This inspection was carried out on 21st July 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Willow Brook Care Home 112 Burton Road Carlton Nottingham NG4 3AX Lead Inspector
Susan Lewis Unannounced 21st July 2005 at 10:30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Willow Brook Care Home Address 112 Burton Road Carlton Nottingham NG4 3AX 0115 9613399 0115 9403848 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Keith Stanley, BUPA Care Homes Limited Care home with nursing 49 Category(ies) of OP Old age, x 43 registration, with number PD(E) Physical disability-over 65, x 3 of places TI Terminally ill, x 3 Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Within the total number of beds a maximum of 3 beds may be used for the category PD(E). 2. Within the total number of beds a maximum of 3 beds may be used for the category TI. Date of last inspection 9 November 2004 Brief Description of the Service: Willowbrook Care Home is a purpose built property set on the edge of the city of Nottingham. There are grounds to the front and rear of the building with ample parking facilities. The accommodation comprises 49 single rooms all of which have an en-suite facility. All bedrooms are fitted with an Alarm Call System and suitably furnished. A passenger lift offers access to the first floor and a range of specialist lifting equipment is available for service users with dependent needs. The home has two lounge areas, a quiet room and a designated dining area, providing a variety of comfortable seating and occasional tables. There are six bathrooms, two of which are fitted with an assisted hoist, one with a Parker bath and a shower room. Healthcare professionals will visit the home on request. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 5 ½ hours as part of the annual inspection process. A partial tour of the premises took place and staff and care records were inspected. Four residents, three relatives and three staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better:
There are three areas that the registered person must focus attention on. Although the medication was recorded appropriately, the temperature of the fridge and the treatment room was incorrect leading to potential risk of medication being stored at incorrect temperatures. This was due to the thermometer used and the manager must correct it. Residents and relatives felt that the staff were caring and they felt safe, however not all staff had received abuse awareness training. The registered person must make arrangements for this to be done. Finally staff are involved in all aspects of providing care to residents including meal preparation and where this is the case staff must have up to date basic food hygiene training.
Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6 Prospective residents are given the information needed to make an informed choice and can be confident that their needs will be assessed and met. EVIDENCE: Intermediate care is not provided at this home. The requirement set at the last inspection to amend the statement of purpose has now been done. The plans of care assessed as part of this inspection evidenced a thorough pre-admission assessment. The manager was visiting a prospective resident and carrying out pre-admission assessment at the start of the inspection visit. From this assessment a plan is created that details all activities of daily living as well as care needs that are pertinent to the individual. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 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 standard(s) 7, 8 and 9 Residents health, social and personal needs are fully met. The inaccurate temperature recording in the treatment room has the potential for placing residents at risk. EVIDENCE: Three plans of care were assessed as part of this inspection all provided clear information on how care was to be provided. Plans clearly showed who were the key staff responsible for updating information on plans. Residents’ health care needs were clearly identified and how these were to be met with risk assessments to evidence how risk was to be minimised. Residents and relatives spoken with were aware of their care plans and that they could see them at any time. Staff spoken with understood the care needs of residents and how to meet them. Medication was stored in well ordered treatment room and all records were up to date. The fridge and room temperatures were being taken however there was some confusion over the thermometer used and so the readings were incorrect. The manager must ensure that a suitable method of recording temperatures is found. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 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 standard(s) 15 Meal times were well managed and provide residents with nutritious well balanced meals. EVIDENCE: The meal was not sampled but was observed. It appeared nutritious and appetising. The majority of residents spoken with were positive in their views of the food. All residents said that they were given a choice and staff would find them something to eat if they did not like the choices. One resident did comment that it was not to their liking but could not be specific in what was wrong with the food. Evidence was seen that fresh cakes were baked for residents and relatives reported that birthday cakes were also baked for their loved ones. The dining room was pleasant and staff were observed providing discreet support for those residents who needed help. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 Residents and relatives are confident that their concerns will be listened to and acted upon. Limited staff adult abuse training places residents at potential risk. EVIDENCE: All relatives and residents spoken with said that if they had a concern they could take it to any member of staff and would feel confident that it would be dealt with. Residents said they felt safe and well cared for. Relatives said they felt happy leaving their loved ones in the care of the staff. Staff spoken with had an understanding of what constituted abuse as well as what they would do about it. Although only one member of staff reported that she had any formal abuse awareness training. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 The home is pleasantly decorated and residents live in a clean and pleasant environment. EVIDENCE: The home was well maintained and clearly regularly decorated. Residents spoken with said that their bedrooms were kept clean and relatives said that the home never smelt bad. Residents confirmed that their clothes were laundered regularly. Throughout the home there was evidence that the maintenance man was carrying out tasks to keep the home well maintained. There was a communication book for visitors to add any requests for maintenance. It is dated when completed. This is very good practice. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The recruitment practices within the home are robust and protect residents from potential risk. EVIDENCE: Five staff files were inspected and all showed evidence that two references were obtained prior to the staff member being employed and Criminal Record Bureau checks were carried out prior to the person being confirmed in post. Staff files were maintained to a good standard. Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 Residents can be assured that the home is run in their best interests. Most practices within the home promote the health and safety of people using the service. All staff must have their basic food hygiene training to minimise potential risk. EVIDENCE: BUPA carries out an annual quality questionnaire and a record of this is kept in the reception area for anyone to read along with the homes last Commission inspection report. This quality audit was of a high standard and carried out by independent auditors. There was evidence of regular monthly residents meetings taking place. Maintenance records were seen, evidence was seen of regular fire drill and other essential safety audits taking place. Evidence was seen that staff receive their mandatory training. The manager did report that staff assist in preparing some meals particularly breakfast, it appeared that not all staff had their up to date basic food hygiene training. The manager must ensure that all staff who are involved in handling food have up to date training.
Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 15 Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x 3 x x x 2 Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 17 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Timescale for action The registered person shall make 31/08/05 arrangemnets for the safe handling and storage of medicines into the home. Temperature of the fridge and treatment room must be correctly monitored The registered person shall make 1/10/05 arrangements, by training or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall make 1/09/05 suitable arrangements to prevent infection, toxic conditions and the spread of infection and ensure all staff involved in food preperation must have basic food hygiene training. Requirement 2. 18 13 3. 38 13 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.
Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 18 Refer to Standard Good Practice Recommendations Willow Brook Care Home C53 C03 S26427 Willow Brook V239661 200705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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