Care Home: Willerfoss House

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What the care home does well A thorough assessment is undertaken that commences before people are admitted to the home. People are only offered a place at the home is it is considered that their assessed needs can be met. The registered manager has produced admission packs so that they are readily available for staff should someone be admitted to the home as an emergency. Care plans are an up to date record of a person`s individual needs and how these are met by staff. Residents are encouraged and supported to live their chosen lifestyle, both inside and outside of the home. Visitors are made welcome at the home and are offered a meal if they are present at mealtimes. This assists people to maintain relationships with family and friends, and encourages visitors.Residents and others tell us that meals at the home are good; there is a choice of meal at each lunchtime. There is a continuous programme of refurbishment in place and this has resulted in a pleasant, clean and comfortable environment for residents. The registered manager is proactive and takes part in various opportunities to expand her knowledge, and in turn, improve the lives of people living in the home. Staff are well trained and this enables them to provide a service that meets the needs of residents accommodated at the home. There is an effective quality assurance system in place at the home that gives residents and others the opportunity to affect the way in which the home is operated. What has improved since the last inspection? A medication fridge has been purchased so that medication can be stored at the temperature recommended by the pharmacist. There are now risk assessments in place to record the safe use of bed rails, and there is evidence that safety checks are undertaken on the bed rails that are in use. The staff rota records the role of each member of staff on duty. The refurbishment of the kitchen is now complete; this has provided improved hygiene standards in this area of the home. CARE HOMES FOR OLDER PEOPLE Willerfoss House 6 Victoria Avenue Withernsea East Yorkshire HU19 2LH Lead Inspector Diane Wilkinson Key Unannounced Inspection 10th April 2008 10.35 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willerfoss House Address 6 Victoria Avenue Withernsea East Yorkshire HU19 2LH 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) 01964 614290 willerfosshouse@denestar.co.uk Denestar Limited Jayne Louise Clarke Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Willerfoss House DS0000070926.V362228.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 within the following categories: Old age, not falling within any other category - Code OP; Dementia - Code DE. The maximum number of service users who can be accommodated is: 26 30th August 2007 2. Date of last inspection Brief Description of the Service: Willerfoss House is a privately owned care home that is situated in the seaside town of Withernsea, in the East Riding of Yorkshire. The home is registered to provide care and accommodation for twenty-six people aged 65 years and over, including those with dementia. Private accommodation is provided in single bedrooms, apart from one shared bedroom; the majority of bedrooms are situated on the ground floor. Communal accommodation is provided in two lounges (one with a dining area) and a separate dining room. People have access to all areas of the home via the provision of a stair lift and ramps. The garden area is on a level approach and the grounds are well kept. The home is close to the main road therefore service users have easy access to a range of local shops, services, transport facilities and to the sea front. The registered manager told us that the current weekly fees range from £350.00 to £395.00. Residents pay an additional fee for hairdressing and private chiropody. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 30th August 2007 including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day; it began at 10.35 am and ended at 4.35 pm. On the day of the site visit the inspector spoke on a one to one basis with three residents, two relatives and a community nurse as well as a member of staff and the registered manager. Inspection of the premises and close examination of a range of documentation, including four care plans, were also undertaken. The registered provider and manager submitted information about the service in advance of the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. Survey forms were sent out prior to the inspection; seven were returned by residents and four were returned by relatives. Comments from discussions with people on the day of the site visit and from returned surveys were mainly positive, such as, ‘during our visits, the staff seem to have the right, personal commitment’ and ‘staff are very helpful, cheerful and friendly’. Other anonymised comments are included throughout the report. What the service does well: A thorough assessment is undertaken that commences before people are admitted to the home. People are only offered a place at the home is it is considered that their assessed needs can be met. The registered manager has produced admission packs so that they are readily available for staff should someone be admitted to the home as an emergency. Care plans are an up to date record of a person’s individual needs and how these are met by staff. Residents are encouraged and supported to live their chosen lifestyle, both inside and outside of the home. Visitors are made welcome at the home and are offered a meal if they are present at mealtimes. This assists people to maintain relationships with family and friends, and encourages visitors. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 6 Residents and others tell us that meals at the home are good; there is a choice of meal at each lunchtime. There is a continuous programme of refurbishment in place and this has resulted in a pleasant, clean and comfortable environment for residents. The registered manager is proactive and takes part in various opportunities to expand her knowledge, and in turn, improve the lives of people living in the home. Staff are well trained and this enables them to provide a service that meets the needs of residents accommodated at the home. There is an effective quality assurance system in place at the home that gives residents and others the opportunity to affect the way in which the home is operated. What has improved since the last inspection? What they could do better: All staff should undertake core training as soon as possible after their appointment. The home should continue with plans to provide a dedicated medication room. Although thermostatic valves had been purchased for washbasins in some bedrooms, the work had not been carried out. This placed residents at risk of scalding themselves, as some water temperatures were too high. Essential maintenance work must be carried out quickly; if contractors do not attend as arranged, it may be necessary to seek alternative arrangements. (This work was carried out quickly following the day of out site visit to the home). Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 8 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 Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A thorough assessment is undertaken for residents prior to their admission to the home and they are only admitted if it is considered that their assessed needs can be met. EVIDENCE: Staff at the home undertake a basic assessment of a person’s care needs when they initially make enquiries about admission, or when they are visited in their own home. The registered manager said that they have refused admission at this stage if it has become apparent that the home would not be able to meet a person’s care needs. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 10 They then start to complete a very thorough assessment form; they have devised one document for people wanting respite care and another for those wanting permanent care. Both are very detailed and include information on all areas of a person’s physical, social and emotional care as well as their likes and dislikes and previous lifestyle. The registered manager told us that some people have day care or respite care at the home prior to making a decision about permanency; this was confirmed by people we spoke to on the day of the site visit. The registered manager has produced some assessment packs ready to be used should someone need admission in an emergency during her absence; this is good practice. Risk assessments are completed within the first few days of a person’s residency at the home; these include general risk assessments for such areas as mobility and pressure care, as well as more individual risk assessments for such things as road awareness. This information, along with community care assessments and care plans produced by the local authority when they commission the service, are used to begin the development of an individual care plan. The registered manager told us that she also produces a care plan for people who have a respite stay at the home; this should start to be developed from the date of admission. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health care needs are met in a way that respects a person’s privacy and dignity; this is recorded in and supported by well-maintained care planning documentation. EVIDENCE: We examined three care plans in addition to the care plan for a newly admitted resident. These contained an individual care plan that was based on the needs assessment undertaken by the home as well as information gathered from care management and family members. There is evidence that people are involved in developing their plan of care; various agreements have been signed by them, including a care plan agreement, consent to staff opening their mail (apart from private official correspondence) and consent to the sharing of information. Care plans include very detailed risk assessments that record a person’s risk level for areas such as moving and handling, pressure care, Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 12 nutrition and dependency levels. It was noted that risk assessments and care plans clearly record any allergies that affect the resident concerned. Key workers record a monthly progress report and care plans are updated accordingly. There is also evidence that the registered manager undertakes a care plan review periodically via completing a review checklist. Care plans include a person’s medical history and details of the medication that they are currently prescribed by their GP. People are weighed on a regular basis as part of nutritional screening. Information about visits from GP’s and other health care professionals is recorded, included the reason for the visit and the outcome. There is evidence that other health and social care professionals are consulted appropriately when staff at the home have concerns about a person’s welfare. There is evidence that a person’s need for continence care and pressure care is acted upon; appropriate assistance is offered and the necessary equipment is obtained. We spoke to an auxiliary nurse who told us that someone from the community nursing services visits the home most days, and that there is a good relationship between them and staff at the home. She said that staff seek advice when necessary, and follow any advice offered. We examined medication systems and records at the home. There is evidence that all staff that administer medication have undertaken accredited training, and there are sample signatures held with medication records to enable signatures to be checked for authenticity. We spoke to the senior carer on duty about medication practices at the home and they displayed a good understanding of safety procedures when administering medication. They also confirmed that staff at the home do not sign medication administration records until the resident has actually taken the medication. Medication records were examined and these had been completed accurately. There are two new secure medication trolleys in use; both are fastened to the wall in the dining room and are kept locked at all times. At the last key inspection the manager was advised that security would be improved if alternative storage arrangements could be found for the trolleys, and we were told at this site visit that they have now made plans for a medication room to be created; this is included in their maintenance plan for this year. A medication fridge has been purchased but is not yet in use, as none of the current residents have been prescribed medication that requires storage at this temperature. We observed in care plans that there is now a new risk assessment in place to record a person’s ability to manage their own medication. Provision is made for controlled drugs to be stored separately and securely within one of the medication trolleys; these storage arrangements will be further improved when the dedicated medication room is completed. The controlled drugs book records medication received, administered and the Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 13 balance remaining, and all entries have double signatures. Equipment used by district nurses for individual residents is now kept in their own bedroom. Residents and visitors told us on the day of the site visit that staff, including ancillary staff, always speak to residents ‘nicely’ and with respect. One relative recorded in a survey, ‘during our visits, the staff seem to have the right, personal commitment’ and residents who returned a survey recorded that staff always listen to them, and act on what they say. Residents confirmed that any assistance with personal care is done sensitively, in a way that promotes their privacy and dignity. Most residents have a single room so they are able to see visitors in private and there are private areas of the home where meetings can be held with family and friends, health and social care professionals and other visitors. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to maintain their chosen lifestyle and to take part in activities inside and outside of the home. Visitors to the home are always made welcome. Residents tell us that meal provision at the home is good. EVIDENCE: Care plans record information about a person’s life history and lifestyle choices; this includes details about their friends and relatives. Residents told us that they are able to spend the day how they choose, and that they can get up and go to bed at a time chosen by them. On the day of the site visit residents were sitting in various areas of the home, including their own room. The inspector observed that bedrooms are a reflection of a person’s chosen lifestyle and their hobbies and interests. One relative recorded in a survey when asked what the care home does well, ‘Make continuous attempts to keep the residents well – in mind and body - and to offer an active environment and interesting lifestyle for them’. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 15 Residents told us that they have a key worker and records evidence that key workers spend time with residents on a regular basis – this contact is recorded on a ‘quality time log sheet’ and records such events as ‘had a walk around the home with x’ and ‘sat with x and cleaned and trimmed her nails’. Residents have a photograph of their key worker in their room to assist those with memory problems to identify their particular key worker. There is an activities coordinator employed on three days per week – residents told us that they have bingo on a Monday, music and singing on a Wednesday and a quiz on a Friday. Two outside entertainers attend once a month – one person from Music Academy and another who plays the piano and sings. Residents told us that they enjoy these activities and that they are able to choose whether or not to take part. We observed that residents are encouraged and supported to take part in activities in the local community as well as those within the home, and that they are supported to remain in touch with family and friends. Relatives seen on the day of this site visit told us that they are kept informed of events concerning their relative and that they are always made welcome at the home. They confirmed that residents are supported to live their chosen lifestyle. One relative commented in a survey, ‘the staff have actually persuaded my relative to enhance their lifestyle – to become more a part of the in-house activities and to enjoy themselves more’. We saw that information about advocacy is displayed in the entrance hall and the registered manager told us that a ‘best practice’ meeting would be requested via Social Services if this were needed. She also said that every effort is made to adhere to the principles of the Mental Capacity Act. On the day of the site visit we observed that there was a menu on display; this recorded two choices of main meal – bacon chops with leek sauce or chicken casserole followed by a choice of two desserts. The registered manager recorded in the AQAA from that there is always a vegetarian option available, and that a wide variety of desserts suitable for diabetics are made available. Residents confirmed that there is a choice of meal at every mealtime. All of the residents told us in surveys that they like the meals provided by the home; one person said, ‘the meals have improved’. A visitor seen on the day of the site visit told us that they often stay for lunch at the home, and the registered manager told us that other visitors are also invited to stay for lunch; this enables people to remain in touch with family and friends and encourages visitors to the home There are two dining rooms at the home and both are pleasant and bright. Staff were seen to assist residents appropriately to eat and drink. The inspector observed that there are ample drinks provided throughout the day. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and others know how to use the complaints procedure and residents said that staff listen to them. Residents are protected from the potential to be abused by the training and skills of the staff group. EVIDENCE: The home’s complaints procedure is displayed in the entrance hall and in the manager’s office. We examined entries in the complaints log – there has been one complaint to the home since the last key inspection and this was about the broken central heating boiler - this was dealt with satisfactorily. The CSCI were informed of this event in the home via normal reporting procedures. Residents and relatives that returned a survey told us that they know how to make a complaint to the home, and some added that they had never needed to do so. In addition to this, residents recorded that staff listen to and act upon what they say and that they know who to speak to if they are not happy. Residents confirmed this on the day of the site visit, stating that they would talk to the registered manager or a senior carer if they had any concerns, and were certain that things would be rectified. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 17 The home has appropriate policies and procedures in place on safeguarding adults and we notes that there are notice place in prominent places to remind staff about safeguarding and whistle blowing information. The registered manager has undertaken refresher training on safeguarding adults from abuse, and senior care staff have undertaken the manager’s awareness course. All care staff have now undertaken training on this topic. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained, well furnished and decorated and provides comfortable surroundings for residents. EVIDENCE: There is a refurbishment programme in place and the AQAA form submitted by the registered manager records that lounges, the small dining room and the entrance hall have been redecorated and new carpets have been fitted. These areas now provide attractive and comfortable living accommodation for residents. The refurbishment programme records that all bedrooms will be redecorated during the forthcoming year, and that residents will be able to choose their own furnishings. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 19 A handyman is employed for 20 hours per week and he records day-to-day maintenance work in the home’s maintenance file. This is a clear record of the work undertaken by the handyman to keep the home in good order. His weekly checklist includes duties such as checking wheelchair tyres, checking that light bulbs inside and outside of the premises are working, cleaning fly screens in the kitchen and undertaking a weekly test of the fire alarm system. Communal areas of the home are light and bright, and provide ample access to sunlight for residents. Some bedrooms have a door into the garden, and one resident showed the inspector a small garden area that had been provided for her, where she was able to feed and watch the birds. The refurbishment programme records that a similar garden area is to be provided for another resident. Special provision has been made for the storage of mobility scooters belonging to people living at the home, including facilities to recharge the batteries. A shed has been provided to store these vehicles and access from the home to the shed is level and free of obstacles. This enables people to retain their independence and to access facilities within the local community. Laundry facilities at the home are satisfactory and we observed good hygiene practices being used by staff on the day of the site visit. The home was seen to be clean and hygienic and there were no unpleasant odours. Most care staff and ancillary staff have undertaken training on infection control; this reduces the risk of harm for residents and staff. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care staff are recruited in a safe way and receive induction and on-going training to ensure that they are qualified and skilled to care for the residents living at the home. EVIDENCE: There is a satisfactory staff rota in place that records the role of each staff member. The rota evidences that there are sufficient staff on duty to meet the needs of residents living in the home. In addition to care staff, the rota evidences that there is a cook and a domestic assistant on duty each day, and that a handyman is employed. This enables care staff to concentrate on care duties, and reduces the risk of cross infection. The registered manager showed us a projected rota that has been completed until the end of the year. This gives staff the opportunity to plan holidays and days off, and is good practice. Four of the fourteen care staff have achieved NVQ Level 2 in Care. Four care staff are working toward this award and this will enable the home to achieve the 50 qualification target. In addition to this, three care staff are working towards NVQ Level 3 in Care. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 21 There have been no new staff employed at the home since the last key inspection. The registered manager told us that she is in the process of recruiting new staff and we saw the application form submitted by an applicant. This included information to assist the home with employing staff in a safe way, including the applicant’s employment history, relevant training experiences and a criminal convictions declaration. The registered manager confirmed that two written references and a satisfactory CRB check would be obtained prior to this person commencing work at the home. She is aware that, if a POVA first check is obtained, the new employee must work under supervision until their CRB check arrives. Care staff undertake appropriate Induction training that meets Skills for Care requirements. They have a full day’s induction training followed by further training input over a 6-week period. We were shown details of this training on the day of the site visit and were satisfied that it meets the needs of the staff group, preparing them for their role as care worker. There is a training and development plan in place that records the training undertaken by each member of staff. This includes the dates that staff undertake training so that the need for refresher training can be readily identified. The plan evidences that all staff have undertaken training on safeguarding adults (including ancillary staff), dementia care, fire safety and infection control. Most staff have undertaken other core training such as health and safety, first aid, food hygiene and moving and handling. There should be plans in place to ensure that all staff undertake core training as soon as possible after their appointment, and then on an ongoing basis. The registered manager told us that they are working towards the Investors in People award. As part of these preparations, they have appointed a training organisation to manage training programmes for the home, and to deliver the training needed by staff. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is managed by a pro-active manager who liaises with others to ensure that the home follows good practice guidelines, and that the health and safety of residents and others is protected. People are able to affect the way in which the home is operated via quality assurance systems. EVIDENCE: The registered manager is well qualified and has the skill and experience to manage the home. She keeps her practice up to date via continuing with her own training, and during the last few months has attended an update on safeguarding adults for managers. The manager is taking part in an initiative involving local mental health care services. A psychiatrist, a community psychiatric nurse and the managers of Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 23 three other care homes meet on a monthly basis to discuss individual cases and general information about residents with mental health concerns. This has provided the registered manager with a professional network for learning and sharing information. The registered manager said that local GP’s have said that there is a reduction in requests for house calls as staff have a better understanding of the implications of mental health issues, and some relatives have requested a service from this group of homes as they believe that they will offer an improved service. The registered manager said that there is an understanding that the skills of the staff group need to continually improve so that this client group can receive optimum care. We noted on the day of the site visit that the registered manager has a plan for the forthcoming year recording the dates that staff will receive supervision and appraisals, and that this is being adhered to. There is an on-call rota in place for management support in the evenings and at weekends, so it is clear to staff who they should contact should they need advice or should an emergency arise. The home is working towards the Investors in People Award and they have achieved QDS parts 1 and 2; this is the local authority’s quality scheme. As part of the quality assurance system, surveys are sent to residents, relatives and health and social care professionals. Responses to these surveys were seen by the inspector and most were positive. These responses are collated and the registered manager told us that any areas of concern are acted upon. The most recent quality assurance survey or audit results are displayed in the entrance hall, along with the statement of purpose and complaints procedure. In addition to this, the registered manager undertakes a full audit of systems in place at the home on a six-monthly basis, and policies and procedures are reviewed annually. The information collected via quality assurance surveys, audits etc. is used to assist the home in producing their annual business plan. We observed that residents meetings and staff meetings are held on a regular basis. Minutes evidence that residents and staff are encouraged to express their opinions and that these are acted upon whenever possible. We checked the records for monies held on behalf of residents, and the actual monies held – both were found to be accurate. Some residents are handed their personal allowance and sign to record that they have received this money. Residents that hold their own monies have a lockable drawer or cash box so that they can hold their money safely. Receipts are obtained for all transactions made on behalf of residents, including monies received and monies paid out. We examined health and safety documentation for appliances, equipment and services at the home. These were all up to date, including the fire alarm test, portable equipment testing, the gas safety inspection and the servicing of hoists. There is an accident book and the information recorded in the book is Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 24 cross-referenced to a person’s care plan. A copy of any accident forms should be held in individual care plan to assist in monitoring their care. There are risk assessments in place to record safe working practices and this information is updated appropriately. There are now risk assessments in place to record the safe use of bed rails, and there is evidence that safety checks are undertaken on the bed rails that are in use. Water temperatures are tested on a regular basis. On the day of the site visit these records evidenced that water temperatures in bedrooms on one corridor were too high. The registered manager told us that they had purchased thermostatic valves for these bedrooms but that they were waiting for the plumber to fit them. She said that none of the occupants of these rooms was able to access the washbasins and water without assistance from a member of staff. It was agreed that the registered manager would ask the plumber to complete this work by the 25th April 2008, and that she would undertake a risk assessment for each of these residents in the interim period to ensure that the risk of scalding is minimised. We received a telephone call from the registered manager the day after this site visit to inform us that the risk assessments had been completed, and a further telephone call on the 18th April 2008 to inform us that the thermostatic valves had been fitted. This was followed up with a letter of confirmation from the registered provider. Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Willerfoss House DS0000070926.V362228.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 23 Requirement Water temperatures at outlets accessible to residents should be at around 43°C, to control the risk of scalding. An immediate requirement notice was left at the home in respect of this breach of regulation. (We were informed that this work had been completed on 18/4/08). Timescale for action 25/04/08 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 OP3 OP9 Good Practice Recommendations A care plan for people having respite care should begin to be developed as soon as they are admitted to the home. The home should continue with plans to create a dedicated medication room. When this has been completed, the security of controlled drugs would be improved by fixing the container to the wall. All staff should undertake core training as soon as possible after their appointment, and then appropriate refresher training should take place on an on-going basis. DS0000070926.V362228.R01.S.doc Version 5.2 Page 27 3 OP30 Willerfoss House Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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