Inspection on 30/06/06 for Willow Bank Residential Home

This inspection was carried out on 30th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Willow Bank Residential Home 09/01/08

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Willow Bank Residential Home Albert Street Hadfield Glossop Derbyshire SK13 1DG Lead Inspector Nancy Bradley Unannounced Inspection 30th June 2006 09:00 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 Residential Home DS0000065701.V301456.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. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Bank Residential Home Address Albert Street Hadfield Glossop Derbyshire SK13 1DG 01457 868594 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) Christine Jackson Christine Jackson Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All outstanding items identified during the site visit must be completed within the agreed timescale. This was the first inspection of this service since registration Date of last inspection Brief Description of the Service: Willowbank is a privately owned home, offering facilities for the residential care of 18 elderly people. The home comprises of a large detached house in pleasant well-maintained gardens and is situated at the end of a cul-de-sac. The home has twelve single and three shared rooms, two rooms have en suite facilities. Stairs and a chair lift access the rooms on the first floor Willowbank is close to the centre of the village of Hadfield in the High Peak of Derbyshire and within easy walking distance of the local shops. The near by town of Glossop is accessible via the local bus or train service. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over five hours. The inspector spoke with the deputy manager and members of staff on duty. During the site visit the inspector made a tour of the home and spoke with several residents. The inspector observed throughout the visit how the staff were meeting residents immediate and long-term needs. The inspector stayed and had lunch with the residents. No family or relatives were present during this visit. Mrs Christine Jackson is the new owner/manager and has recently been registered with the Commission for Social Care Inspection. Records were examined relating to the residents and the running of the home. What the service does well: 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. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 6 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 Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 7 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): Standards 1 and 3 Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home has a Statement Of Purpose and User Guide Arrangements are in place to ensure that potential residents needs are fully assessed and met prior to admission. EVIDENCE: There is information available to residents and potential residents about the service. This has been updated in line with the new ownership arrangements. Residents spoken with during the visit confirmed they were able to visit the home prior to moving in. The records of two residents were checked. The majority of the residents who are admitted to the home have their needs assessed through care management. The care plans seen contained evidence of assessments and reviews by social workers or care management . Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 8 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): Standards 7,8,9,and 10. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Although the care of the residents was planned and delivered in a way that respected their privacy, residents were potentially placed at risk through inconsistency in care planning and risk assessments. EVIDENCE: During the visit, the records of two residents were examined in detail. They had been reviewed on a regular basis. The review of care plans needs to be in more detail,recording no change on the care plan and dating the entry is insufficient. Although care plans recorded individuals’ needs, preferences and abilities, not all the required documents had been completed particularly assessments about areas of risk affecting the welfare and safety of the residents with pressure scores. The personal care and health needs of the residents were recorded in care plans. Information relating to visits from health care professionals such as G.P, dentists, podiatrists and opticians were recorded. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 9 The home operates and monitors service users medication. None of the residents are able to administer their own medication. All staff have received training on medication training procedures. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to be satisfactory. There was a clear audit trail of all medication used at the home. The staff were observed routinely knocking on residents bedrooms and bathrooms before entering. The residents spoken with considered that the staff working at the home were good and that their privacy and dignity was respected. Conversations between residents and staff were appropriate and respectful taking account of any communication difficulties the residents may have. .. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 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): Standards 12,13,14 and15 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. The home provides activities and stimulation in line with the wishes and recreational interests of the residents. Contact with family and friends is encouraged and seen as a priority. The meals offer both choice and variety, catering for any special dietary requirements. EVIDENCE: The residents spoken with during the inspection were very positive about living at the home. The daily routine is flexible and they were able to make decisions about how they spent their time during the day. The residents are encouraged to remain as independent as possible and are able to go out on trips. The residents described the range of activities on offer and stated that the staff respected their wishes if they choose not to take part. Activities included board games, singing, going out for a meal and local entertainment. There are no restrictions on family and friends visiting the home and visits are recorded in care plans. Family and friends call in and maintaining links with their family is given priority. The residents are all encouraged to personalise their rooms as they wish and bring in their own possessions. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 11 The inspector joined the residents for lunch and residents stated they were very happy with the meals provided. Resident’s individual preferences were considered and condiments are routinely offered. Residents are made aware of menus, and have opportunity to comment on these. Catering staff indicated that they had sufficient knowledge to met individual residents dietary needs. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home has a satisfactory complaints procedure in place with evidence to show that resident’s views are listened to and acted upon. The staff had a working knowledge and understanding of adult protection procedures. EVIDENCE: The home has updated its complaints procedure and this includes a timescale for resolution. However the policy falls short in detailing the method of response. i.e. verbally, written or through the Advocacy service The procedure contains the current address of the Commission for Social Care Inspection and informs the complainants that they are able to contact the Commission at any stage of the complaint if they wish to do so. As discussed with the Registered Manager, the policy will need amending to reflect the change pf procedure by the Commission for Social Care Inspection when dealing with complaints. Residents spoken with during the inspection would have no hesitation in putting their concerns to the Registered Manager/owner. There has been no adult protection issue raised in the home since the last inspection. The staff spoken to had a good understanding of procedures and would report any concerns to the manager/owner. The home has received a number of compliments, which they may wish to acknowledge and record. . Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The residents live in comfortable, pleasant and safe surroundings. The home generally was well maintained and clean. EVIDENCE: This was covered extensively in the registration visit for of the change of ownership. The manager/owner has complied with all the requirements from the last inspection regarding the environment. However the bathroom situation has not been resolved and this still does not fully meet the needs of the residents. The home has submitted plans to the local district council for refurbishments and alterations to the premises incorporating changes to the bathrooms and gardens area. Parts of the garden area are still not fully accessible to the residents. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 14 On the day of the visit the home was clean and there were no unpleasant odours. There were sufficient rooms for a variety of activities to take place and an area were residents could meet family and friends in private. Bedrooms had been personalised and individually decorated. A tour of the home highlighted the areas were work is required, as discussed with the Registered Manager/owner; the main stair carpet requires clearing due to staining. As discussed with the Registered Manager/owner an annual maintenance programme for renewal of the fabric and decoration of the premises needs to be produced and implemented with records kept. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 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): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home has an enthusiastic and effective staff team that works positively with the residents. The home has robust recruitment procedures and practices in place which ensure the safety and protect the residents. Importance to given to staff training. EVIDENCE: The residents living at the home have benefited from a stable staff team who have worked together for a number of years. The staff rotas seen confirmed that staffing levels were being met. Residents spoken with stated there was always sufficient staff in the home and this was supported through observation. The home has a good percentage of staff who hold a NVQ level 3 or the equivalent. Although it was not possible to view staff recruitment records, the Registered Manager/owner verbally confirmed that robust recruitment and section procedures are in place to protect residents from potential harm. Staff recruitment is in line with Schedules 2 and 6 of the National Minimum Standard. Since taking over ownership of the home, the Registered Manager has introduced a range of staff training to include moving and handling, fire training, and specialist training on working with Parkinson’s Disease. The staff spoken with confirmed that there is no restriction on training and staff are supported in this. All staff have a Personal Development Plan. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 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): Standards 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home was generally well managed, and regularly seeks the views of the residents on the running of the home. Arrangements are in place to safeguard the residents’ financial interests and handling of their money. EVIDENCE: The Registered Manager/owner is currently on the NVQ level 4 with a majority of staff having completed the NVQ level 3. The residents spoken with during the visit stated that the manager was approachable and the atmosphere within the home was relaxed and friendly. The Registered Manager/owner is suitably qualified and has a number of years experience running this home. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 17 The Registered Manager/owner has established a residents group, and minutes of these meeting were displayed. A more formal system of quality assurance is being established, with the home looking at all aspects of care provided. Robust systems were in place for the safe keeping of resident’s monies. The records and monies held on behalf of the residents were crossed referenced with records and found to accurate. Where family maintained responsibility for residents monies this was clearly identified in the residents care plan. A sample of service/maintenance records was examined (including gas and electricity services) and there was confirmation that all the equipment had been properly maintained. Evidence of checks having been carried out was provided to the Commission for Social Care Inspection Systems were in place for the monitoring and maintaining the hot water temperatures. Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 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 3 X 3 X X N/A 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 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 Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 19 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 Care plans must include all residents needs, and kept updated following changes in their needs. Care plans must be completed with involvement of residents were possible or their representative. Care Plans must be reviewed regular or when there is a change of circumstances. The garden must be made safe and fully accessible for all residents to use. This is a previous requirement. The original timescale was 31/07/04 An annual maintenance programme for renewal of the fabric and decoration of the premises needs to be produced and implemented with records kept. The current bathroom provision must be reviewed, as it does not meet the needs of the residents. This is a previous requirement. The original timescale was 31/12/05 DS0000065701.V301456.R01.S.doc Timescale for action 31/08/06 2 OP7 15 31/08/06 3 4 OP7 OP19 15 23 31/08/06 30/10/06 5 OP19 23 30/10/06 6 OP21 23 30/10/06 Willow Bank Residential Home Version 5.2 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 Refer to Standard OP19 Good Practice Recommendations The Registered Person should ensure that there is an on going plan for refurbishment of the home Willow Bank Residential Home DS0000065701.V301456.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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