assessment is carried out prior to admission, where possible. A service user recently admitted to the home from another area had had information gathered about them prior to admission. This included information from them, their families and their GPs. Staff at the home had carried out their own assessment once the service user had been admitted. The manager was clear about what category of service user the home can admit. Willows The DS0000029969.V314632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. Service users healthcare needs are met. This judgement has been made using available evidence including a visit to this service EVIDENCE: Service users all have a written care plan. These care plans are made available for all staff and they confirmed that they have access to them. There was evidence that the care staff review the plans regularly. However, there was written evidence to show that a number of service users had displayed challenging behaviour yet there were no care plans in place to guide staff to how this should be managed. Referrals had been made in some cases to the Community psychiatric nurse and Psychiatrist yet their advice had not been recorded within the care plans. The written records indicated that staff were managing the incidents but not addressing the causes or possible triggers of the episodes. Service users were satisfied with the care at the home. One commented, ‘I feel that I always get the help I need’. Another service user said, ‘I wouldn’t change a thing, you always get attention and are able to see the doctor when Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 10 you ask’. Another commented, ‘The staff are really good and treat you as an equal, more like a friend, A relative said, ‘I am very happy with all the care that…receives, they couldn’t be better looked after’. Another said, ‘All of. …family will be forever grateful for the care, love and attention that..receives at The Willows.’ Medications are dealt with correctly ensuring that all service users receive prescribed medication safely. Some service users had bed rails fitted to their beds. However some were fitted incorrectly and there were no risk assessments in place for their safe use. There had been accidents recorded in the service user files that were directly related to the use of bed rails. The manager was given a written notice to make sure that all bed rails in use were fitted correctly before they were next used. She attended to this immediately and arranged to obtain a copy of the document, ‘The safe use of Bedrails’ in order that she and her staff would be better informed as to their use. Willows The DS0000029969.V314632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. Service users are very happy with their lives at The Willows This judgement has been made using available evidence including a visit to this service EVIDENCE: Service users said that they are consulted about what they like to do. They have regular entertainment brought in such as indoor games and music. Comments received include, ‘I couldn’t be in a better place, I consider myself very lucky to have live here.’ Another commented, ‘It’s a good spot! The music man comes every month…he is good. We all thoroughly enjoy him.’ Other comments received include, ‘I always had a cat at home and we have one here, it’s the next best thing to home’. Relatives comments received include, ‘Nothing is too much trouble for the staff, I am always made to feel very welcome and always get a cup of tea’. Another said, ‘It’s like going home when you call in, you’re always made to feel welcome.’ The food provided is well presented and provides a well balanced diet. There is home cooking and baking available at all times. Comments received from Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 12 service users included, ‘The food is excellent’ and ‘You never get a poor meal, if you don’t like what’s on offer there’s always a choice’. The last two visits from the Environmental Health Officer had highlighted the need for the cook to identify and record food safety hazards during the receipt, storage and cooking processes, (HACCP controls). The cook had not managed to implement this yet. Implementation would ensure that food safety is addressed at each stage of the process. Further training would ensure that the cook is aware of her responsibilities in this area. Recommended work was also outstanding in the kitchen area. Willows The DS0000029969.V314632.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. Service users are listened to and protected 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.V314632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Quality in this outcome area is adequate. Service users live in a clean and comfortable environment but some elements within the environment may place service users at risk. This judgement has been made using available evidence including a visit to this service EVIDENCE: The home is decorated and maintained well. The gardens are on a level access and service users said they enjoy using this area, weather permitting. Private accommodation is clean and pleasantly decorated. Service users have been able to personalise their rooms with photos and ornaments from home. One said, ‘Although this isn’t home it’s the next best thing’ Some fire doors did not close correctly leaving gaps. Some door closers were broken or had been disconnected so were ineffective. These issues were discussed with the manager and she agreed to have them rectified. Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 15 Around the home there were numerous radiators with high surface temperatures that were not guarded. Some of these were in the private ensuite rooms of service users. They could pose a risk to somebody if they fell against them and as such a risk assessment should be carried out and measures put in place to reduce any risk. This was also discussed with the manager. Willows The DS0000029969.V314632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. Service users are cared for by well trained staff but are not fully protected by the home’s 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. Recruitment records (5) showed that all five of the staff had been deployed at the home before receipt of a satisfactory CRB check. POVA 1st checks had not been carried out. In two cases the home had not asked for written references before employing the member of staff. One member of staff had since supplied these, the other had not. Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. The home is managed well and in the best interests of the service users. To ensure this continues the registered person needs to be more proactive in recognising shortfalls in order that they can be addressed promptly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is currently undertaking the Registered Managers Award. She has many years experience. She is assisted in her role by a supportive staff team. Service users, staff and relatives spoken with feel the manager has an open, inclusive approach and operates an open door policy. Relatives, staff and Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 18 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. The intention is that this is 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 with the exception of the electrical wiring certificate that had expired. Service users monies are handled safely and receipts are kept for all transactions. To ensure the continued safety and good care of service users the issues identified in this report around health and safety and staff recruitment need to be addressed. Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 X X N/a 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 1 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 20 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 OP7 Regulation 15(1) Requirement The registered person must ensure that all care needs are identified and planned for. This is specifically in relation to mental health needs and challenging behaviour. The registered person must make arrangements to meet the requirements of the Environmental Health Officer The home must consult with the Fire Safety department to ensure that the fire precautions in the home are adequate. The registered person must carry out a risk assessment for the unguarded radiators in the home. Control measures must be put in place to reduce or eliminate any identified risk. The registered person must ensure that all the necessary pre employment checks are in place before any new staff recruits to the home are deployed. The registered person must arrange for checks to be completed to ensure that the bedrails in use are fitted safely DS0000029969.V314632.R01.S.doc Timescale for action 26/10/06 2. OP15 16(2(j)) 30/11/06 3 OP19 23 (4) 26/10/06 4 OP25 13(4(c)) 26/10/06 5. OP29 19 26/10/06 6. OP38 13(4(c)) 28/09/06 Willows The Version 5.2 Page 21 7. OP38 13(4(c)) 8. OP38 13(4(c)) and correctly before they are next used. The registered must arrange for a risk assessment to be carried out for the safe use of bedrails and put in place a system whereby they are checked regularly to ensure their safe use continues. The registered manager must arrange to have the fixed wiring tested as recommended on the previous certificate. A copy of the certificate should be forwarded to the Commission on receipt. 26/10/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations The registered person should make arrangements for the cook to complete an intermediate food hygiene course in order that she is fully aware of her responsibilities in relation to HACCP controls. The registered manager should complete the Registered Managers Award. 2. OP31 Willows The DS0000029969.V314632.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 The DS0000029969.V314632.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!