Inspection on 09/03/06 for Willow Bank Care Home

This inspection was carried out on 9th March 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.

Other inspections for this house

Willow Bank Care Home 20/06/07

Willow Bank Care Home 25/01/05

Willow Bank Care Home 15/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Willow Bank Care Home Bell Dean Road Allerton Bradford West Yorkshire BD15 Lead Inspector Pamela Cunningham Unannounced Inspection 10:00 9 March 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Bank Care Home DS0000038927.V283333.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. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow Bank Care Home Address Bell Dean Road Allerton Bradford West Yorkshire BD15 01274 889275 F-P 01274 889275 darrenpwalkden@aol.com 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) Victorguard Care plc Ms Carol Delaney Care Home 59 Category(ies) of Old age, not falling within any other category registration, with number (59) of places Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: Willow Bank Care Home, which is a purpose built establishment, is situated in a rural area of Bradford. It provides care for 59 elderly people requiring personal care, and is within approximately two miles from the City centre. There are local shops and amenities close by. There is ample parking for visitors, and the home is protected around the periphery of the building by closed circuit television. All rooms are very spacious and have en-suite facilities. There is a lawned area to the rear of the home where residents can sit out weather permitting. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 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 visit 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 on 6 July 2005. This was an unannounced inspection carried out by one inspector who was at the home from 10.30 until 16.00. The main purpose of this inspection was to make sure that the home provides 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 care records; observing working practices and talking to staff, residents, relatives, and to the manager. In addition conducting the inspection, time was spent in preparation. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI). I discussed any comments received with the manager, without revealing the identity of those completing them During the course of the inspection I met with many of the residents, and spoke at length with six of them, and also with one lady relative. The daughter of one resident said that her mum was so ill on admission to Willow Bank, she thought she would lose her, however, within a few weeks there was 100 improvement. She said, “I can’t sing the homes praises enough, I’ve got my mum back. However long my mum remains in the home, I know she will be well cared for.” She said she was involved with the care planning, but declined to sign the care plans. One lady resident said she was looking forward to starting on the Easter bonnets. Residents spoken to said that they are able to go to bed and get up when they want, and are able to go out with family or have them visit with no restrictions. All of the residents spoken to said that they feel respected by staff and that they are well looked after, and that nothing was too much trouble. Another lady said she had been assessed at her home before coming to live at Willow Bank, and that the home was recommended to her. Everyone said that they feel happy to speak to the manager or staff if they have any concerns/worries. Residents are happy with the meals stating that there was always something on the menu they could eat and enjoy. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are no requirements or recommendations as a result of this inspection. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 7 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. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 9 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, 4, 5 and 6 Prospective residents and near relatives are provided with information to enable them to make an informed choice about the home. The admission process is good and includes introductory visits. Residents’ needs are met at the home by well-informed and knowledgeable care staff. Intermediate managed care is not provided. EVIDENCE: Two senior carers who took part in the inspection process at the start of the visit told me either the deputy manager, or the registered manager assesses all prospective residents prior to them coming to have a look around the home, or coming for a trial visit. They also said the homes brochure is taken to the pre admission assessment and explained to the relatives and resident. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 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 the following standard(s): 7, 9 and 11 The health care needs of residents are met and care plans provide clear and detailed instructions for staff to follow. Staffs is aware of the residents’ needs and there is good communication amongst the staff group. Residents are treated with dignity and their privacy maintained at all times. EVIDENCE: I reviewed three sets of care plans and undertook case tracking. The standard of care plan documentation is good, and includes a pen picture of the resident, and pre admission assessment information. All necessary risk assessments were present with coping strategies on how the risks can be minimised. Review of the daily care record identified any problems had been carried forward to the care planning process, some as a short term care plan in the case of a minor injury such as skin tears. The manager said the home has a sudden death policy, and that end of life situations were discussed sensitively with relatives and residents on admission to the home. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 11 The medication system in use is safe. The home has a self-medication policy, however, currently there are no residents who have expressed a wish to handle their own medication. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 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 the following standard(s): 15 A good, varied and nutritious diet taking into account individual choices is provided at the home. Any changes made to the menus take place after consultation with the residents. EVIDENCE: Residents said they are asked about their preferences on admission, and are consulted by the chef if changes to the menus are to be made. Special diets are provided, and the chef, who has similar dietary needs to certain residents, consults them when they are first admitted, and when planning the menus. Residents are happy with the meals stating that there was always something on the menu they could eat and enjoy. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 13 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, 17 and 18 The home has a detailed complaints and adult protection procedure which is robust and protects residents. The level of staff understanding gives assurance that complaints will be taken seriously and service users will be protected from abuse. EVIDENCE: There is a communication book in every resident’s bedroom, which is looked at daily. If any concerns are documented, the resident’s relatives are contacted to discuss them. This is good practice. Residents’ rights regarding voting are promoted, and those who are able, are taken to the polling station to vote. Residents who cannot be taken out to vote have postal votes arranged for them. Any unopened voting papers are returned unopened to the returning officer. The manager is aware of POVA, and the procedure to be taken if abuse is suspected. One of the senior carers who has completed the registered managers award also demonstrated awareness of the procedure. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 14 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 on this occasion. EVIDENCE: Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 15 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, 28, 29 and 30 Residents are supported and protected by robust recruitment procedures. Staffing numbers and skills ensure that residents’ needs can be met. Staff are trained and competent to do their jobs. EVIDENCE: Rotas indicated that there was sufficient staff on duty to meet the needs of the residents. The total numbers remain constant, which negates the need for the use of agency staff. Care staff are supported in their work by domestic, catering and laundry staff. The provider is based at the home, and there is also an administrator. In addition to the manager having completed the RMA (Registered Managers Award, two of the senior carers have this qualification. On the day of the inspection staff comprised of the registered manager, five senior carers, and three carers, both of who have achieved level 2 NVQ. Training undertaken by the majority of care staff includes manual handling training, Fire Safety Training. Training in Health and Safety, and basic food hygiene. Infection Control training has been undertaken as a distance learning course. Training on the monitored dose system of medicine control, has been provided for all staff involved in medicine dispensing. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 16 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): 33, 35, 36 and 38 The manager has the skills and knowledge to provide effective leadership. Staff are well motivated, residents are consulted and their interests are safeguarded at all times. Personal finances are not handled by the home. EVIDENCE: The homes activity programme is well established with resident’s choices and preferences taken into account The visitors and residents spoken to during the visit said that communications were good. One relative said she thought the communication book in the room was a good idea. She was also aware of the complaint procedure but had not, and could not envisage ever having to use it, as all the staff were very approachable. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 17 Formal staff supervision is taking place 6 times per year. One of the senior carers was clear about the difference between formal supervision and appraisal, which takes place annually. Health and Safety checks at the home were all up to date. Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 3 Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willow Bank Care Home DS0000038927.V283333.R01.S.doc Version 5.1 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. 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