Inspection on 17/11/05 for Burley Willows Home For Older People

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burley Willows Home For Older... 08/11/07

Burley Willows Home For Older... 09/01/07

Burley Willows Home For Older... 02/11/04

Burley Willows Home For Older... 13/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Burley Willows Home For Older People Willow Garth Leeds LS4 2HL Lead Inspector Catherine Paling Unannounced Inspection 17th November 2005 09:15 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 Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 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. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burley Willows Home For Older People Address Willow Garth Leeds LS4 2HL 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) 0113 2456579 0113 2456579 Leeds City Council Department of Social Services Mrs Kathryn Louise Yeoman Mrs Colette Shekarchi-Khanghahi Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Burley Willows is a local authority home providing personal care for men and women over pensionable age. There are 30 permanent places including two places for respite care and five places for intermediate care. The home is single storey and there is level access throughout the building. Accommodation is in single rooms, all of which have their own washbasin. None of the rooms have en-suite facilities but the three bathrooms and two shower rooms have been recently upgraded and there are plenty of toilets throughout the building. There are six lounges, one of which is a designated smoking area, and all lounges have television and hi-fi units. There is level access to the enclosed gardens. The home is situated about two miles from Leeds City Centre and is close to many local amenities including shops, library, doctors and dentist. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was in June 2004. This was an unannounced inspection by one inspector who was at the home from 09.15 to 1500. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents and to assess progress on meeting any requirements or recommendations made at the last visit. The methods used at this inspection included looking at records; observing working practices; talking to staff and residents; and discussion with the managers. Comment cards were left at the home for residents and relatives inviting them to share their views of the home with the CSCI. Any comments received would be shared with the manager anonymously. What the service does well: What has improved since the last inspection? The home continues to operate at a good level and good standards of care are maintained. New carpets have been fitted to the corridors and there has been refurbishment of the kitchen. There are white boards in the various communal areas used to display information about activities and events at the home. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 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 Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The assessment processes do not guarantee that the needs of residents can be met. EVIDENCE: Pre-admission information provided to the home was in the form of the local authority care plan and the Easy care document. The information was not always detailed enough to be able to guarantee that the needs of the residents could be met at the home. A recommendation has been made. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. Care plans are poor and although health care needs are met the lack of detailed care plans provides the opportunity for care needs to be overlooked. Medication practices are safe. EVIDENCE: Permanent residents have individual plans of care in the form of a Lifestyle plan. The standard of recording is variable. There is some very good personal detail in some plans clearly indicating personal preferences about care needs. In addition this residents’ changing and deteriorating condition was well documented. Another lifestyle plan was not fully completed and provided no information about the day-to-day care needs of the resident. There was no falls risk assessment or nutritional risk assessment for this resident. There were regular reviews carried out involving the resident and family and there was update seen in the plans that was dated but not signed. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 10 In the case of a resident admitted for respite records indicated that care needs had not been re-assessed at each admission. There were some detailed risk assessments in place but no evidence to show that these had been reviewed at every admission. There were no risk assessments for falls or nutrition. The respite care plan had not been completed and there was little information about the day-to-day care needs of this resident. A respite feedback form had been completed following an admission in October providing update for the family and social worker about care needs. Some Lifestyle plans had been signed by residents, but this was not always the case. However, it was clear from discussion with staff and residents that staff did discuss care needs with the residents. Care staff were knowledgeable about the individual care needs of the residents who said that they felt well looked after by the staff. Records should provide evidence of the care provided. The medication room is a well-organised area also used by the district nurses. Staff receive training in the administration of medicines and are supported by policies and procedures. Some drugs stored in the fridge had not been dated on opening as indicated to make sure that they are not used after the expiry date. Staff should be reminded to do this. A record is kept of returns to pharmacy this was not always signed by the pharmacist. A requirement and recommendation has been made. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. A good, varied and nutritious diet is provided at the home. EVIDENCE: The planned refurbishment of the kitchen was almost complete. This has been very disruptive to the meal service, as the kitchen has been closed for longer than was planned. The normal meal service has now been resumed. The lunchtime meal was well served taking into account individual appetites. It looked and smelt appetising and residents said that they enjoyed the food. Residents are to be consulted about their favourite meals as part of a review of the menus. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Residents are protected from abuse. EVIDENCE: All staff have received training in adult protection. This was provided over two sessions by a member of the local authority adult protection team and had been very well received by staff. Procedures were available for staff to refer to if needed. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Overall, service users are provided with a safe and well-maintained environment. EVIDENCE: The smoking room remains in an unacceptable condition. The carpet has been removed revealing a wooden floor in a poor condition. The furniture has not been renewed and looks worn, uncomfortable and shabby. This is not a pleasant sitting area. It is in sharp contrast to the other lounge areas which are well decorated and homely. Only personal laundry is done on site. The laundry was clean and tidy with the equipment in working order. Hand washing facilities are provided throughout the building in the interests of the prevention of cross infection. The home was clean and odour free, overall providing a pleasant environment for residents. A requirement has been made. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28. The numbers and skill mix of staff were sufficient to meet the needs of the residents. The staff are trained and competent to do their jobs. EVIDENCE: Staffing levels are maintained at minimum levels. There continue to be some vacancies and long-term sickness. Care staff are covering additional shifts on overtime to maintain adequate staffing levels for both care duties and for ancillary support for the carers. Care staff continue to work towards National Vocational Qualifications in care at level 2. The 50 trained carers had been achieved but staff have left leaving the home currently just short of the target. There is a commitment to training and staff are knowledgeable about the needs of the residents Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The home is well managed and the managers are well able to discharge their responsibilities. They offer good leadership to the staff and ensure that the residents are protected and cared appropriately. EVIDENCE: Two experienced and capable managers share the role of the registered manager. Both managers have completed the Management Charter Initiative. They have both commenced ‘fast track’ National Vocational Training in management at level 4, with workshops held every two weeks. The managers are accessible to staff and residents who regularly call in at the office. All residents, relatives, staff and visiting healthcare professionals were surveyed in may this year. These audit results have been collated and made available on the notice board in the entrance area. The results were positive about the service at the home. It was clear from the results that there was a Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 16 lack of awareness about the CSCI. In response to this the manager has provided information about the CSCI, including the website address in the newsletter. A newsletter is produced regularly to provide information about changes at the home and such things as activities and events. Communication with residents and relatives is carried out informally and also at the regular care reviews held at the home. Information about the recent refurbishment of the kitchen was displayed on the notice board provided informally by the managers and also included in a newsletter. The home do not act as appointees for service users and do not handle service users money, other than a small amount of personal allowance for incidentals. Clear records are kept of any money kept with receipts of all transactions. These procedures are subject to regular in-house checks and external audit. Residents have lockable space within their rooms for the safe keeping of their valuables. All the senior staff have attended a course in managing safety run by the Institution of Occupational Safety and Health. Regular checks of the building are made to make sure that there is a safe environment for staff and residents. Mandatory training is provided to staff with regard to manual handling. In addition staff have access to expertise to assist them with particular handling issues when they arise. Records are kept of accidents involving residents. The detail recorded in the daily records was variable and the manager should make sure that staff consistently record the necessary detail about accidents to include the time a resident was last seen before an unwitnessed accident and how they have been recovered from the floor. The fire training provision is currently under review by the Provider. Fire drills are being carried out for the staff who work the day shift but there have not been any drills for the night staff this year. The home is fitted with a sprinkler system for fire protection providing a high level of protection in the event of a fire. A requirement has been made. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement The individual care records must provide detail and evidence of care. (previous timescale of 19/09/05 not met) The smoking lounge must be refurbished. The provider must make sure that all the night care staff take part in at least one fire drill in a twelve month period. Timescale for action 05/03/06 2 3 OP19 OP38 23(2)(d) 23(4)(e) 03/04/06 03/04/06 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 All residents should have their needs fully assessed prior to admission to the home. Staff should be reminded to date, on opening, those medicines with a limited shelf life. The medicine returns book should be signed by the pharmacist. The managers should make sure that the information DS0000033139.V264828.R01.S.doc Version 5.0 Page 19 3 OP38 Burley Willows Home For Older People recorded in the daily records is sufficiently detailed. Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Burley Willows Home For Older People DS0000033139.V264828.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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