Inspection on 01/10/08 for Willowthorpe Care Home

This inspection was carried out on 1st October 2008.

CSCI found this care home to be providing an Good service.

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

Willowthorpe Care Home 29/12/05

Willowthorpe Care Home 15/07/05

Willowthorpe Care Home 02/03/05

Willowthorpe Care Home 01/03/05

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Claremont House

Oak Ridge

Sun Court Nursing Home

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Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Willowthorpe Care Home High Street Stanstead Abbotts WARE SG12 8AS     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Bijayraj Ramkhelawon     Date: 0 1 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 23 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 23 Information about the care home Name of care home: Address: Willowthorpe Care Home High Street Stanstead Abbotts WARE SG12 8AS 01920871811 01920871821 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Janice Pittom Type of registration: Number of places registered: Colley Care Limited (Trading as B & M Care) care home 56 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Bedrooms 2, 3 and 4 in the old Manor Building on the first floor must only be occupied by service users who have a high degree of mobility. No service user will be admitted or occupy these rooms that require a hoist or wheelchair. The home may accommodate one named female service user, under the age of 65 years, until the individual reaches the age of 65 or leaves the home. Date of last inspection Brief description of the care home Willowthorpe is a care home providing personal care and accommodation for 56 older people of whom 24 may have dementia. It is owned and managed by Colley Care Limited (Trading as B & M Care). The home is situated close to the River Lea in Stanstead Abbotts. Accommodation is provided on the ground and first floors with an additional Country Suite. All the bedrooms are for single accommodation with ensuite Care Homes for Older People Page 4 of 23 Over 65 53 32 0 0 Brief description of the care home shower facilities. Assisted bathrooms are provided on both floors. There is a passenger lift. The home has extensive gardens that are secured, well maintained and easily accessible. There are enclosed courtyards, all of which are part of the overall landscaping of the site. A copy of the Statement of Purpose, Service users Guide and the latest CSCI inspection report is available from the care home. The current weekly fees as at (01/10/2008) range from £650 to £800. Care Homes for Older People Page 5 of 23 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection was carried out on the 1st October 2008 and took one day. It included talking to people using the service, talking to visitors, examining care plans, staff files, staff training records, medicine systems, fire safety procedures, maintenance records, all other records and documents and a tour of the premises. The home sent us their annual quality assurance assessment (AQAA) when we asked for it. The AQAA is a self-assessment document that focuses on outcomes for people using the service and also provides us with some statistical information. The information in the AQAA shows that the home is still providing a good service and that they involve people using the service and they listen to and act on their views. The home works well with us and have shown us that their service continues to provide Care Homes for Older People Page 6 of 23 good outcomes for the people who use it. Feedback received from people using the service is very positive. They said that they are happy with their rooms, the food, activities provided and the staff. One resident said I consider that I am well looked after and if I had to leave my home, I would rather be here than anywhere else. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 23 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 23 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who would like to use the service are able to make an informed choice and be sure that their needs could be met. Evidence: An up to date copy of the Statement of Purpose and Service users Guide was available to current and prospective residents. Information about the home was also available to prospective residents and care plans examined showed that a preadmission assessment of needs was completed prior to a resident moving to the home. (Standard 6 does not apply to this home). Care Homes for Older People Page 10 of 23 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can benefit from the care and support they receive in a person centred way with respect to their preferences, choices, right to their privacy and treated with dignity. Evidence: Residents were well dressed, groomed and they said that they were being well cared for. They also said that staff were thoughtful, helpful and supportive. Five care plans were examined and these were found to be detailed, reviewed regularly and kept up to date to reflect the changing needs of the residents. These included a pre-assessment of needs carried out by senior members of staff from the home to ascertain whether the home would be able to meet the identified needs. Information about the residents in the form of a profile was devised, risk assessments, nutritional assessments and risks to fall were also undertaken. Care plans included evidence of the involvement of a range of healthcare professionals and visits made by the G.P. Overall, the administration and management of medicines was good. However, there Care Homes for Older People Page 11 of 23 Evidence: were some minor failures in recording and good practice, which indicate a need to reinforce the monitoring and auditing of medication practice to ensure that policy and procedures are being complied with. These included hand written instructions on MAR sheets not being signed by the person making the entries, where medicines were not given and code f entered, no written explanations were given for the reason for these omissions. A resident who was prescribed anti-convulsant medicine Epilim for epilepsy did not have a specific care plan devised to support the resident should an epileptic seizure occurs. Staff spoken to said that they were informed of any changes in the needs of a resident and that care plans provided adequate information for them to support each individual. They also said that they were provided with relevant training to meet the needs of the residents. Information provided in the Annual Quality Assurance Assessment (AQAA) stated that the registered manager will within the next twelve months continue to facilitate additional training to staff and audit the service provision in accordance with the homes new Quality Management System, thus seeking to continuously improve the quality of service delivery. Care Homes for Older People Page 12 of 23 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be assured that their autonomy and choice would be promoted and that they would have opportunities to participate in planned activities. Evidence: A programme of activities was devised and displayed on the notice boards. Residents spoken to said that they are provided with a variety of activities and that they are reminded by staff of activities taking place on a daily basis. Small groups of residents were observed participating in activities in their respective lounges and sitting rooms. Residents said that staff were supportive and respected their views, privacy and dignity. Lunch was served unhurriedly with assistance and prompts given by staff to those who needed such encouragements. Residents spoken to were complimentary of the food and choices provided. Information taken from the AQAA states that the manager will within the next twelve months provide additional sensory equipment and develop a sensory garden; a picture menu book for people using the dementia unit will be devised. Care Homes for Older People Page 13 of 23 Care Homes for Older People Page 14 of 23 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be assured that their concerns and complaints would be listened to and acted upon and that they would be safeguarded from abuse, neglect and harm. Evidence: A copy of the complaints procedure was available to prospective and current residents. People using the service spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. Three complaints were received during the last twelve months and these were dealt with in accordance with the homes complaints procedure. Thirteen compliments received during the same period. Staff spoken to confirmed that they had received training in safeguarding adults. Staff confirmed they had received training on adult abuse via video sessions and were aware of the Whistle Blowing Policy. Care Homes for Older People Page 15 of 23 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home benefit from a comfortable environment that is well maintained and kept clean. Evidence: The home is well maintained and the standard of decor and general cleanliness was high. Each bedroom provides single room accommodation with ensuite facilities. People using the service have access to all communal areas. There was adequate number of domestic staff and records showed that staff have been provided with training in hygiene and infection control. Care Homes for Older People Page 16 of 23 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that their identified needs would be met by competent and trained care staff. Evidence: There was adequate number of staff rostered on duty per shift during the day and night. There were also adequate number of domestic and catering staff allocated per day and the home has the services of a full time maintenance person. People living in the home were complimentary of the support they received from staff. They said that staff are good, caring and are very kind. At present there are 24 care staff who have completed their NVQ Level 2 and 4 staff have attained the NVQ Level 3. Two staff are currently undertaking the NVQ Level 2 and 8 staff the Level 3. 6 staff files for recently recruited staff were examined. These were kept in good order with the required documents in place including two written references and CRB checks carried out prior to employment. Staff were provided with induction training, all mandatory training and regular formal supervision. Staff spoken to confirmed that they have received appropriate training and support from management. Care Homes for Older People Page 17 of 23 Care Homes for Older People Page 18 of 23 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be assured that they live in a home that is well managed and where they will be able to express their views. Evidence: Feedback received from people living in the care home, their relatives and staff was positive. The management communicate a clear sense of leadership within the home and have an open door policy where staff could see them anytime with any issues or concerns they may have. Residents and their relatives have commented positively about the quality of service provision. Regular audits were carried out and there were good quality assurance systems in place to ensure safe practices were maintained. The home does not manage residents money. All statutory records were available for inspection and maintained in accordance with legislation. Records examined were kept up to date and accurate and were held securely. Staff spoken to were aware that people can access their records and Care Homes for Older People Page 19 of 23 Evidence: information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of people using the service and staff are promoted and protected. These records were accessible to staff. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The Commission has been kept informed of all accidents and admissions to hospital. Regular checks on the hot water temperatures and moving and handling equipment were recorded. A valid insurance certificate was displayed in the reception area and this offered cover of no less than five million pounds and expires on the 30th April 2009. Care Homes for Older People Page 20 of 23 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 21 of 23 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 Specific care plan should be devised for resident who suffer from epilepsy so that staff are aware of the support they should provide in an event of the resident having an epileptic seizure. Hand written instructions in the medicine record charts should be signed by the person making the entries. When prescribed medicines are not given, the reasons for these omissions should be recorded. 2 9 Care Homes for Older People Page 22 of 23 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 23 of 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!