Inspection on 21/09/06 for Willow Brook Care Home

This inspection was carried out on 21st September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Brook Care Home 28/03/08

Willow Brook Care Home 06/09/07

Willow Brook Care Home 28/02/06

Willow Brook Care Home 21/07/05

Willow Brook Care Home 09/11/04

Willow Brook Care Home 10/06/04

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 Brook Care Home 112 Burton Road Carlton Nottingham Nottinghamshire NG4 3AX Lead Inspector Susan Lewis Key Unannounced Inspection 21st September 2006 10:00 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 Brook Care Home DS0000026427.V306643.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 Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Brook Care Home Address 112 Burton Road Carlton Nottingham Nottinghamshire NG4 3AX 0115 961 3399 0115 940 3848 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) BUPA Care Homes (AKW) Ltd Helen Elizabeth Rodrigues De Oliveira Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (43), Physical disability over 65 years of age of places (3), Terminally ill (3) Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Within the total number of beds a maximum of 3 bed maybe used for the category PD(E) Within the total number of beds a maximum of 3 bed maybe used for the category TI Within the total number of beds a maximum of 1 may be used for PD for a named person Within the Total number of beds, a maximum of 43 may be used for the category OP 28th February 2006 Date of last inspection Brief Description of the Service: The fees for 2006/07 range from £400-£580. There are separate charges for hairdressing and newspapers. The most recent Inspection report can be found in the entrance hall to the home. 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 DS0000026427.V306643.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible and observing the practice of staff who provide care as well as talking with care staff. The inspection was unannounced and took place over 7 hours one Thursday in September 2006, and was conducted by one inspector as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms were inspected. Residents’ and staff records were inspected and residents, visitors and staff on duty were spoken with. 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 Brook Care Home DS0000026427.V306643.R02.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 Brook Care Home DS0000026427.V306643.R02.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): 3 and 6 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Residents only move into the home after an assessment has been carried out and they are assured that their needs will be met. EVIDENCE: Intermediate care is not provided in this service. Three care plans were viewed as part of this inspection and all three plans had copies of assessments, which were carried out prior to the resident moving into the home. They contained sufficient information for the assessor to ensure that the home could meet the needs of the resident. Willow Brook Care Home DS0000026427.V306643.R02.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): 7, 8, 9 and 10 The quality outcome for this area is poor. This judgement has been made using available evidence including a visit to this service. Residents’ personal care needs are set out in an individual plan but residents or their representatives are not involved in their creation or review. Residents’ healthcare needs are fully met. Residents, where appropriate are responsible for their medication and are protected by the homes policies and procedures for dealing with medication. Residents do not always feel they are treated with dignity and respect. EVIDENCE: The three care plans viewed provided information on how staff were to meet residents needs. There was some details lacking such as oral hygiene and individual likes and dislikes in how personal care was to be provided, this would ensure residents were involved and felt in control of the care provided to them. Staff spoken with said that they talked to residents where possible about the care to be provided. Residents spoken with said that they were not involved in reviews; relatives spoken with also confirmed that they were not aware of care plans or reviews. Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 9 Evidence was seen in diary notes that healthcare professionals were involved when required and that residents were able to see doctors when needed. This ensures residents health care needs are met appropriately. Evidence was seen that residents who had pressure care needs had the necessary equipment to minimise the risk of deterioration. Evidence was seen in diary and care notes that the Tissue Viability Nurse was also contacted and action taken as advised again ensuring residents received appropriate care. Care plans showed that residents were risk assessed for their continence needs, their nutritional needs and their risk of falls, each plan showed how these risks were to be minimised with clear instructions for staff to follow, ensuring that residents safety was maintained. Only trained staff administer medication, and staff observed administering medication on the day of the inspection were seen to follow the homes policy and procedure, ensuring residents receive the correct medication safely and at the times indicated by the prescription. Medication was stored in locked trolleys and the records of medication given were signed and up to date. However it was noted on the controlled drugs records that there were a number of omissions, where staff had signed to say they had seen the medication administered but the person who administered the drug had failed to sign the book. The Registered Person must ensure that medication records are kept up to date and signed appropriately to ensure residents safety. Where residents administer their own medication a risk assessment takes place and the resident signs this themselves. Ensuring that where possible residents are able to maintain responsibility for their own medication Through out the day staff were observed with residents, they spoke to them with respect and there was a clear affection amongst staff and residents. Staff were seen to inform residents of what they were about to do particularly when needing to hoist someone. Residents spoken with said that staff were ‘alright’, a resident commented that she felt ‘staff rush me’, another resident commented that ‘I don’t ask for much help so it isn’t a problem for me’. A resident was observed going for lunch with the belt on his trousers not through the loops and he looked dishevelled. A relative spoken with said that on a number of occasions they had come in and found their loved one was soaking wet as a result of being incontinent. The Registered Person must ensure that residents’ dignity is maintained at all times. Willow Brook Care Home DS0000026427.V306643.R02.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): 12, 13, 14, and 15 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. . The lifestyle experienced by most residents in the home matches their expectations and preferences. Residents are able to maintain contact with family and friends. Residents are not always helped to exercise control over their lives. Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: On the day of the inspection a quiz was taking place in the main lounge and from information provided prior to the inspection visit it was evident that residents are able to take part in a number of activities. Meal times enable residents to ensure they can eat when they want to, residents spoken with said that they were able to get up when they wanted to, however one resident said that often she would like to be in bed by 10pm so as to be able to watch television in bed but staff often do not get her to bed until much later. However in discussion with other residents they all said that they were able to go to bed when they wanted to. Visitors spoken with said that they were made to feel welcome and were able to see their relative in private if they so wished. Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 11 Residents spoken with were unaware that they could look at their care plan. Residents confirmed that they had been able to bring in personal possessions to the home to personalise their bedrooms. Residents spoken with said that they did not feel they were in control of their lives and that they had little choice in what they could do or when they could do it. Information regarding how to contact advocacy services was available on the notice board ensuring they are able to contact someone to act in their interest if they so wish. Evidence was seen that there was a choice of midday meal, however residents spoken with could not remember what choice they had. The meal was observed and was presented in an appetising manner. The cook was spoken with and understood nutrition and the importance of providing balanced, nutritious meals to all residents including those with special dietary needs. Staff were observed assisting residents who required support to eat, it was noted that some residents were struggling to eat and were dropping food down themselves and no help appeared forthcoming. The Registered Person must ensure that appropriate assessments take place to ensure all residents who need support to eat their meal are provided with appropriate help. Willow Brook Care Home DS0000026427.V306643.R02.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): 16 and 18 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: From information received prior to the inspection the home has had nine complaints, evidence was seen that these have been dealt with appropriately. The Commission has received no complaints about this service since the last inspection 28th February 2006. Residents and relatives spoken with said that they felt able to complain. Staff spoken with understood how to ensure that residents were supported in making a complaint and who to pass this information on to. Staff spoken with understood what constituted abuse and were aware of the whistle blowing policy in the home; relatives said that they feel the residents are safe from abuse. The home does not act as appointee for any residents, and each resident has their own account that money is paid into by their relative, evidence was seen that appropriate measures are taken to protect residents from financial abuse. Willow Brook Care Home DS0000026427.V306643.R02.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): 19 and 26 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: Evidence was seen that the home is undergoing refurbishment; communal areas and bathrooms are currently being redecorated. Evidence was seen that new curtains and carpets are also due to be fitted The grounds were tidy and accessible to residents ensuring that they were able to sit in the sun should they so wish. The home is safe and well maintained and suitable for the residents needs. There was evidence from observation that the home is kept clean and hygienic with sufficient cleaning staff around the home. Resident spoken with all said that their bedrooms were clean and tidy. The laundry is sited so that soiled clothes are not carried through areas where food is stored, prepared, cooked or eaten and does not intrude on residents. Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 14 The laundry is well laid out with floor and wall surfaces that are washable ensuring that appropriate infection control is maintained. Willow Brook Care Home DS0000026427.V306643.R02.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): 27, 28, 29 and 30 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skills mix of staff. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and procedures. Staff are trained and competent top do their job. EVIDENCE: A requirement was set at the last inspection to ensure that sufficient staff are on duty to meet the needs of residents. Residents spoken with said that they had to wait a long time for staff to help them and relatives spoken with commented that it was possible to sit in the lounge and not see any staff for over half an hour as they were busy with residents in other parts of the building. However, evidence was seen from information provided prior to the inspection and from observation on the day of the inspection visit that sufficient staff are on duty throughout the day to meet the needs of the residents. There are sufficient domestic staff to ensure that standards relating to hygiene and dietary needs are also met. The requirement set has been met. Evidence was seen that 50 of staff (excluding trained nurses) have their NVQ level 2 or above. This ensures that staff have reached a minimum competence level in providing personal care to residents. Staff spoken with confirmed that Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 16 they were able to access NVQ training and were encouraged to achieve NVQ standards. Staff files were viewed as part of this visit and along with information provided prior to the visit it was evident that the manager operates a robust recruitment procedure. All files viewed had two references and a Criminal Records Bureau check, ensuring that residents are protected by appropriate recruitment practices. Staff spoken with confirmed that they were able to attend a wide variety of training, evidence was seen that all staff have their food hygiene certificates and that they are renewed every three years and the kitchen staff every year (this is good practice). From information received prior to the inspection visit staff have attended a variety of courses including Adult Abuse awareness training, Moving and Handling, Health and Safety, Dementia Care and Fire Training. Staff spoken with confirm that they received induction when they started at the home and senior staff spoken with confirmed that new staff are super numerary until they have completed their induction. Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. The acting manager has yet to apply for registration with the Commission. The home is run in the best interests of the residents. Residents’ financial interests are safeguarded. The health and safety of residents and staff are promoted and protected. EVIDENCE: There is new acting manager in post and as yet not registered with the Commission. The Registered Person must ensure that the acting manager is registered as a fit person with the Commission as soon as possible. The acting manager has over ten years of experience in managing care homes and has a good understanding of what her role and responsibility is as a manager. As part of the BUPA care home business there are clear lines of accountability Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 18 within the home and externally ensuring that the acting manager receives support and is able to manage the home appropriately. BUPA has an effective quality assurance and monitoring system and copies of previous questionnaires and what they mean in terms of care provided to residents can be found in the reception area of the home. Evidence was seen that where possible residents remain in control of their finances and written records are maintained for all transactions. Any monies or valuable items are held securely on behalf of the resident ensuring that personal items do not go missing. There is good clear evidence that health and safety is taken seriously within the home, with records for testing water temperatures, ensuring residents are protected from Legionella. All staff receive appropriate health and safety training to ensure that they are able to carry out their role safely not placing residents or themselves at risk. The acting manager ensures that the Commission is notified of any incidents and accident records are maintained and these are audited to look at any possible trends that may adversely affect residents or staff. (This is good practice). Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 20 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 2 Standard OP9 OP10 Regulation 13(2) 12(4)(a) Requirement The Registered Person must ensure that medication records are signed correctly. The Registered Person must ensure that residents are treated with respect and their dignity is maintained. Timescale for action 01/11/06 01/11/06 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 4 Refer to Standard OP7 OP7 OP14 OP15 Good Practice Recommendations The Registered Person should ensure that residents or representative are involved in reviews. Care plans are in sufficient detail to ensure care is provided in an individual manner. Residents are able to exercise control over their day-today lives. Residents receive the help they need to eat their meal. Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Nottingham Area Office 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 © 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 Willow Brook Care Home DS0000026427.V306643.R02.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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