Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 15/09/05 for The Withins Residential Home

Also see our care home review for The Withins Residential Home for more information

This inspection was carried out on 15th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All residents spoken to like their accommodation and the cleanliness of the home. Staff members consulted clearly had a caring attitude towards the residents and said that they are provided with the training that they need. The activities available are enjoyed by residents and the activities organiser is enthusiastic in her approach. Suitable fire checks take place regularly to help ensure a safe environment.

What has improved since the last inspection?

Some staff have received training in dementia care. The home continues to have residents` meetings to give them an opportunity to air their views. At this inspection, a visiting district nurse was consulted and felt that there is good care and communication at the home.

CARE HOMES FOR OLDER PEOPLE Withins Residential Home 38-40 Withins Lane Breightmet Bolton BL2 5DZ Lead Inspector Rukhsana Yates Unannounced 15 September 2005 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 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. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Withins Residential Home Address 38-40 Withins Lane Breightmet Bolton Lancashire BL2 5DZ 01204 362626 01204 381240 withinsresthome@aol.com Withins (Breightmet) Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Janet Carr CRH Care Home 65 Category(ies) of OP Old Age : 65 Places registration, with number of places Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 65 service users, to include: Up to 65 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 01 February 2005 Brief Description of the Service: The Withins is a large, purpose built, private residential home providing personal care and accommodation for up to 65 older people. The home is privately owned and registered under the company name of Withins (Breightmet) Limited. The home is located in a residential area in Breightmet, about 2 miles from the centre of Bolton and may be reached by public transport. There are shops, pubs and other amenities nearby. Accommodation is provided on three floors and there is good wheelchair access throughout the home. All bedrooms are single and have en-suite facilities. There is a passenger lift. Garden and patio areas are well maintained and accessible to residents. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 9 hours, to include an evening visit. Discussions took place with 8 residents, a relative, a district nurse, 5 staff members and the manager. Some time was spent watching the manner in which staff supported residents. Care plans, staff records and other paperwork relating to the care and safety of residents were also examined. What the service does well: What has improved since the last inspection? What they could do better: Areas for improvement include the availability of an inspection report for visitors, a detailed audit of accidents, the safe use of bed rails for those who need them, a change to the main meal time, and a review of staffing arrangements. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 6 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. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 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 standard(s) 1 and 3 Each person considering moving to The Withins has their needs assessed, and is given information about the home, before admission. The latest inspection report needs to be readily available for visitors to peruse. EVIDENCE: Standard 6 is not applicable and therefore not assessed. The home has a statement of purpose and service users’ guide containing the range of information required. The user guide contains a copy of the contract for the provision of services and facilities to be provided, and a copy is supplied to each resident and / or their representative. The latest inspection report needs to be readily available for visitors to access and read. Displaying this in the entrance would ensure access without visitors having to ask for it, and would also provide visitors with the contact details of the Commission for Social Care Inspection in the event that they wanted to pass on a compliment or concern. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 9 The admission process ensures that community care assessments are in place for those placed by the Local Authority, and pre-admission assessments were included in the care files. The manager or a senior staff member would carry out an assessment following referral to assess the home’s ability to meet each prospective resident’s needs. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 Each person’s personal, social and general health needs are reflected in their care plan and regularly reviewed. Issues relating to falls, and risks at bedtime, need close monitoring and review to ensure these are appropriately addressed. EVIDENCE: Care plans seen contained assessments of need in a range of areas. The care plans are reviewed monthly and the plan rewritten if necessary. Records of weights and visits from health professionals are included in care files. The visiting district nurse felt that there is good communication and cooperation between the home and the district nursing service. All accidents are recorded and notified appropriately. In order to demonstrate the risk assessments are comprehensive, and that measures are in place to minimise risk through staff supervision of residents, there is a need to analyse accident occurrences and records. Accident records must have the full name of the resident concerned. Analysis should cover factors such as frequency, location, whether the nurse call was used, whether the accident was witnessed and by whom. This will enable the manager to better identify and address the areas requiring attention, such as an increase in staffing levels at certain times in certain areas for example. Residents consulted felt that the care provided at Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 11 the home was reasonable at times, but that their perception that there are not enough staff on duty is covered in the section on staffing. A concern discussed with the manager during the inspection concerns the risk of injury to some residents should they fall out of bed. The current guidance in Bolton suggests that bedrails should not be used unless a person has a nursing need. Some residents have a mattress pushed against the bed kept in place with chairs in order to create a barrier to falling out. The manager is awaiting guidance in terms of a solution as she recognises that the method being used is not satisfactory. Suitable beds with suitable rails must be in place for those assessed as in need of them. Propped mattresses are not acceptable, and therefore the registered person must refer residents affected for a review of their needs as a matter of urgency. The home has an obligation to ensure that only residents whose needs the home can meet, and whose risks the home can manage are accommodated. A Pharmacist inspection is due to take place at the home. The findings of this will be reported upon separately. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Residents enjoy activities offered at the home, the number of which should increase when one activity organiser post has been filled. Residents enjoy their meals but there is a need to review the timing of the main meal to satisfy residents’ clearly expressed choice. EVIDENCE: At present, one activities organiser is employed over 5 days a week and there is a vacancy for another organiser to cover 3 days a week. The activities organiser was consulted briefly during the inspection. She was enthusiastic and had a good rapport with residents. On this day, some residents enjoyed gentle exercise in the morning and sewing in the afternoon. In between communal activities, the activities organiser spent some of her time with individual residents who chose to stay in their rooms. In respect of meals, residents consulted were complimentary. One said “we get a choice and the meals are good. I like the meals here”. It was clear that the choice of rising times meant that some residents were having a late breakfast and this is good practice. However, the main meal is served at lunchtime, and some residents struggled to manage a big meal after a late breakfast, and said they would prefer their main meal at teatime. This preference is also reflected in the minutes of a residents’ meeting in January 2005. The minutes state “Residents felt that they could not eat the main meal at lunch time as they felt Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 13 full from breakfast. We have now moved the main meal to tea time. At lunch time the residents will have a light lunch; the residents prefer this change.” The manager said that the change was made, but that it created organisation problems for the kitchen, so arrangements had been changed back. Residents want their main meal at teatime and this has been clearly expressed. The home must, therefore, ensure that organisational arrangements are made to manage this change successfully. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents and relatives are provided with information about the complaints procedure, and concerns reported have been investigated by the manager. Some written guidelines and staff training are in place to help ensure the protection of residents from abuse. Current inter-agency guidelines and training are needed so that the correct action is taken should protection issues arise. EVIDENCE: The complaints procedure is included in the service users’ guide. A record of complaints, their investigation and outcome , is maintained. Staff at the home have attended a training course on the subject of abuse and protection, and the home has a policy in place. However, the procedure needs to be consistent with the Bolton Metro Vulnerable Adults multi-agency policy and procedure. Training on this procedure is offered by Bolton Social Services. The manager was advised that she and the staff must apply to attend this training as Bolton Metro guidelines have to be followed whenever an allegation is made. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The environment in which residents live is generally safe, well maintained, clean and hygienic. EVIDENCE: The Withins maintains good physical standards and is suitable for purpose. Carpets, furniture and furnishings are of an acceptable quality throughout. The grounds are safe and accessible to residents. The fire precautions record was up to date and a fire risk assessment survey has recently been carried out. Residents were happy with their bedrooms. All bedrooms are single with ensuite facilities, and measure at least 12 square metres. The home was clean and hygienic. Issues relating to safety and bed rail use is covered under standard 8. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The comments made by residents consulted suggest a need to review staffing levels to ensure they are suitable to meet needs. EVIDENCE: The home aims to meet needs by providing a staffing ratio of 1 carer for 8 residents during the day, resulting in 8 or 9 care staff on duty, in addition to the registered manager and administrator. There are usually 7 or 8 care staff on duty in the evening, and 4 carers on duty during the night. The residents consulted said that they liked most of the staff but felt there are not enough of them. One said “they’re always rushing you” and another said that in the evening especially, there is nobody to assist them to the toilet when they need it. On occasions where a resident has to go to hospital, and a member of staff accompanies the resident, this can create great pressure on the existing staff. In addition, the length of time needed to carry out the medication round impacts on the staff time available to provide direct care to residents. In terms of recruitment, the manager stated that the home is “constantly recruiting” and staff comments suggested pressure to work long hours and switch shifts on demand has led to a relatively high staff turnover. The registered person should review staffing levels needed, taking account of the dependency levels of residents and layout of the building. Staffing will be reassessed during the course of an additional visit. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Management standards were not assessed during this inspection. EVIDENCE: Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x x Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 19 No Are there any outstanding requirements from the last inspection? 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 8 Regulation 12 Requirement There is a need to analyse accident occurrences and records. Accident records must have the full name of the resident concerned. Analysis should cover factors such as frequency, location, whether the nurse call was used, whether the accident was witnessed and by whom. Suitable beds with suitable rails must be in place for those assessed as in need of them. Propped mattresses are not acceptable, and therefore the registered person must refer residents affected for a review of their needs as a matter of urgency. Residents want their main meal at teatime and this has been clearly expressed. The home must, therefore, ensure that organisational arrangements are made to manage this change successfully. Current inter-agency protection guidelines must be obtained and training applied for so that the correct action is taken should protection issues arise. Timescale for action 1 December 2005 2. 8 12, 13 20 October 2005 3. 15 16 1 December 2005 4. 18 13 1 December 2005 Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 20 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 1 27 Good Practice Recommendations The latest inspection report should be readily accessible for visitors to access. The registered person should review staffing levels needed, taking account of the dependency levels of residents and layout of the building. Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich Bolton BL6 6HG 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 Withins Residential Home F56 F06 S9310 The Withins V231001 150905 Stage 4.doc Version 1.40 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!