Inspection on 15/07/05 for Willowthorpe Care Home

This inspection was carried out on 15th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Willowthorpe Care Home 01/10/08

Willowthorpe Care Home 29/12/05

Willowthorpe Care Home 02/03/05

Willowthorpe Care Home 01/03/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Willowthorpe Nursing Home High Street Stanstead Abbotts Hertfordshire SG12 8AS Lead Inspector Bijayraj Ramkhelawon Unannounced 15 July 2005 10:00 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 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. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Willowthorpe Nursing Home Address High Street Stanstead Abbotts Hertfordshire SG12 8AS 01920 871811 01920 871821 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Colley Care Limited (Trading as B & M Care) Janice Pittom Care Home 56 Category(ies) of DE(E) Dementia - over 65 - 24 registration, with number OP Old Age - 32 of places Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: This registration allows for up to 32 service users (OP) accommodated in the old Manor Building. The other 24 beds are registered for dementia (DE(E)) and provided in the new extension. Bedrooms 2, 3 and 4 in the old Manor Buidling 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. Date of last inspection 2 March 2005 Brief Description of the Service: 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 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. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection since the home was renovated, extended and became operational in May 2005. On the day of the inspection there were 12 service users in the home. Feedback received from service users, their relatives and visitors was positive and the standard of care and practices observed were good. The majority of time was spent talking to residents, visitors and staff. Some time was spent in the office scrutinising care plans, staff files and other records. Discussions were held with the manager to whom the feedback of the inspection was given. The experience of service users was that there was a pleasant and relaxed atmosphere in the home and they were complimentary of the staff, the food, activities and their rooms. However, the administration and management of medicines had major shortfalls and an immediate requirement was made for the home to take corrective measures. What the service does well: What has improved since the last inspection? This was the first inspection since the home became operational in May 2005 after being closed for renovation and a new extension being built. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 6 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. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 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 standard(s) 1-5 Adequate information was available to prospective service users and their relatives to assist them in their decision making process when chosing the home. Each service user has an assessment of needs carried out by the home prior to an offer of placement is made. Good observations were made of staff’s approaches to service users and to the appropriateness of their delivery of care. EVIDENCE: The home has a written ‘Statement of Purpose and a ‘Service User Guide’ and both documents were available to prospective and current service users and their relatives. Service users and relatives spoken to confirmed that they were encouraged to visit the home prior to admission. There was evidence in the care plans scrutinised that a pre-admission assessment of needs of the service users were carried out either in their homes or places of residence. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 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 standard(s) 7-10 Service users observed during the course of this inspection appeared to be well cared for, were comfortable and received care and attention in a timely manner. Good care practices and interactions were also seen. Care plans were comprehensive and reviewed regularly to reflect the changing needs for health, personal and social care needs of the service users. However, it was recommended that care plans should be signed by the service user or their representatives. There were major shortfalls in the management and administration of medicines and an immediate requirement was made. The manager must ensure that a robust system for the management of medicines is put in place with regular monitoring and audits carried out to prevent similar shortfalls in the future. EVIDENCE: Care plans were comprehensive and had all the relevant information required by this Standard including assessment of needs, risk assessments and how the needs of service users were being met. The care plans were reviewed regularly but these were not signed by the service users or their relatives. One of the service users had MRSA and the home had implemented the infection control policy whereby staff were provided with alcohol gel, gloves and aprons and these were also left outside the bedroom door for use by Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 10 visitors. Adequate information was available on infection control for staff and visitors with simple instructions without causing alarm. The District nurses provided attended to service users who required nursing care. Each service user had a nutritional assessment on admission, which was reviewed, if needed, based upon monthly weight gain or loss. All service users were registered with a GP, who referred service users to all other health care agencies as and when required. On the day of the inspection, individual care practice observed was good. However, medicines were not given as prescribed and the reason for any omissions was not recorded. Medicines containers/bottles were not dated when first opened. Medicines returned to the pharmacy for disposal were not signed for each item by the pharmacist and hand written instructions on MAR sheets were not signed by the person making the entry. It was noted that the temperature in the medicine room was 30 degrees C with a fan in use. All service users were appropriately dressed and were correctly addressed by staff. The home has a “knock and wait” policy on entering service users’ bedrooms, toilets and bathrooms. Staff members on duty were seen to deliver care and to attend to service users’ needs in a manner that was conducive to respect for their privacy, dignity, choice and wishes whilst actively promoting independence where possible. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 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 standard(s) 12-15 The staff at the home promoted autonomy and choice. Visitors were welcomed and the integration with the local community is promoted in accordance with service users preferences. EVIDENCE: The home has an activity co-ordinator who organised a variety of activities. Service users spoken said that there were activities provided for them and these included art and crafts, sing-a-long, reminiscence, movement to music, flower arranging, colour therapy, games, current affairs etc. and trips outside of the home. The lunch was unhurried with assistance and encouragement given by staff sitting down next to service users. Tables were laid nicely and a choice of drinks was available and there was individual cutlery. Service users spoken to were complementary of the food provided. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 12 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 standard(s) 16-18 The home has a complaints procedure of which all service users and visitors spoken to were aware. The manager has a presence within the home, thus safeguarding service users. EVIDENCE: A copy of the complaints procedure was available to prospective and current service users. Those 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. No complaints had been received since the home was re-opened in this May. Staff confirmed they had received training on adult abuse via video sessions and were aware of the ‘Whistle Blowing Policy’. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 13 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 standard(s) 19-26 The home and its surroundings offer a pleasant, comfortable environment over looking the River Lea. The home was kept clean and well maintained and bedrooms were personalised offering a homely, lived in feel. EVIDENCE: The home was reopened in May of this year with an extension built to provide an additional 24 bedded unit for people with dementia. All bedrooms are for single accommodation with ensuite shower facilities. These were kept clean and contained service user’s personal furniture and belongings. Pressurerelieving aids were provided for service users who required nursing care. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-30 The skills and experience of staff were varied. The majority of them were recently recruited, some were transferred from other sister homes and prospective employees were being interviewed. However, the staff were enthusiastic, dedicated and caring who brought different experiences and skills to the team. EVIDENCE: There was adequate numbers of care staff rostered on duty per shift during the day and night. Service users were complimentary of the staff and management of the home. Staff files inspected were found to have all the required documents including the references, CRB and POVA checks. Staff spoken to confirmed that they have received appropriate training, this included NVQ, moving and handling, food hygiene, first aid, dementia, adult abuse and other mandatory training. The management of the home has implemented a formal supervision for all care staff. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32,33, 3538 The home was well managed and was achieving its aims and objectives. There were only twelve service users and the manager said that she is gradually filling the vacancies at the same time recruiting staff to compliment the number of service users. However, it was required that fire drills must be carried out at regular intervals and that food stored in the fridge should be dated. EVIDENCE: The manager has an open-door policy where staff could see her at any time with any issues or concerns they may have. Service users and their relatives have commented positively on the good practices and quality of service provision. All statutory records were available for inspection and maintained in accordance with legislation. Records inspected were up-to-date and accurate and were held securely. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 16 Staff spoken to were aware that service users can access their records and information held about them in accordance with the Data Protection Act 1998. There are policies and procedures in place to ensure that the health, safety and welfare of service users and staff are promoted and protected. These records are accessible to all staff. All accidents and injuries are recorded in the accident book. A valid insurance certificate is displayed in the reception area and this offers cover of no less than £5 million. The management adopts the organisation’s employment policies and procedures and facilitated the induction and training to staff. However, fire drills were not carried out since the home became operational and food stored in the fridge was not dated. Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 3 3 3 3 3 N/A 3 3 3 1 Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 18 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard OP 9 OP 9 OP 9 Regulation 13 (2) 13 (2) 13 (2) Requirement Medicines must be given as prescribed and the reason for any omissions must be recorded Medicines containers/bottles must be dated when first opened. Medicines returned to the pharmacy for disposal must be signed for each item by the pharmacist. Hand written instructions on MAR shets must be signed by the person making the entry. Medicines must be stored at room temperature of 25degrees C. Fire drills must be carried out at regular intervals. Timescale for action 15/07/05 15/07/05 15/07/05 4. 5. 6. OP 9 OP 9 OP 38 13 (2) 13 (2) 23 (4) (e) 15/07/05 15/07/05 09/09/05 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. 2. Refer to Standard OP 7 OP 38 Good Practice Recommendations Care plans should be agreed and signed by service user whenever capable and/or representative (if any). Food stored in the fridge should be dated. I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 19 Willowthorpe Nursing Home Willowthorpe Nursing Home I52 s19619 willowthorpe v238406 150705 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City AL7 3BQ 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. 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