Care Home: The Willows Older Peoples Mental Health Resource Centre

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What has improved since the last inspection? This was the home`s first inspection under the new registration. What the care home could do better: They should consider expanding the care plan documentation to include more information on how people prefer to receive their care. Refurbishment and redecoration works to the first floor servery are needed to ensure that food management in this area is safe. Hot water temperatures should be monitored on a more regular basis to keep people safe. Key inspection report CARE HOMES FOR OLDER PEOPLE The Willows Older Peoples Mental Health Resource Centre Barmouth Drive Grimsby North East Lincolnsh DN37 9EJ Lead Inspector Jane Lyons Key Unannounced Inspection 9th April 2009 09:00 DS0000072987.V374881.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Older Peoples Mental Health Resource Centre Barmouth Drive Grimsby North East Lincolnsh DN37 9EJ Address 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) 01472325444 01472325440 North East Lincolnshire NHS Care Trust Plus Karen Margaret Wood Care Home 16 Category(ies) of Dementia (16), Mental disorder, excluding registration, with number learning disability or dementia (16) of places The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only- Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are withinthe following categories: Dementia - Code DE, maximum number of places, 16 Mental Disorder, excluding learning disability and dementia - Code MD, maximum number of places 16 The maximum number of users who can be accommodated is: 16 2. Date of last inspection Brief Description of the Service: The Willows is a care service run by North East Lincolnshire Care Trust Plus and provides respite and rehabilitation support for older people and adults with identified mental health needs and their carers. The services provided by the home divide into three key areas; the intermediate care unit provides support for up to seven persons, the respite unit provides six designated beds for respite care and three beds are for rotating respite care support. The third unit provides twelve mental health day care places. The home comprises of a two storey building and a separate two bedded bungalow. All bedrooms are for single occupancy, one en-suite facility is provided. There are a good variety of lounge and dining rooms. Assisted bath and shower facilities are provided on each floor. The home has a range of equipment and facilities to meet the care and rehabilitation needs of the people who stay in the home to ensure their independence is maximised. The home is situated on the Willows estate on the outskirts of Grimsby, approximately three miles from the town centre. The home is well served by the local bus service. There are a number of shops and local amenities close by. The grounds are secure and well maintained. There is car parking space at the front of the property. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 5 Information on the service is made available to prospective and current individuals via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are always held in the reception area. There is no charge for persons admitted for intermediate care support, charges for respite and day care services are means tested. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing, chiropody The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means people who use the service experience excellent outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) from the last six months including information gathered during a site visit to the home which took approximately eight hours. This service was registered with North East Lincolnshire Care Trust Plus in October 2008 and as this is the first inspection of a newly registered service all the thirty eight national minimum standards have been assessed. As part of this inspection process surveys were sent out to ten people using the service and ten staff who work there. Surveys were received from six staff members and four individuals. Comments were very positive such as ‘The care is very good’ and ‘The staff at the home are wonderful and provide myself and my husband with all the support we need’. Anonymised comments from surveys and from discussions on the day of the site visit will be included throughout the report. Throughout the day we spoke to people staying in the home to gain a picture of what life is like at The Willows during their stay. We also had discussions with the registered manager, the responsible individual, care staff, the cook, an occupational therapist, registered nurse and care manager. We looked at assessments of need made before people were admitted to the home and the home’s care plans to see how those needs were to be met while they were staying there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff recruitment, staff training, how the home monitors the quality of service provided and how the home is managed overall. We also checked with people to make sure that privacy and dignity is maintained, that people can make choices about aspects of their lives and that the home ensures they are protected in a safe, clean environment. We observed the way staff spoke to people and supported them and checked out with them their understanding of how to maintain privacy, dignity, independence and choice. We would like to thank the people who were staying at The Willows, the staff team and the management for their hospitality during the visit and also thank the people who spoke with us. This was a very positive and enjoyable visit. We have reviewed our practice when making requirements, to improve national consistency. In future if a requirement is repeated it is likely that enforcement action will be taken. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 7 What the service does well: The home deals very well with the process of assessing and welcoming new people to the service and supplies them with all the information they need. The service provides very good programmes of intermediate, respite and day care support enabling people to maximise their independence where possible. All interactions observed between the people who use the service, staff and the manager evidenced that the home has a close and caring staff team. Staff are well trained and supported to carry out their work. People are able to exercise choice in their daily lives during their stay, maintain relationships with family and friends, and take part in social, religious and recreational activities. The home provides a healthy and balanced diet. People’s legal and civil rights are well protected and promoted. The home provides ongoing support for ‘carers’ to help them continue in their role. The home provides a very clean, pleasant and well maintained environment for people to live in. The home is well equipped to maximise people’s independence. It has a friendly and homely feel and people told us they were very comfortable, which was observed during the visit. Staff recruitment and selection practices are robust and protect people who live in the home from harm by ensuring that only people who are considered safe to work with vulnerable people are employed. ‘Carers’ participate in the recruitment of new staff as the home’s management recognises the importance of their involvement. The home is consulting widely with people who use the service, carers, relatives staff and other stakeholders and is evidencing the home’s ability to meet its aims and objectives and make continued improvements to the service. There are effective health and safety measures in place that protect people who use the service and others from harm. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 8 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 9 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 The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides detailed information to enable people to make an informed choice about the services they provide. The home is able to demonstrate that people’s needs are being fully assessed and the range of needs presented is being sensitively and appropriately met to maximise their independence and return home where possible. EVIDENCE: The home has a detailed statement of purpose and service user guide in place which ensures that people considering using the service have helpful, accurate and up to date information. The service also provides a user –friendly The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 11 information booklet. These documents are made available in the home or could be sent to prospective persons. A copy of the service user guide is provided in each person’s room. The manager confirmed that there are strict eligibility criteria for admission to the service which is supported by robust referral and assessment procedures, these are all clearly detailed in the home’s statement of purpose. All people admitted to the service have a full community care assessment carried out prior to admission. We looked at a sample of files, which belong to people who are staying at the home, and we saw that these contained copies of assessments undertaken by the care management team and the home. The assessments cover all aspects of health, personal and social care needs. In addition to this, information is also requested from the family and health and social care professionals where possible so that the home has as much information about the prospective individual prior to their admission. All of the information gathered at the time of admission is collated and used to develop an individual care plan for each person which clearly identifies all their rehabilitation and support needs. People spoken to confirmed that they were involved in their assessments and have a say in what happens to them. Copies of people’s statements of terms and conditions are held in their care files. Given the admission route of the majority of people there is little opportunity for them or their relatives to visit the service prior to moving in, however the home would accommodate this where possible. Many of the people who visit the service for day care support have also received residential services at some time, the manager and staff confirmed that new clients have every opportunity to visit the service with their relatives and carers. The staff team at the service includes health and social care professionals such as a registered nurse, social worker, occupational therapist and a doctor. The team also benefits from having the support of The Mental Health Community Support Team on site. The various assessments, support plans and enablement programmes indicate that care and support needs for people receiving intermediate and respite care are being very well assessed and met in this home, and that people who use the service, their relatives and carers are being fully involved in the assessment, review and care planning process. The home provides good facilities to support intermediate care support. There is a comprehensive and ongoing programme of training for staff which is tailored to the care and support needs of this client group. People who use the service can be assured that their individual needs can be met at The Willows. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s rehabilitation and support needs are well met and they receive excellent standards of care. People are being well protected by the home’s medication policies and procedures. People are treated with respect and dignity in all aspects of their daily living. EVIDENCE: People can be confident their care needs will be understood by the carers who look after them. We sampled care records for people residing in all units. Each person has a care plan that has been written following a detailed assessment of their needs. People who use the service have been involved in the drawing up of their plan and have signed to agree them where possible. Care plans The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 13 seen covered all areas of identified needs including health, personal care, risks, nutrition, social activities, relationships and emotional well being. Some discussion took place about how the plans could be further developed to include more detailed information about people’s individual preferences on how their care is delivered. There is good evidence that the plans are reviewed and evaluated very regularly and therapy programmes are targeted to meet people’s changing needs. Formal meetings are held daily by the care, therapy and medical staff to discuss each individual’s progress, current care needs and plan the individual’s discharge arrangements effectively. There are risk assessments in place for mobility, tissue viability, medication, nutrition, falls and general issues. Records show that the risk assessments are reviewed regularly and where high risk areas have been identified, care plans are in place to support appropriate care provision. Daily records are detailed they describe how the individual’s health and personal needs have been met and also describe in detail how the individual has spent their day and what they have enjoyed. Communication sheets are in place and well maintained. The service provides short stay respite and intermediate care support and people who are admitted remain with their current G.P. wherever possible. The service employs a resident medical officer who is responsible for people’s mental health needs during their stay, any concerns or changes to an individual’s physical health is managed through the person’s G.P. Agreed interventions have a planned outcome of maximising independence and enabling people to resume their preferred living arrangements. Staff on the intermediate care unit are able to provide outreach work as part of people’s therapy programmes, many assessments are carried out in people’s homes. There is very good evidence that the staff at the home have developed very positive working relationships with the community nursing, care management and therapy staff to provide an excellent enabling service for people. We spoke with a number of professionals during the visit who commented ‘The staff team here is fantastic, they are very motivated and we work well together. The enablement programmes are good with very positive results’ and ‘The staff are very professional and provide excellent standards of care’. The way medicines are handled and stored in the home keeps people safe. The staff make sure that the correct medication has been brought in with the individual on admission and any omissions are quickly followed up. The staff make sure that the recording of the medication is up to date and storage seen is well managed. The records of administration were checked and had been completed accurately and fully. Storage of controlled medication was also checked and found to be satisfactory. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 14 People are supported to regain and maintain their independence with medication administration where possible. An assessment of their needs is completed to ensure they will be able to manage their medication safely and to ensure they are provided with the support they need. There are robust monitoring systems in place to ensure people are managing and are safe. All of the staff who give out medication have had the proper accredited training and we saw certificates which confirmed this. The medication systems are audited regularly with evidence that any issues found are addressed promptly. The home has detailed policies and procedures in place which cover privacy, dignity and confidentiality. Throughout the inspection we observed staff interacting with people in a polite, caring and professional manner. One person told us ‘The staff are all very kind and lovely’. Although the home provides short stay care support there are systems in place to support end of life care. The home has a policy for ‘death and dying’ and staff have accessed training in palliative care support. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are actively enabled to exercise choice and control in their day- to –day activities and routines, a range of activities are provided to support their social needs and to improve their life skills. People receive a good quality, varied and nutritious diet. EVIDENCE: People are given choice around their daily living and social activities. When we spoke to people who stay at the home they said they could make choices about activities, what they wear, meals, how they spend their time and when to get up and go to bed. This was observed during the visit. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 16 The home encourages contact with carers, friends and relatives. People are able to receive visitors at any time, use the telephone and make visits home as part of their enablement programmes. People’s social, religious, recreational and psychological needs are identified in assessments and care plans. The home provides a good range of activities, entertainment and occasional outings. A daily activity programme is in place and displayed on notice boards in both dining areas. During the inspection we saw that a selection of activities was arranged for people to take part in if they wished and all care staff are involved in supporting the activity programmes. On the respite unit we observed people making Easter cards and enjoying manicures. One person told us ‘I haven’t had my nails done for years, that was lovely’. There is a structured activity programme in place for people receiving day care, although staff told us that the activities in all units are very flexible and are changed at people’s request. Records show that people receiving intermediate support have programmes developed which are tailored to developing their independence around life skills, for example people are encouraged to be involved in food preparation and laying tables, assisting with tidying their rooms and managing their laundry. Spiritual needs are supported and various clergy visit the home on request and access to places of worship are arranged for those people who wish to do so. The service values the role of the ‘carer’ and the staff at the home also provide support and advice to ‘carers’. A carer’s support group is held at the home each month and they can also telephone the service throughout the day or night and speak to a staff member if they have concerns or feel isolated in their caring role. A senior staff member has lead responsibilities to facilitate the carers meetings and feedback any concerns or suggestions made. The home safeguards people’s rights and supports them to exercise choice and control over their lives. There was evidence that the home has sought the input from Independent Mental Capacity Advocates (IMCA’s) where people who use the service need support to make decisions. All staff have received training in The Mental Capacity Act and staff are now receiving training on The Deprivation of Liberty legislation which has recently come into force. The catering arrangements in the home are very good. People who use the service are consulted on admission regarding their dietary needs. Menus are planned over a four week period with input from individuals, and knowledge of needs and preference. Lunch is the main meal, which includes a choice of main courses and is provided by the cook. People who stay on both units are supported to prepare their breakfast and evening snack meals where possible, with support from staff as part of their enablement programmes. People were seen enjoying lunch in a relaxed and comfortable atmosphere. When we spoke with the people who stay at the home about the food they told us that it was very good and there is plenty of choice. Lunch on the day of the inspection was The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 17 nicely presented and looked wholesome and nutritious. Although none of the individuals seen required assistance with eating, staff were always on hand to provide support. The kitchen is well organised, the cook demonstrated a good knowledge of the dietary needs of older people during discussions. The appropriate records relating to food hygiene and environmental health are in place, the home has been awarded a 4 star rating from the Environmental Health Team. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. People using the 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 know how to make a complaint if they need to and feel confident they will be listened to. There are suitable policies and practices within the home to ensure people are safeguarding from harm and abuse. EVIDENCE: The home’s philosophy is one of open-ness and of transparency, where people who use the service and their carers / representatives are encouraged to raise any concerns they may have, and for these to be addressed in an open and non judgemental way. There have not been any complaints since the service was re- registered and none since the previous inspection. The complaints procedure is simple and clear; it outlines the process for managing complaints and for ensuring that these are dealt with promptly and effectively. Details of the complaints procedure are clearly displayed in public areas and copies also provided in the service users guides in each bedroom. Information provided in the home’s AQQA detailed ‘We protect service user’s legal rights and have utilised the services of IMCA’s. Although we have no long The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 19 term service users and most only stay for a short period of time all service users are assessed around their needs in relation to their civil rights’. Records seen during the visit supported this statement. Vulnerable Adult Procedures for the protection of adults are in place together with the local authority Safeguarding Adults Policy, a copy of which is available in the home. All staff undertake safeguarding adults training during their induction and annual refresher training for staff is provided. When we spoke with the staff they were able to tell us what they would do if they witnessed any abuse within the home or if anyone made any allegation to them. Staff were observed throughout the visit listening to what people said and treating them with dignity and responding to their wishes. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe, clean and comfortable for the people who stay there. People have the equipment and facilities they need to maximise their independence. EVIDENCE: The home is set within its own grounds and is safe and secure. It provides spacious single accommodation over two floors, accessed by lift or stairway. The home is divided into separate units, each having its own bath/ shower facilities, bedroom facilities, dining area, sitting room and kitchenette. The home has been undergoing major refurbishment and development over some time in line with the new registration which has enhanced the standard of The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 21 accommodation and facilities. The first floor of the home has been completely refurbished and redecorated. The reception area has been restyled and provides a warm and more welcoming atmosphere in the home. The décor and furnishings throughout the building are of good quality and reflect a contemporary, homely style, providing very comfortable and pleasant accommodation. All areas of the home are well lit the lighting is domestic in style. We looked at a number of people’s rooms, though only one room has en-suite facilities, the rooms present as being pleasantly decorated and arranged. Although people who use the service are only in the home for short periods of time they are encouraged to personalise their rooms with photographs and ornaments. There are a number of communal rooms, which are very comfortable and allow people a choice of where to spend their time. The general atmosphere throughout the visit was very calm and happy. There are a variety of bathrooms and shower facilities on each unit which are well equipped. Toilet facilities are spaced throughout the home and are easily accessible. Corridors and doorways are wide to accommodate wheelchair users. Grab rails have been provided in corridors, bathrooms and toilets. The home has a range of equipment to meet the care and rehabilitation needs of the people who stay in the home to ensure their independence is maximised; there is a therapy kitchen, activities room and a wide range of specialist equipment in the home. Laundry facilities are sited appropriately. Policies and procedures are in place for control of infection. Records show that all staff have accessed training and updates in this area. One of the senior staff has lead responsibilities for infection control and represents the home at meetings with the Community Infection Control Team, guidance on best practice is in place which staff have implemented. The home was spotlessly clean and tidy and there were no unpleasant odours noted in any areas of the home. People who completed surveys said the home is ‘always’ fresh and clean. The main kitchen facilities have been refurbished with new equipment and flooring provided. Although there is good evidence that the home is generally very well maintained there is outstanding work to refurbish the servery on the first floor. Improvement works to the units, flooring and ceiling are needed to ensure that food preparation and management in this area is safe. The manager confirmed that this work has been identified and reported to the maintenance department, however the home is experiencing delays in the work being carried out. Garden areas are accessible and secure. They are very well maintained and seating and shade is provided for people who use the service. During the visit The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 22 the maintenance team were developing a new sensory garden which will be a positive addition to the facilities. A kitchen garden is provided with a greenhouse and people are supported if they wish to grow and tend a variety of plants, flowers and vegetables. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs are well met by a skilled staff team who are trained, qualified and competent. People are protected by the homes robust procedures for recruiting new staff. EVIDENCE: The home has a stable staff and management team. Discussions with staff and people who use the service and from observation during the day evidenced that there are enough staff rostered to meet people’s needs; staff told us they had enough time to carry out their tasks and spend time with people. Discussions with the manager during the visit confirmed that the dependency needs of the people who use the service fluctuated and staffing levels are reviewed on a regular basis to ensure people’s needs are properly met. This was confirmed by staff during discussions and evidenced on staff rotas. Surveys returned from staff included comments ‘Sometimes extra staff are required as some service user’s need one-to-one support and this is always provided’ and ‘The staff team is very dedicated and provides a professional service to meet service user’s individual needs’. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 24 Observations during the inspection visit demonstrated that staff have a good understanding of people’s needs and positive and respectful relationships with them. Comments from people who use the service included: ‘they look after us very well’ and ‘the staff are very nice and kind’. Senior staff have been delegated areas of specialist responsibility such as health and safety, infection control, medication etc. They access any specialist training and attend relevant forum meetings and feedback to the staff which supports the home’s commitment to maintaining standards of good practice. The home also employs a large team of ancillary staff who are highly motivated ensuring that the standards relating to food, cleanliness, laundry and administration are fully met. People who use the service are protected through robust recruitment procedures. The manager told us that ‘carers’ are included in the recruitment panel as the home’s management feel it is important that they are involved in selecting the right staff to work at the home and look after their loved ones. Staff records sampled during the visit show that face-to-face interviews take place and formal questions and responses are noted. The home has an equal opportunities and non- discriminatory policy and procedure which clearly states the commitment of the service in working towards equality and opportunity for each employee. Recruitment records are well maintained and up to date. Safevetting procedures are followed: these include taking up written references and carrying out checks through the Criminal Records Bureau before appointment. All staff files contain a photograph and proof of identification. People who use the service can be confident that staff in the home are competent to deliver their care. Staff files include training records and all new staff follow a formal induction programme which includes the NTO Skills for Care common induction standards, this assesses their competence and is signed off by a Senior Care Officer on completion. Information provided by the manager during the visit shows that the home has recently achieved the target of having 50 of care staff qualified at NVQ in care at level 2 or 3, further staff are currently working towards this qualification. The home has a training plan that provides opportunities for participation in a range of courses and each staff member has an individual learning plan to record training participated in and details when refresher courses are required. Training consists of in- house DVD’s, distance learning, in house sessions from the health professionals and courses provided by the workforce development team at the CTP. Records show that the staff are up to date with mandatory courses such as first aid, moving and handling, basic food hygiene and fire safety. Staff have The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 25 also accessed a very good range of general and service specific training such as the Mental Capacity Act, Deprivation of Liberty, dementia, challenging behaviour and mental health first aid. Senior staff are scheduled to access training in dementia care mapping later this year and a number of staff are completing degree and modular courses at university. Views expressed by staff on this inspection indicated staff are feeling well supported, that they are receiving good training, supervision and encouragement to develop their skills and potential. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from a home that is run by a competent, experienced and qualified manager. The management approach is open, enabling and conducive to creating a positive and inclusive atmosphere in the home. People are consulted on their views of the service and their opinions are listened to and acted upon. The health and welfare of people and staff are promoted and protected in the home. EVIDENCE: The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 27 The home’s manager is very experienced and exemplifies a very enlightened, caring and committed approach to managing the home. Throughout this inspection, the manager was able to demonstrate an in- depth knowledge and understanding of the physical, psychological, cultural and spiritual needs of older people, and a thorough knowledge of the relevant regulations and care standards that apply. These are routinely discussed within staff meetings, staff development being a high priority.There is a comprehensive programme of ongoing support and training for staff. The evidence across all standards inspected is that there is a firm commitment to maintaining standards of good practice in all aspects of the home’s day to day operation, and that the home provides an open, friendly and inclusive environment for the people that use the service. As evidenced in key documents and policies, and observed in practice, this includes a strong commitment to promoting the welfare, independence and rights of people. Very positive views were expressed by people who use the service and staff regarding the home and the way in which it is being run. Comments received from individuals, regarding the manager and staff, were very praiseworthy. No concerns were expressed. The manager was observed to interact very well with both staff and people who use the service and to provide a positive model of care and support. Following the registration of the service under the Care Trust Plus a number of the management systems have changed or are in the process of changing, these include the staff appraisal systems and complaints management. All the home’s policies and procedures are currently being reviewed. The home has developed a very effective quality assurance system which includes and takes into account of the views of people who use the service. The staff make courtesy calls, satisfaction surveys are issued to each person on discharge, surveys are also issued to staff and stakeholders periodically. Regular care review meetings are held .The management team carry out regular audits of key areas and action plans are developed to support any areas of deficiency identified. A full audit report is produced on a quarterly basis. A notice board in the hall displays the findings from courtesy calls and satisfaction surveys and this information is also included in the home’s service user guide. Records confirmed that staff attend regular team meetings. Staff told us that the meetings were positive and that their comments and suggestions about service improvements was a regular agenda item. There is evidence that the responsible individual visits the service regularly. The manager confirmed that she had recently completed a comprehensive programme to identify areas that will be assessed each month and reports to support these visits will be now provided. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 28 The staff supervision and appraisal programmes have been well maintained with evidence that the staff are receiving the appropriate number of sessions and that they are linked to the staff development programme. The home’s business and financial plan and insurance arrangements were in place and submitted to support the home’s new registration in 2008. People’s financial interests are safeguarded by the financial systems and procedures in place. Individual records are maintained for monies held in safekeeping and receipts obtained for expenditures. These records are audited periodically by representatives from the CTP. The home is a safe place to live and work in. There is a fire safety policy and an up to date fire risk assessment in place. Tests on equipment are undertaken and regular fire drills for staff are carried out. All the equipment in the home is tested at the appropriate intervals and all maintenance certificates are up to date. The AQQA which was returned by the home prior to the site visit was well completed and told us about identified areas for improvement. The staff are trained in health and safety and their mandatory training is updated as required. Hot water temperatures in the home are currently monitored annually by the maintenance staff and care staff check the water temperature prior to each bath however it would be safer practice if staff check the water temperatures at all outlets accessible to people who use the service more regularly such as monthly, given the ‘hard water’ in the area and the effect this has on thermostatic valves. Accidents in the home are audited by one of the senior care officers; records are maintained of action taken to further reduce the risk of reoccurrence. The home liaises with the community falls co-ordinator where necessary. The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 29 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 3 3 3 4 3 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 4 3 4 3 3 3 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 4 3 3 The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations They should consider expanding the care plan documentation to include more information on how people prefer to receive their care. Refurbishment and redecoration works to the first floor servery are needed to ensure that food management in this area is safe. The hot water temperatures should be monitored more frequently. 2. OP19 3. OP38 The Willows Older Peoples Mental Health Resource Centre DS0000072987.V374881.R01.S.doc Version 5.2 Page 31 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. 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