Care Home: Willow Cottage

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What the care home does well Information made available about the home and pre-admission assessment processes will ensure that placement is only offered to those residents whose needs can be met. The people who live at Willow Cottage can be assured that their care needs will be met because of the care planning processes and the procedures for dealing with medications. The people who live in this home are able to participate in a range of different activities. Visitors are welcomed and interests outside of the home are supported. They are well fed with good quality home cooked meals. The people who live in this home can be assured that any concerns they have will be listened too and acted upon. They will be cared for by staff who are aware of safeguarding issues and of their responsibilities. Willow Cottage is well maintained and safe. It is comfortably furnished and nicely decorated and it contains sufficient equipment to meet the needs of the people who live here. The staff team are well trained, skilled and competent. This means that they will be able to meet the care needs of the people who live here. The people who live at Willow Cottage live in a safe place that is run in their best interests. What has improved since the last inspection? Only one requirement was issued following the last inspection and this was in respects of one part of the care documentation that was not being completed adequately. Since this time, a new home manager has been employed who has changed the procedures for recording this information. The new methods are being monitored to ensure they remain effective. This evidences that the home strive to meet any requirements made. What the care home could do better: It has not been necessary to issue any requirements following this inspection however it would good practice if the manager thought of a means of recording an overview of a persons nutritional and hydration status, when a person has been deemed "at risk". This is in addition to the way in which the home records fluid intake and output. CARE HOMES FOR OLDER PEOPLE Willow Cottage 127 Station Road Yate South Glos BS37 5AL Lead Inspector Vanessa Carter Unannounced Inspection 18th March 2008 09:00 18/03/08 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 Willow Cottage DS0000070991.V359998.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. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Cottage Address 127 Station Road Yate South Glos BS37 5AL 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) 01454 329133 01454 319112 Salix Care Ltd Mrs Jan Wilkins Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Willow Cottage DS0000070991.V359998.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 with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. 3. Old age, not falling within any other category (Code OP) The maximum number of service users who may be accommodated is 34. May accommodate 6 service users aged 50 years and over requiring nursing care. First Inspection of a newly registered service Date of last inspection Brief Description of the Service: Willow Cottage has been trading as a residential and nursing care home since 1991, but has recently been re-registered following a change in the legal status of the owners to a limited company. Mrs Roberts remains the owner of the home. Willow Cottage is a care home for up to 34 persons. It is a Georgian property situated in the centre of Yate, opposite the main shopping area. It is one of a group of two homes, the other being Firgrove. From the home there is easy access to the shops, the library and the health centre. Willow Cottage has retained many of its original features but has been extended to provide accommodation that is comfortable and homely. The accommodation is provided on three floors – bedrooms are both single and shared. The rooms on the top floor are for those people who do not require nursing care. There are several areas around the home that are used for communal purposes such as the lounges, dining room and the conservatory. Fee’s currently range from between £445-550 but will be £460-565 after the 6th April 2008. Willow Cottage DS0000070991.V359998.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 key inspection was unannounced and took place over one day. A total of 8.5 hours were spent in the home. Evidence to form the report has also been gathered from a number of other sources:• Information provided by the Home Manager in the Annual Quality Assurance Assessment (AQAA) • Talking with the Home Manager and the proprietor Mrs Roberts • Talking with some of the registered nurses, care staff and ancillary staff • Observations of staff practices and their interaction with the residents • A tour of the home • Case Tracking the care of a number of residents • Talking with a number of the residents • Talking with visitors to the home • Looking at some of the homes records • Information supplied by 9 residents and 15 relatives in CSCI survey forms • Information supplied by 2 GP’s and 1 other healthcare professional. What the service does well: Information made available about the home and pre-admission assessment processes will ensure that placement is only offered to those residents whose needs can be met. The people who live at Willow Cottage can be assured that their care needs will be met because of the care planning processes and the procedures for dealing with medications. The people who live in this home are able to participate in a range of different activities. Visitors are welcomed and interests outside of the home are supported. They are well fed with good quality home cooked meals. The people who live in this home can be assured that any concerns they have will be listened too and acted upon. They will be cared for by staff who are aware of safeguarding issues and of their responsibilities. Willow Cottage is well maintained and safe. It is comfortably furnished and nicely decorated and it contains sufficient equipment to meet the needs of the people who live here. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 6 The staff team are well trained, skilled and competent. This means that they will be able to meet the care needs of the people who live here. The people who live at Willow Cottage live in a safe place that is run in their best interests. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information made available about the home and pre-admission assessment processes will ensure that placement is only offered to those residents whose needs can be met. EVIDENCE: The Statement of Purpose for this service contains all the required information to enable readers to be able to judge what facilities and services the home has to offer. The home manager has very recently been registered by CSCI, and therefore her details will be added to the document in order to bring it up to date. In addition there is a brochure or service users guide – this will be given to anyone who makes enquiries about the home and is looking for a placement. All residents and relatives and people who completed CSCI survey forms said that they had received enough information about the home prior to make a decision about living here. Anyone who lives at Willow Cottage will be provided with a statement of terms and conditions or a contract, upon admission. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 9 Seven of the nine people who completed CSCI survey forms said they had received a contract. One person wrote “my daughter dealt with everything so I don’t know if I have a contract”. Evidence was shown of the most recent contracts that have been issued. Prior to any placement being offered to a new person, a ‘pre-admission assessment’ will have been undertaken. The manager and the deputy care manager visited the local hospital on the day of the inspection to see if they could meet the care and support needs for someone who now needs nursing care. An initial assessment form is completed that covers all aspects of care including mobility, healthcare needs, skin integrity, and dietary requirements. Where appropriate, care plans and healthcare assessments are gathered from social workers and healthcare workers in order to gain as much information as possible. These measures will ensure that placement is only offered to those people whose needs can be met People are encouraged to visit the home prior to moving to Willow Cottage. In most circumstances, it will be the relatives who have visited and made decision on that persons behalf. One person spoken with during the course of the inspection said “ my son took me around four nursing homes. When I came here it was so homely and friendly that I made the decision right away”. Visitors who had called at the home during the course of the inspection, were shown around and given information about the home. All new placements are made on an initial four-week trial basis with a review being held at the end of this time. This time can be extended if necessary. Records were viewed of one persons recent review meeting. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 10 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Willow Cottage can be assured that their care needs will be met because of the care planning processes and the procedures for dealing with medications. EVIDENCE: Care planning documentation for three residents was looked at in order to determine how the home identifies needs and then plans the support required. The plans for one person were still in the process of being prepared as they had only just moved in to the home, but assessments had been completed in respects of moving and handling, likelihood of falls, likelihood of pressure sore development and nutritional needs. The process of developing the care plans was underway but in no way complete. The care plans for the other two people were comprehensive, person centred and detailed the specific support required to meet their care needs. Personal preferences were recorded about times of getting up and retiring to bed and the plans evidenced a person centred approach to organising the care delivery arrangements. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 11 Those people who completed CSCI survey forms said that they always or usually received the care and support that they needed. One person spoken with said “everything is fine, and staff do the things that I need help with”. Healthcare monitoring includes regular observations of body weight, urine samples, pulse rate and blood pressure, temperature and where appropriate blood glucose levels for diabetics. Some staff members are able to take blood samples for analysis when instructed by the GP. Wound care planning documentation includes monitoring processes to ensure that the treatment is being effective. Photography and wound evaluation are the measures used to evidence this. A requirement was made following the last inspection, in respects of documentation concerning positional changes for those people who are at risk of pressure sore formation. The new manager has dispensed with the ‘form’ and staff must now record all positional changes in the log of daily care. This was verified when checking records and also in observations made of peoples care whilst visiting the home. This method is also used to record fluid intake and output, but there does not appear to be procedures in place to keep an overview of the hydration and nutritional status of those people who may be deemed ‘at risk’. Whilst the manager explained that this was not currently the case with any person, it would be good practice for them to decide in the meantime how they will achieve this. There was generally a good standard of detailed recordings in the daily notes, evidencing the care provided, any significant events and the involvement of other healthcare visitors. A record is kept of GP visits. Two GP’s returned comment cards to CSCI and both said that they were satisfied with the overall care provided to people who live in the home. Both said that the staff team had a clear understanding of the peoples individual needs and that any advice they gave was acted upon. Medication systems were discussed with one registered nurse and the manager. There have been no changes to the systems followed since the last inspection although an additional medication trolley has been purchased, to improve storage. The procedures in place for the ordering, receipt, storage, administration and disposal of medications are sound. Oxygen signs are displayed to identify the location of oxygen cylinders or concentrator machines. GP’s will review each person’s medications on a regular basis. “My relative is very well looked after and they respect her dignity” was one comment made by a relative in a CSCI survey form, whilst another said “I would recommend this home to anyone”. Those people who were spoken to during the inspection said “I am very looked after, the staff are my friends” and “I love the friendly and caring staff”. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 12 Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home are able to participate in a range of different activities. Visitors are welcomed and interests outside of the home are supported. They are well fed with good quality home cooked meals. EVIDENCE: The home is currently without an activities organiser and therefore the care staff are leading the social activities with those that wish to participate. During the morning of the inspection, a number of residents were taking part in a game of quoits. One person said “I am not very good but it gets me moving my arms about”. Examples of other things arranged include film shows, quizzes, outside entertainers and visits by the hairdresser. One person said “I take part in some things but really I like to stay in my own room and read my newspaper”. A number of people said that when their relatives visit they like to go over to the shopping centre and have refreshments or look around the shops. One other person said “I like to sit by my window reading my books and watching the world go by. I am on top of the world”. There was a great deal of banter and respectful familiarity noted between people who live there and visitors, and staff members, evidencing that the home is a very friendly place. Comments made on both relative and resident survey forms included the need for more trips and outings. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 14 It has already been recognised that more could be done in this area and the manager is exploring arrangements for each person, where appropriate, to have a travel pass. This would mean that more outings could be arranged. Seasonal events are arranged, such as a summer party, bonfire evening, Christmas and Easter parties. Friends and family are always invited to join in the celebrations – a newsletter is sent out to inform everyone about forthcoming events Visitors are welcomed at any reasonable time and good relations are forged to ensure that there is an open and honest means of communication. There is plenty of evidence to show that the people who live here are offered a choice in how they spend their time and what they have to eat. Personal preferences are recorded in the care planning documentation so that staff are aware of each persons likes and dislikes. Very positive comments were received about the quality of the meals. Choices are available each meal-time and snacks and drinks are available throughout the day and night. Traditional “home-cooked” meals are provided – “the food is always good” and “we get lots of choice throughout the week. There is always something that I like” were just two comments made following the midday meal. The environmental health officer visited the home in January 2008 and award 5* to the catering services – the kitchen staff should be commended for this. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home can be assured that any concerns they have will be listened too and acted upon. They will be cared for by staff who are aware of safeguarding issues and of their responsibilities. EVIDENCE: A copy of the complaints procedure is displayed on the wall in the main foyer by the front door. It was noted at the last inspection that the procedure was not displayed here and although a good practice recommendation was not made, the comment has been acted upon. The complaints procedure is also included in the homes brochure and service users guide. It contains all the necessary information about the processes that would be followed if concerns were raised, and information about how to contact the Commission for Social Care Inspection. Those people who were spoken with during the course of the inspection, were full of praise for the staff team and said they were well looked after. All the relatives and people who live at the home, who completed CSCI survey forms, said that they knew about the home’s complaints procedure. One person wrote “concerns I have had have been dealt with”. One relative wrote “the staff are always willing to listen about how we feel and do their very best at all times”. CSCI have received no concerns or complaints about this service, and the home have only dealt with one complaint in the last 12 months. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 16 There is policy regarding the protection of vulnerable adults (POVA), this was not looked at during this inspection, but has previously been regarded as meeting the required standard. New staff will always be recruited following robust vetting procedures and staff training includes sessions on abuse awareness. All those staff spoken to during the course of the inspection demonstrated a good awareness of adult abuse matters and of their responsibilities towards protecting the people who live there, from coming to any harm. People spoken with during the inspection said that they were safe and “everyone is very kind and considerate”. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Willow Cottage is well maintained and safe. It is comfortably furnished and nicely decorated and it contains sufficient equipment to meet the needs of the people who live here. EVIDENCE: Willow Cottage is a Georgian property situated in the centre of Yate opposite the main shopping area. It is able to accommodate up to 34 people in either single or shared rooms. From the home there is easy access to the shops, the library and the health centre. The home has retained many of its original features but has been extended to provide accommodation that is both comfortable and homely. The accommodation is provided over three floors. The rooms on the top floor are for those people who do not require nursing care. There are private gardens to the rear of the property, and visible from the main lounge and conservatory area. There is a large patio area with garden furniture and raised “wheelchair friendly” planters have been positioned, since the last inspection – these were done by the local school. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 18 There are several areas around the home that are used for communal purposes such as the lounges, dining room and the conservatory. The front door into the home leads into a large hallway, and this is also used by some of the residents, as a place to sit. The hallways and stairs have recently been relaid with a new specialist flooring – this change has provided a fresh and easily cleanable surface, that is more suitable for moving hoisting equipment across. Toilets and bathrooms in sufficient numbers are located throughout the home. One bathroom is in the process of being converted into a wet room with level access shower fittings, and consideration is being given to doing the same in the ground floor shower room. Some of the baths are fitted with bath seats whilst others can be used with a mobile hoist and sling. There are two shaft lifts installed and all areas of the home are fully accessible. In some parts of the home, steps have been replaced with sloping ramps. Additional works are planned to change the steps between the old and new parts of the house on the first floor. This would improve the accessibility for residents and staff into one of the bathrooms. Dorguards have been fitted to all bedroom doors so that they can be left open if residents wish – they are linked to the fire system and the doors will close if the fire alarm is activated. A new nurse call bell system has been installed in all bedrooms and communal areas. The home has a number of stand-aids and hoists to assist with moving and handling tasks. There are a number of bedrooms that are shared by two people. Screening is in place so that privacy can be provided when personal care is being administered. Two rooms have en-suite facilities. New soft furnishings have been provided for a number of rooms, but all rooms were homely and cheerful. All rooms were seen during the inspection, were clean and tidy, and comfortably furnished. All of the beds are ‘hospital type’. The comfortable seating provided for one person, in their bedroom was not appropriate for the persons needs, but this was attended to during the course of the inspection. The people who live here are encouraged to personalise their rooms with family photographs, pictures and small items of furniture. The home is centrally heated and well lit with domestic style light fittings. “We like to have pretty things for the people who live here to look at” was the proprietor comment, when asked about the lovely lampshades. Each bedroom has an opening window, and radiator covers have been installed throughout the home. Infection control measures are sound. New sluice room equipment has been installed and new hand towel and soap dispensers have been located in each bedroom, to improve hand-washing facilities. The laundry room is equipped with machines that are able to meet disinfection standards. The home was clean and tidy throughout and there were no unpleasant odours. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are well trained, skilled and competent. This means that they will be able to meet the care needs of the people who live here. EVIDENCE: Staffing levels are arranged according to the care needs of the people who live in the home. The home currently has 25 people in residence, out of a possible 34 and six of these do not require nursing care. In addition, a number of these people are currently in hospital. Staffing levels on the day of inspection were six care staff in the morning and five in the afternoon. There is always one registered nurse on duty. The manager explained that currently there are only two staff vacancies (one care assistant and one cook) and that as from April, the shift patterns for care staff will be changing. The reason for this is to have staff covering an 11-5pm shift and provide better cover at tea-time. The care staff are supported by catering, housekeeping, maintenance and administrative staff in meeting all the daily living needs of the people who live there. Willow Cottage is committed to an NVQ programme of Level 2 training for care staff and has achieved a 63 ratio of staff who have either already obtained the award of are working towards it. The staff files of two members of staff who have joined the team since the last inspection were looked at to determine what processes the homes follows to make sure it employs the right staff. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 20 Both had completed an application form, had been provided with two satisfactory written references, and had had POVA1st and CRB checks completed prior to employment starting. These are effective measures in safeguarding the people who live in the home from being cared for by unsuitable employee’s. All new staff will complete an induction-training programme at the start of their employment and will be allocated a mentor to look after them and teach them about the job. As part of this programme, fire awareness and manual handling training will be undertaken – new staff are not allowed to use hoisting equipment until they have had the training. The training matrix shows what training each staff member has received. All staff bar a few are up to date on fire safety. Examples of other training sessions attended include health & safety, first aid, skin care and continence care and medication management. Several of the staff team attended the planned PEG feed training that was held at the home on the day of the inspection. Staff reported that the training opportunities were good and that there was always some training being planned. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 21 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, 36, 37 and 38, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Willow Cottage live in a safe place that is run in their best interests. EVIDENCE: The new home manager, Jan Wilkins was appointed in November 2007 and her registration with the Commission for Social Care Inspection was completed in February 2008. She is a registered nurse, has been working for many years in the care sector, and will be signed up to start the registered managers award (management training) in the near future. She participated in the inspection process and demonstrated her competence and abilities. An annual survey is completed each year and captures the views and opinions of the people who live there and their families. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 22 Regular visits to monitor the service are completed by Mrs Roberts the proprietor and a report written and submitted to the Commission. Monthly care plan reviews are completed with these regularly being undertaken with the family too. One person who was visiting their relative confirmed this. The home manager and the proprietor have a management meeting on a monthly basis. These measures ensure that the home is run in the best interests of the people who live there and that any improvements needed are discussed and planned for. The home does not look after personal monies for any one however have procedures in place to be able to purchase requirements on their behalf and invoice for payment. Staff are supervised regularly on an informal and formal basis. The responsibility for supervision is shared between the home manager and the registered nurses. Staff confirmed that they have supervision regularly and that the manager is available at any time to answer questions or provide advice. It is very apparent that the staff team work well together and support each other in meeting the care needs of the people who live there. All of the home records that were looked at were in good order, easily made available for inspection and kept secure in the manager’s office. All the necessary maintenance contracts were up to date and the home is well maintained throughout. No health & safety issues were noted during the course of this inspection Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 24 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. 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 OP8 Good Practice Recommendations Where there are concerns regarding the hydration and nutritional status of a person deemed “at risk”, a method for monitoring an overview of the situation must be kept, and records kept accordingly. Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. Extracts may not be used or reproduced without the express permission of CSCI Willow Cottage DS0000070991.V359998.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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