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Inspection on 30/01/06 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 30th January 2006.

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, the cleanliness of the home, and commented on the helpfulness of the care staff. Staff members consulted reported good teamwork, training and management support. The activities available are enjoyed by residents and the activities organiser is enthusiastic in her approach. She listens to residents` suggestions and organises outings that she knows they will enjoy. There are regular checks in place to make sure the environment is safe at all times.

What has improved since the last inspection?

The home has made good progress in meeting the requirements and recommendations made at the last inspection. Staff members reported better morale amongst the staff team, and this had resulted in better teamwork and a more relaxed atmosphere.

CARE HOMES FOR OLDER PEOPLE Withins Residential Home 38-40 Withins Lane Breightmet Bolton Lancashire BL2 5DZ Lead Inspector Rukhsana Yates Unannounced Inspection 30th January 2006 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 Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 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. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Withins Residential Home Address 38-40 Withins Lane Breightmet Bolton Lancashire BL2 5DZ 01204 362626 01204 381240 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) Withins (Breightmet) Limited Mrs Janet Carr Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. 15th September 2005 Date of last inspection 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 DS0000009310.V280860.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out by two inspectors over the course of 6 hours. During the inspection, discussions took place with five residents, two visitors and four members of staff. The inspectors observed the way in which staff assisted residents, and looked at care records to make sure they were accurate, clear and up to date. Staff files were examined to see if suitable recruitment checks and training were in place. What the service does well: What has improved since the last inspection? What they could do better: Areas the home should now address include better checks on staff before they start working. Results of the questionnaires about the quality of the service should be put together and shared with residents and relatives to show that the home is always looking at ways to improve. The manager said that another hoist was going to be bought for the home to better meet residents’ needs. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 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 DS0000009310.V280860.R01.S.doc Version 5.1 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 Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 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 Each person considering moving to The Withins has their needs assessed, and is given information about the home, before admission. EVIDENCE: 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. The file of a resident new to the home contained an initial assessment, summary care plan, information relating to social interests and family history, and risk assessments. Standard 6 is not applicable to this home. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 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, 8 and 10 Each person’s personal, social and general health needs are reflected in their care plan and regularly reviewed. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans seen were well organised and contained assessments of need in a range of areas. The areas of need covered include personal care, mobility, spiritual needs, diet, dependency, health needs and risk. It was evident that care plans are reviewed monthly and the plan rewritten if necessary. Records of weights and visits from health professionals are included in care files. Residents and relatives consulted felt that staff attitudes are good and that care staff are respectful and polite. Staff members were able to give several examples of the ways in which they promote residents’ privacy and dignity. For example, always knocking on bedroom doors before entering, providing assistance with personal care in a discreet manner, and respecting residents’ choices in their daily routines. One resident said “they’re friendly and very helpful” and a relative commented on a better teamwork and consistency of staff since the last inspection, resulting in an improved atmosphere for residents. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 10 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): 13 and 14 Service users feel they have flexible daily routines, are enabled to exercise choice, and helped to maintain links with family and friends. EVIDENCE: Residents said they have a choice in their daily routines, including what time they get up and go to bed. They also make decisions about where to spend their time during the day. The home has open visiting arrangements, and visitors described a welcoming atmosphere and helpful staff. Church services take place in the home for those who choose to attend and the manager stated that staff would support residents who wished to attend church. There are regular residents’ meetings where topics discussed include activities and outings. The minutes of the most recent meeting were displayed and showed that residents’ requests were recorded. The meeting is also attended by the activities coordinator who arranges for trips to take place, as evidenced by the planned timetable of activities. These include trips to Bury Market, Rivington Barn, a garden centre, and a Rivington tour followed by a pub lunch. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 11 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): 16 and 18 Residents and relatives are provided with information about the complaints procedure and concerns are investigated by the manager. Some written guidelines and staff training are in place to help ensure the protection of residents from abuse. Familiarity with current inter-agency guidelines will help to ensure that the correct action is taken should protection issues arise. EVIDENCE: The complaints procedure is included in the service users’ guide and is also displayed in the entrance to the home. A record of complaints, their investigation and outcome, is maintained. There have been no complaints received since the last inspection. Some staff at the home have attended training on the subject of abuse and protection, and the home has a policy in place. Staff members interviewed said that they would always report incidents to management, and they understood their responsibilities in terms of whistle-blowing. The manager stated that attempts are being made to book staff on training with the social services department, but places are limited. It is recommended that, in the meantime, the home obtains a copy of the Bolton Metro Vulnerable Adults multi-agency policy and procedure, the contents of which should be discussed in team meetings and during supervision. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 12 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): These standards were not assessed during this inspection. EVIDENCE: These standards were not assessed during this inspection. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 13 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): 28, 29 and 30 Staff training arrangements ensure that care staff have the knowledge and skills they need to carry out their roles. Recruitment procedures need some improvement so that they are robust and promote residents’ safety. EVIDENCE: Currently, of 35 care staff, 16 have achieved the NVQ qualification at level 2 or above. Records show that there is an ongoing training programme that aims to ensure mandatory training is updated at the required intervals. Staff interviewed said that they discuss their training needs with the manager and were satisfied with the training opportunities provided. The manager was advised to obtain the Skills for Care induction standards and to use them for new staff. Examination of three staff files highlighted a need to improve recruitment procedures, particularly in terms of background checks. The home needs to take up a POVA listing check and CRB check in respect of any new staff commencing employment at the home. Gaps in employment history must be explored, and staff should sign a declaration that states they are physically and mentally fit to carry out their role Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 14 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 Effective management arrangements ensure that the home runs smoothly. The manager seeks and records the views of residents and visitors, and now needs to is produce a summary that will show residents and others how their views are being used to improve the service. The health and safety of residents and staff are promoted through safety checks and staff training. EVIDENCE: The registered manager is competent and has several years of relevant experience in a senior capacity. In line with the standards, she regularly attends training to update her knowledge and expertise and to keep abreast of current good practice. She has completed the Registered Manager’s Award. Staff interviewed felt that, at present, morale and teamwork at the home was good. They also said that it is a well managed home, with approachable managers who support and listen to them. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 15 The manager encourages suggestions and comments from staff, visitors and residents themselves, and questionnaires are distributed to ascertain views about the quality of the service. The results now need to be collated and summarised in a development plan. One way of sharing this may be via the home’s newsletter so that residents and relatives can see how their views and the views of others, eg, visiting health professionals, have affected the home’s annual improvement plan. Safe and secure arrangements are in place for administering and managing residents’ day to day finances, and accurate records are maintained. Current and satisfactory certificates were seen in respect of electrical and gas safety, and lift servicing. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 18 Requirement Timescale for action 01/03/06 2. OP33 24 Recruitment procedures must be robust. The home needs to take up a POVA listing check and CRB check in respect of any new staff commencing employment at the home. Gaps in employment history must be explored, and staff should sign a declaration that states they are physically and mentally fit to carry out their role. The results of quality surveys 01/06/06 need to be collated and summarised in an annual development plan for the home. 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 OP18 Good Practice Recommendations It is recommended that the home obtains a copy of the Bolton Metro Vulnerable Adults multi-agency policy and DS0000009310.V280860.R01.S.doc Version 5.1 Page 18 Withins Residential Home 2. OP30 procedure, the contents of which should be discussed in team meetings and during supervision. The manager was advised to obtain the Skills for Care induction standards and to use them for new staff. Withins Residential Home DS0000009310.V280860.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office 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 DS0000009310.V280860.R01.S.doc Version 5.1 Page 20 - 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!