CARE HOMES FOR OLDER PEOPLE
Willow Brook Care Home 112 Burton Road Carlton Nottingham Nottinghamshire NG4 3AX Lead Inspector
Susan Lewis Unannounced Inspection 28th February 2006 10:15 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.V279927.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Willow Brook Care Home Address 112 Burton Road Carlton Nottingham Nottinghamshire NG4 3AX 0115 9613399 0115 9403848 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.V279927.R01.S.doc Version 5.1 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 21st July 2005 Date of last inspection 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 DS0000026427.V279927.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the 2005/06 inspection year. It was carried out by one inspector and took place over seven hours. A partial tour of the premises took place with communal areas and bathrooms and toilets inspected. Care records were inspected as were staff training records. Residents, relatives and staff were spoken with during the course of the inspection. What the service does well: What has improved since the last inspection?
The manager has now successfully completed her registration as manager with the Commission after her ‘fit person’ interview. The three requirements left at the last inspection; regarding the fridge temperature for medication, staff training regarding adult abuse awareness and basic food hygiene have all been met. The home is currently undergoing a change in the heating system and new radiators are being placed around the home. The manager reports the home would be redecorated to make good the areas that were damaged as part of the process. A Malibu bath has been fitted in one of the communal bathrooms providing an alternative to the Parker bath for residents who need assistance with bathing. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 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. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 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 Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 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 the following standard(s): 2, 4 and 5 The preadmission procedures are thorough and ensure that residents have information available prior to moving in. EVIDENCE: Residents were all provided with a contract that detailed the bedroom to be occupied and overall care to be provided. Three care plans were assessed as part of this inspection and showed where residents needed specialist services that these were obtained, staff liaised with relevant specialists as well as having a variety of skills and knowledge themselves. Residents spoken with said they did not have trial visits but this was by choice. The registered visits all prospective residents prior to them moving in and ensures that sufficient information is gathered at the preadmission assessment to form an opinion as to whether the home could meet the person’s needs. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 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 the following standard(s): 7, 9, 10 and 11 Residents are well looked after with regards to their personal and healthcare needs and their privacy and dignity is maintained throughout their stay at the home. EVIDENCE: Three care plans inspected and provided detail as to how residents’ care is to be provided. Staff spoken with were aware of the importance of care plans all plans were reviewed regularly and amendments made as necessary. It was not always clear where a plan had been drawn up with the involvement of a resident or relative although diary notes evidenced where relatives were involved in reviews. None of the plans viewed had been signed by a resident or relative. A requirement had been left at the last inspection regarding monitoring the temperature of the fridge in the medication room. The registered manager has now obtained a new fridge and records seen showed that the temperature is kept at appropriate levels. This requirement is now met. All residents spoken with said that staff were very kind and always knocked before entering their bedroom and also made sure that their dignity was respected when providing personal care support. Staff observed throughout
Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 10 the day were courteous to residents and ensured doors were closed when assisting to the bathroom or the toilet. Residents were all clean and well presented without food spilt down their clothing their hair was brushed and clean. A relative commented ‘he’s always well presented when I visit’. There is a private room available to the side of the main lounge where a resident could meet with relatives or others in private. The home does not have any shared bedrooms. Care plans viewed provided evidence to show that residents’ wishes regarding their death were recorded including where it impacted on care provision such as resuscitation. There was evidence that discussion had taken place with the doctor and next of kin. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 11 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 and 14 Residents are assisted to maintain control and choice over their lives. EVIDENCE: The registered manager strongly promotes residents wishes to get out of bed when they want to. This often means that residents may well still be in bed by midday. Breakfast therefore runs throughout the morning with lunch starting at approximately 1pm but running until all residents who wish to have lunch have had it. Residents spoken with were very positive about this and felt that it gave them some control over their lives. Relatives spoken with said that the home had a visiting vicar who took services for those interested. The home employs an activities coordinator who arranges a variety of different things throughout the week. Relatives spoken with said that they felt there were enough activities for those residents who were interested. Information regarding activities was available on the notice board. Residents are able to see visitors where they want to, there is a phone if they wish to make or receive a call. Relatives spoken with said they were always made to feel welcome and felt that some of the staff had become friends. The registered manager holds regular residents meetings and minutes were available on the notice board. Not all residents were aware of care plans however some relatives were.
Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 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, 17 and 18 Procedures are in place to protect residents. EVIDENCE: All residents and relatives spoken with said that if they needed to complain they would feel confident that the manager would deal with it promptly. Where complaints have been made records are kept and information is audited by the organisation to ensure that everything that appropriate action is taken. The registered manager reported that residents are registered to vote, although no evidence was available to confirm this. Information regarding advocate services is available for those who want it. A requirement was made at the last inspection regarding staff training in adult abuse awareness, staff spoken with confirmed that they had attended this training last year, staff training records also confirmed this. Those staff who are new are to attend at the earliest opportunity. This requirement is now met. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 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): 20, 21, 22, 23 and 25 The environment meets the needs of the residents and is safe. EVIDENCE: During a partial tour of the building the toilets and bathrooms were inspected. There are three accessible toilets near the lounge/ dining room. Each floor has access to an assisted bath or shower, all bathroom or shower rooms also have toilets in them. All bedrooms in the home are ensuite. Fixtures and fittings are of good quality and are homely in character. Residents are able to ventilate their bedrooms if they so wish and regulate the temperature of the radiators. Random sample of taps were run and water was kept at an appropriate temperature to minimise the risk of scalding. Throughout the home there are hoists and other aids to promote residents independence where possible, evidence was seen that these are regularly maintained to ensure they are safe. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 14 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 and 30 It is not clear that sufficient staff are employed to meet the needs of residents. EVIDENCE: Throughout the inspection residents and relatives spoken with all commented on how busy staff were and there never seemed to be enough around. Staff were observed throughout the day performing various tasks such as assisting residents with personal care. Although staff were kind and did not rush residents, staff did not appear to have opportunity to spend time with residents other than in a functional role. A number of residents needed two staff to perform tasks such as bathing or transferring from their chair to wheelchair with a hoist. The registered person must ensure that staffing levels are consistent with the dependency needs of residents. Staff spoken with confirmed that they were able to access training including NVQ training ensuring that the staff group are trained and competent to carry out their role. Staff spoken with confirmed that they received induction training and that training is paid for and time is given ensuring that training can be attended. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 15 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, 32, 34, 35, 36, 37 and 38 Residents benefit from a well managed home where their health and safety and that of the staff is protected the risk of accidents is minimised. EVIDENCE: The Commission following a ‘fit person’ interview has now confirmed the manager as registered manager. The manager has clear understanding of her responsibilities as registered manager and takes her role seriously particularly when undertaking recruitment and training. She is only responsible for one home there are clear lines of accountability within the BUPA structure. Staff spoken said that the manager gives a clear direction regarding the standards expected. Residents found the manager approachable and felt able to be involved in decision making within the home. Comments were made that
Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 16 the manager ‘runs a tight ship’. Evidence was seen that appropriate insurance for the running of the business is available. Written records are maintained for all residents’ possessions coming into the building. Following a recent complaint regarding money allegedly going missing the manager has improved procedures to minimise risk. Staff spoken with confirmed that they receive regular supervision that covers their development needs as well their care practice skills. All records inspected were up to date and stored in accordance with the Data Protection Act 1998. BUPA has a number of systems in place to ensure that the home is well maintained and all health and safety checks are carried out in line with legislation. Documentation was seen to show that this is carried out in a thorough manner and any maintenance carried out and recorded. All accidents and incidents are recorded, these are audited on a monthly basis and evidence was seen that accidents and incidents within the home have been decreasing over the last few years. Staff receive all mandatory training thereby ensuring the residents and the staff safety. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 17 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 X 3 3 N/A X 3 3 3 3 X 3
X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 X
3 3 3 3 4 Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 18 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 OP27 Regulation 18 Requirement The Registered Person must ensure staff are employed in sufficient numbers to meet the dependency needs of residents Timescale for action 01/04/06 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 Refer to Standard OP37 Good Practice Recommendations Residents are more involved in keeping their care records up to date. Willow Brook Care Home DS0000026427.V279927.R01.S.doc Version 5.1 Page 19 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
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