CARE HOMES FOR OLDER PEOPLE
Willows The The Willows Bridlington Road Burton Fleming East Yorkshire YO25 3PE Lead Inspector
Karen Ritson Unannounced Inspection 10:00 8 December 2005
th 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.V262598.R01.S.doc Version 5.0 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.V262598.R01.S.doc Version 5.0 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) Mr Trevor David Cruxon Mr Stephen Paul Hepworth Amanda Jayne Warkup Care Home 17 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (17) of places Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd November 2004 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. An application to increase the number of service users this facility may accommodate is being processed by CSCI at present and if successful would increase the registration 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. Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on December 8th. The manager was available throughout the inspection. Several service users and all staff on duty were spoken to. The inspection took ten hours to complete which includes time for preparation and writing the report. This inspection has focused upon several core standards. Those core standards not inspected at this time will be covered at the next inspection. Staff and service user comments will be mentioned in more detail in the body of the report, however, all comments were positive regarding level of care offered by the home. What the service does well: What has improved since the last inspection? 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.V262598.R01.S.doc Version 5.0 Page 6 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.V262598.R01.S.doc Version 5.0 Page 7 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 and 6 Service users are assured their care needs will be met. EVIDENCE: The home completes a detailed assessment of care, with risk assessments in place. The assessment of a recently admitted service user was examined, and the home had gathered extensive information, which formed a clear picture of the care needs of this person. The assessment forms a thorough base upon which the care plan can be developed. Service users said that the staff were particularly kind and attentive and that they understood each persons care needs very well. The home does not offer intermediate care. Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 8 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 and 10 Service users are assured that their health care needs will be met. EVIDENCE: The care plan provides a detailed guide to the care required for each person and is regularly reviewed. Service users said they were involved in drawing up their care plan and in reviews. All professional health care visits are recorded separately and all areas of care are well covered. Medication is suitably stored and recorded. Policies are available regarding the administration of medication including self -medication. The home operates a Boots Blister monitored dosage system. The records and stocks were checked and it was found that the morning doses had not yet been signed for. The manager assured the inspector that this had been due to her being urgently required elsewhere at the time. She said she understood the importance of signing at the time of administration and that medication must not be given without signing. An examination of the records revealed no further discrepancies. Service users said they were treated with the utmost regard for their privacy and dignity. One service user said that she ‘could not be better looked after anywhere.’ Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 9 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 and 15 Service users’ social and cultural needs are met. EVIDENCE: The home continues to provide a variety of activities for service users to become involved in and there are many planned for the Christmas and New Year period. Relatives also accompany service users on outings and in the warmer months the staff have time to take service users out for walks around the village. Most of the service users and staff have strong connections with the village and the area. Many visitors call to see more than one of the service users and the home is often visited by people who live locally. Service users said they could get up and go to bed whenever they wished and could live their lives how they wished subject to any restrictions in capacity or through risk assessments. One of the service users attends a local coffee morning. The menus are varied and provide a nutritious diet. Service users said the food was very good and that the cooks provided fresh home made cooking and baking. Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 10 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 and 18 Service users complaints are listened to and acted upon, and they are protected from abuse. EVIDENCE: The home has not had any complaints since the last inspection. Service users said they could speak to staff about any concerns and felt sure that these would be listened to and acted upon. The home has a suitable abuse awareness policy and procedure. Staff have received training in abuse awareness and further training is planned for the New Year. Service users said they felt safe in the home. Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 11 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): None of the above standards were assessed on this occasion. EVIDENCE: Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 12 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 and 30 Service users welfare is protected by well-trained staff in sufficient numbers. EVIDENCE: Staffing rotas were examined and there were sufficient staff to cover the needs of the service users. The home is recruiting more staff to take account of the planned increase in numbers following the opening of the new extension. Service users said the staff were not rushed and had time to complete their duties and to have a chat with them. Service users and staff were seen chatting often throughout the inspection and there was a friendly and relaxed atmosphere. The manager continues to complete some working shifts and identified that she would benefit from spending more time away from hands on caring and more time in managing, particularly when the home is accommodating more service users. This is not to deny that continuing with an element of hands on work informs her management of the home. Over 50 of staff have achieved NVQ at level 2 and others have level 3, with three staff having level 4 in care. Staff are suitably recruited and all said that they received good support from colleagues. Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 13 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 and 38 The health and safety of service users are protected. EVIDENCE: The manager is very experienced and both staff and service users were very complimentary about her ability to manage, her caring attitude and the support she offered colleagues on a day-to-day basis. She is to commence NVQ Level 4 in care soon. The home has a thorough quality assurance programme and service users said they were consulted over the way they led their lives in the home. Personal allowances are kept for some service users and some of these were checked against the records. No discrepancies were found. All health and safety documentation is in place. A letter to confirm the servicing of the oil boiler is to be forwarded. Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 14 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 1 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 X X X X X X X X 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 2 X 3 X 3 X X 3 Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 15 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 9 Regulation 12,13 Requirement All medication must be signed for on administration Timescale for action 08/12/05 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 31 Good Practice Recommendations The manager must be qualified to NVQ level 4 in care and management. Willows The DS0000029969.V262598.R01.S.doc Version 5.0 Page 16 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
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