Inspection on 09/01/08 for Willow Bank Residential Home

This inspection was carried out on 9th January 2008.

CSCI found this care home to be providing an Good service.

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 Residential Home 30/06/06

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 Rose Veale Unannounced Inspection 9th January 2008 09:45 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.V355779.R02.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.V355779.R02.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.V355779.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2007 Brief Description of the Service: Willow Bank is a privately owned home, providing personal care for 18 older people. The home is a large converted detached house with a garden and sitting area at the rear 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. Lounge areas, dining room and a bathroom with hoist facilities are situated on the ground floor. Willow Bank 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 nearby town of Glossop is accessible via the local bus or train service. Current fees range from £352 per week for a shared room to £372 for a single room. This information was provided by the owner/manager on 9th January 2008. Information about the home, including CSCI inspection reports, is available in the main entrance area of the home, or from the owner/manager. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection visit was unannounced and took place over 6 hours. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 18 people accommodated in the home on the day of the inspection visit. People who live in the home, visitors and staff were spoken with during the visit. The owner/manager was available and helpful throughout the inspection visit. Some people were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. The Annual Quality Assurance Assessment had been completed and returned prior to the inspection and information from this has been included in the body of this report. What the service does well: What has improved since the last inspection? The home had complied with all 4 requirements made at the last inspection. Improvements had been made to care plans and risk assessments to ensure people’s needs and preferences were properly documented and met. Also, improvements to the home with the provision of a new shower room and landscaping the garden to allow safe access for people living in the home. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place ensured that people had sufficient information about the home and that their needs could be met at the home. EVIDENCE: The care records of 3 people were seen, including the records of 1 person admitted to the home in the last month. All 3 records included assessment information, including an assessment by social services. The terms and conditions of living at the home were included in the Service User Guide that was given to people coming to live at the home, (or their representatives). Most people living in the home were self-funding and they, or their representatives, had signed a contract with the home. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 9 Standard 6 did not apply to this service. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements had been made in care planning and review so that people received care and support to meet their individual needs and preferences. EVIDENCE: Since the last inspection, new care plans and risk assessments had been introduced. The care plans included details of the person’s preferences regarding routines and personal care. The care plans covered all areas of the person’s needs, including mental health, social, and spiritual needs. The care plans seen were signed by the person or their representative to indicate their agreement and involvement. There were records of monthly reviews of the care plan by the keyworkers. The care plan for 1 person did not include enough detail about how effective pressure area care should be carried out. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 11 The risk assessments covered manual handling in detail and other risks as appropriate. There was no risk assessment in place for 1 person who had frequent falls. There were records of the input of healthcare professionals, such as GP, District Nurse, chiropodist and optician. People living in the home confirmed that they could see their doctor as required and that they had access to other healthcare services. Staff spoken with were familiar with the care plans and were knowledgeable about the care needs and preferences of people living in the home. There were satisfactory arrangements in place for the receipt, storage, administration and disposal of medication in the home. Staff spoken with and training records confirmed that staff had received appropriate training about the safe handling of medication. People living in the home and visitors made positive comments about the approach and attitudes of staff. They said that staff were “friendly”, “nothing is too much trouble”, and “they treat people properly – with respect”. Staff were observed to speak to people in a warm and respectful manner. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a relaxed environment with a range of activities so that people’s expectations and preferences were considered and met. EVIDENCE: People described the home as “homely” and said “we all get on well”. People said that routines were flexible and that they could get up and go to bed when they wanted to. In discussion with staff it was clear that there was an emphasis on ensuring individual choices and preferences were respected. For example, 1 person had expressed a preference for staying in their room for most of the day and this was respected by staff, although they did encourage the person to join others at lunch time. There were photographs displayed of recent activities at the home and details of future events and activities. People confirmed that activities took place, such as bingo, quizzes, crafts, and gentle exercise. People at the home were involved in local community events, and also in sponsoring a child and sending Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 13 gifts to third world countries. A senior member of staff had responsibility for organising activities, events and trips out. There was a regular religious service at the home. 1 person spoken with was pleased they were able to go to the local church they had belonged to before coming to live at the home. Visitors said they were always made welcome and were able to visit at any reasonable time. People were consulted through meetings and surveys about their interests and preferences regarding activities and meals. People said they were happy with the meals provided at the home. The menu was displayed in the main corridor. There were bowls of fresh fruit in each of the lounges and in the main hallway. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies in place and staff awareness were sufficient to ensure that people were protected and their concerns effectively dealt with. EVIDENCE: The home had a suitable complaints procedure that was included in the Service User Guide given to people living in the home. The owner/manager said that no complaints had been made since the last inspection, and none had been made directly to CSCI. The owner/manager said that people living in the home or their representatives usually discussed any issues or complaints with her so that they could be resolved in an informal way. The owner/manager and deputy manager had been trained to deliver training to staff about safeguarding vulnerable adults. There was evidence that safeguarding issues and procedures were regularly discussed during staff supervision. The staff training records were not up to date so it was not clear when staff had last had training updates about safeguarding adults. Staff Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 15 spoken with were aware of safeguarding issues and whistle blowing. They were not all fully aware of the correct procedures to follow internally and externally if abuse was alleged. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained so that people lived in a safe, clean, comfortable and pleasant environment. EVIDENCE: Since the last inspection, a shower room with toilet had been provided on the first floor and the laundry had been re-sited to the ground floor. The shower room had no form of extraction installed. The laundry was suitably equipped. Also since the last inspection, the back garden had been landscaped to provide a large, level paved area with seating. This area was accessible from the main lounge/dining room. The owner/manager said it was planned to further Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 17 improve the area with planted tubs, and said that people living at the home were interested in getting involved with this. The office for the home had been relocated to what had been a small lounge. The owner/manager said that the home had plans to have an extension, including a conservatory. The lounges were pleasant and comfortably furnished in a domestic style. The bedrooms seen were bright and personalised with individual belongings. The home was clean throughout and free from offensive odours. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment practices, staff training programme and staffing levels were generally sufficient to ensure that people were protected and well supported. EVIDENCE: The usual staffing levels for the home were to have 2 care assistants on duty during the day and at night, with an additional care assistant working from 8 to 10am and from 3 to 4pm. In addition, there was the manager, a domestic assistant and the cook. People spoken with said that staff were available when needed, and from observation there appeared to be sufficient staff to meet the needs of people in the home. The files of 2 members of staff were seen, both recruited since the last inspection. The records included nearly all the required information and documents. 1 person had only 1 written reference. The owner/manager said that the second reference had been requested and chased up with no success. 1 application form had an unexplained gap in the employment history. Neither of the files had a photograph of the staff member as required. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 19 There were no records of staff induction and the staff training records were not up to date. The owner/manager said that staff completed a period of induction and shadowing when they first started, and staff spoken with confirmed this. Staff said that there was a good range of training offered at the home, including training to meet the specific needs of people living there. Not all staff had received training about safeguarding vulnerable adults, or first aid training. Other training, such as fire safety and manual handling, was up to date. Out of 17 care assistants employed at the home, 13 had already achieved National Vocational Qualification (NVQ) at Level 2 or 3, and 4 were working towards NVQ Level 2. The owner/manager said that 2 of the senior staff were to start NVQ Level 4. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and there were satisfactory systems in place so that the health, safety and welfare of people were promoted and protected. EVIDENCE: The owner/manager of the home was suitably qualified and experienced to run the home. People spoken with were positive about the manager. Comments included: “she’s very nice – she comes every day to see how we are”, “she’s firm but fair”, “she’s approachable” and “she will listen to any problems”. Staff said they had confidence that the owner/manager would take action on any issues or concerns raised. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 21 The Annual Quality Assurance Assessment was completed as required and returned to CSCI before the inspection. All sections were completed and the information gave a reasonable picture of the current situation at the home. There was limited detail about areas where the home considered they were doing well and also about where they still need to improve. The owner/manager said that quality assurance surveys had recently been sent out to people living in the home, their relatives and friends. There were regular meetings for people living in the home. The owner/manager said that relatives would be welcome to join these meetings. The personal money of people living in the home was kept securely in a safe in the office. Records were kept of all transactions. The records seen had one signature for each transaction. Accident records were kept and were up to date. The records did not comply with data protection legislation. Information from the AQAA showed that policies in the home had been reviewed in the previous six months. Also, that all required maintenance checks had been carried out up to date. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 22 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 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) Requirement Timescale for action 29/02/08 2 OP18 13(6) 3 OP29 19 4 OP30 13(4) Care plans must include all the assessed needs of the person and must have sufficient detail of the action required by staff to ensure those needs are met. All staff must have training, with 31/03/08 regular updates, to ensure they are aware of safeguarding vulnerable adults procedures. This will help to ensure that people living in the home are protected. Staff records must include all the 29/02/08 documents and information required, specifically, 2 written references, a full employment history with explanation of any gaps, and a recent photograph. This will ensure a robust recruitment procedure that protects people living in the home. There must be first aid available 31/03/08 when needed to people living in the home to ensure prompt action in emergency situations. Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 24 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 3 Refer to Standard OP19 OP30 OP33 Good Practice Recommendations There should be adequate ventilation / extraction provided in the first floor shower room to ensure the comfort of people living in the home and of staff assisting them. Records should be kept of staff induction to demonstrate that the induction programme meets Skills for Care standards. The quality assurance system should be further developed to include an annual report made available to people living in the home and their relatives / representatives. This will show where the home has taken action to meet concerns / issues raised and where further improvement is planned. There should be 2 signatures for all transactions in the records of personal money held for people living in the home. The accident records should comply with data protection legislation to ensure confidentiality. 4 5 OP35 OP38 Willow Bank Residential Home DS0000065701.V355779.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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