Inspection on 09/01/07 for Burley Willows Home For Older People

This inspection was carried out on 9th January 2007.

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... 17/11/05

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 Key Unannounced Inspection 9th January 2007 09:30 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.V322778.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. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 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 Collette Noelle 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.V322778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 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. Information about the service is available in a Statement of Purpose and Service User Guide. These documents are reviewed regularly to make sure that the information is up to date. The fees range from £70.85 to £ 458.86 per week. There are additional charges for hairdressing and newspapers. This information was provided by the service on the pre-inspection questionnaire completed in December 2006. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and one inspector was at the home from 09.30 until 16.15 on 9th January 2007. There is a job share arrangement in place with two registered managers at the home. Mrs Yeoman was available to assist during the inspection. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by residents were visited. A good proportion of time was spent talking with residents as well as with the manager and her staff. A pre-inspection questionnaire (PIQ) had been completed before the visit to provide additional information about the home. Some survey forms were left at the home providing the opportunity for residents and/or visitors to comment on the home, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. What the service does well: There is a lively and busy atmosphere at the home. The home is very welcoming and visitors are welcome at any time. Staff and residents have a good rapport. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 6 There is a stable staff team, which is supported by the managers who are committed to making sure that the residents enjoy a good quality of life at the home. There are very good working relationships with other healthcare professionals and the staff are described as ‘competent and caring’. A comment card from a healthcare professional visiting the home stated that staff ‘treat the residents with great respect and there is an obvious affection between staff and residents’. 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. Burley Willows Home For Older People DS0000033139.V322778.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 Burley Willows Home For Older People DS0000033139.V322778.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, 3, 4 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have access to enough information to help them make a decision about moving into the home. Pre-admission information is gathered together before residents move into the home. Residents’ needs are met at the home by well-informed and knowledgeable care staff. EVIDENCE: There is a whole range of information available to current and prospective residents. There is a brochure as well as a statement of purpose and service user guide. The statement of purpose and service user guide is reviewed on a monthly basis by the managers to make sure that the information is accurate. Copies of these documents are available around the home and copies can be provided if necessary. Prospective residents and/or their representatives are Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 9 welcome to visit the home to help them make a decision. On the day of this visit a member of staff was showing around a prospective resident. Detailed information about residents is gathered prior to admission. This includes the local authority EASYcare document as well as other detailed information from other professionals. The manager and her staff are very knowledgeable about the residents and their specific needs. There are just two beds currently for intermediate care clients and one of these was occupied at the time of this visit. Staff at the home have the support of the intermediate care team in caring for these clients, which includes nurses, physiotherapists and occupational therapists. Burley Willows Home For Older People DS0000033139.V322778.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 adequate. This judgement has been made using available evidence including a visit to this service. Health care needs are met but the lack of detailed care plans provides the opportunity for care needs to be overlooked. Medication practices are safe. The staff respect the privacy and dignity of residents. EVIDENCE: The case records of four residents at the home were looked at in detail. Permanent residents have individual plans of care in the form of a Lifestyle plan. The standard of recording information about the residents on these documents was variable. There is some very good personal detail in some plans clearly indicating personal preferences about care needs and how these can be met. The information was brief and incomplete in others. It was not clear who had Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 11 recorded the information or made additions to the plans. Entries were not always clearly dated. Summaries of the lifestyle plans were seen in some records, which had been completed monthly. These included very brief information and were not useful documents. Nutritional risk assessments were seen but had not been completed in every case. Where risk had been identified a specific and clear care plan on how to address the risk had not resulted, although the appropriate action had been taken and was documented elsewhere in the records. There were regular reviews carried out involving the resident and family and action taken on any issues arising from these. Support and guidance is also sought from other healthcare professionals when necessary. There were clear records of the involvement of other healthcare professionals. General Practitioner (GP) visits in particular were very well documented and in conjunction with daily records gave a clear picture of the condition of a resident who was unwell. In other cases daily records were not quite so informative. One GP carries out weekly visits to the home and there is clearly a wellestablished and effective working relationship with the home. The GP continues to speak highly of the staff and the care provided at the home, describing the staff as ‘competent and caring with a close individual knowledge of residents’. 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 need to provide clear evidence of the good care provided. The medication room is a well-organised area. There were a small number of drug administration errors last year all of which were dealt with appropriately by the provider. Staff training in the administration of medicines is ongoing and they are also supported by policies and procedures. The drug administration system was changed in early 2006 and training was provided to staff by the pharmacist on the new system. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 12 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. Residents are able to exercise choice in their daily routines and overall their social expectations are met. Residents are provided with a varied and nutritious diet that they have chosen. EVIDENCE: This is a very busy and lively home with several residents going out to attend day centres on a regular basis, going out with friends and for other outings. On the day of the visit preparations were underway for the 100th birthday celebrations for one of the residents on the following day. Visitors are made welcome at the home throughout the day and refreshments are available for them. All the residents spoken with said that they could exercise choice in their daily routine with support from the staff; one had enjoyed a lie in that morning. One resident who came to the home for regular respite care said she always looked forward to coming into the home for her two week stay. There is a Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 13 regular weekly programme of activities, details of which are displayed throughout the home. Residents were consulted during 2006 about the food provision. Their views have been taken into account in the menu planning and there is a good choice of food available at all mealtimes. Residents spoke well of the food, saying that they were also able to ask for items not on the menu. Residents take their meals in the small dining areas situated in the different areas of the home. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 14 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, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents felt confident that their concerns would be listened to and knew how to make a complaint. Residents are protected from abuse. EVIDENCE: Residents were not necessarily aware of the complaints procedure but felt confident that they could tell the manager about any concerns and they would be taken seriously. All spoken with felt safe and well cared for at the home. Staff have received training with regard to adult protection and there is a whistle blowing procedure in place. There is a comprehensive complaints procedure available at the home and a simple log of complaints is kept. One complaint was received in June 2006 by the CSCI that was forwarded to the provider to investigate. There was a good investigation and the manager completed a detailed and fully appropriate response. Residents are assisted to exercise their right to vote and are registered for postal votes. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained environment. EVIDENCE: All areas of the home which were visited during the visit were clean, tidy and in a good state of repair. Bedrooms were comfortable and inviting having been personalised by residents. There was evidence of ongoing refurbishment of some areas. The smoking room has been redecorated and the furniture and fitting replaced. This is now a much more attractive and comfortable area. The laundry area was clean and tidy, only personal laundry is done on-site. Hand washing facilities are provided throughout the building in the interests of the prevention of cross infection. There have been several minor outbreaks Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 16 over the last year, all of which have been notified to the Environmental Health Department and the appropriate action taken. Staff have received training infection control. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 17 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 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. Recruitment procedures protect service users. EVIDENCE: Duty rotas indicated that there were sufficient staff available to meet the needs of the residents. The care staff are also supported by a team of ancillary staff carrying out domestic, laundry and catering duties. The manager said that a proposal for an additional member of staff on the late shift has been agreed and recruitment is underway. There has been little staff turnover since the last inspection and the stability of the staff team means there is continuity and familiarity for the residents. There has been very good progress in staff achievement of National Vocational Qualifications (NVQ) in care at the home. 80 of the care staff have achieved NVQ level 2 in care, far exceeding the standard of 50 . In addition, one member of staff hopes to complete an NVQ in care at level 3 later this year. Domestic staff have also achieved NVQ level 1 in cleaning and domestic service. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 18 New staff undergo an induction programme and all staff have formal supervision sessions and appraisal where training needs are identified. There is also a variety of other training in such topics as dementia, nutrition and care of the dying made available to staff. There is a clear commitment towards training and making sure that all designations of staff are equipped to carry out their roles and to care effectively for the residents. Recruitment is carried out centrally and records held at the home are photocopies. There was evidence that the required checks are carried out before staff commence work at the home. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the managers are well able to discharge their responsibilities. They provide good leadership to the staff and ensure that the residents are protected and cared for appropriately. EVIDENCE: There are two experienced and capable managers who ‘job share’ the position of registered manager. This is an effective arrangement and they provide clear leadership and stability at the home. Both managers have completed the Management Charter Initiative. They have now completed the NVQ in care at level 4. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 20 All residents, relatives, staff and visiting healthcare professionals were surveyed in May 2006. Overall the results provided positive feedback about the service provided. The results have been made available to all interested parties. A newsletter is produced regularly to provide information about changes at the home and such things as activities and events. Copies of the newsletter are available by the signing in book. There is also a large notice board in the entrance area where a whole range of useful information about the service is displayed. Communication with residents and relatives is carried out informally with the managers operating an ‘open door’ policy. Regular in house care reviews are also held providing the opportunity for residents and their representatives to share any concerns they might have about care or the facilities. Staff meetings are held three monthly, a meeting was already arranged for the week following the inspection visit. Notes are kept of the meetings. 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 a 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. Some ceiling tracking has been provided to assist the staff in the safe moving of residents. Records are kept of accidents involving residents and accident reports are held on the individual files. Training has been provided for staff to provide in-house fire wardens. The home is fitted with a sprinkler system for fire protection providing a high level of protection in the event of a fire. Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 21 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 X 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 22 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 records must consistently provide detail and evidence of care. Care plans must be in place and contain detailed instructions on how to meet the needs of the residents. The care plan must be reviewed and updated if needed on a monthly basis. Previous timescale of 19/09/05 not met. Timescale for action 11/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Burley Willows Home For Older People DS0000033139.V322778.R01.S.doc Version 5.2 Page 24 - 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. 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