Inspection on 28/03/08 for Willow Brook Care Home

This inspection was carried out on 28th March 2008.

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 06/09/07

Willow Brook Care Home 21/09/06

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 Lee West Unannounced Inspection 28th March 2008 10:30 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.V359722.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Brook Care Home DS0000026427.V359722.R01.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) www.bupa.com BUPA Care Homes (AKW) Ltd *** Vacant *** 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.V359722.R01.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 6th September 2007 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 are 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. The current charges are £290 to £636 dependent on whether residential or nursing and the level of care required. There are separate charges for hairdressing and newspapers. The service user guide, statement of purpose and most recent inspection report Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 5 are available in the entrance hall and the current Certificate of Registration is also on display. Due to changes of registered manager, and removal of the Terminal Illness category, this certificate requires updating. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and involved two inspectors, one a Pharmacist Inspector. The main method of inspection used is “case tracking”, which involves selecting four residents and looking at the quality of the care they receive by speaking with them, observation, reading their records, and asking staff about their needs. Members of staff and visiting relatives were also spoken with. The Commission had been informed of some errors within the service’s medicines procedures and it was decided to involve the Pharmacist Inspectors, to inspect this area for the protection of residents. The Pharmacist Inspector carried out an in-depth audit of the home’s Medicines policies and procedures, ordering, storage, administration, recording and disposal. His findings are contained in the body of this report in the Health and Personal Care standards section. Documents, including care plans and financial records were inspected to help form an opinion about the health, safety and welfare of residents at the home. Information supplied to the commission by the manager, on the Annual Quality Assessment, with information received by the Commission about the home, since the last inspection, were also considered, and helped the decision of which areas to focus on. The acting manager for this service has only been in post for the past seven weeks, but is supported by a BUPA Regional Manager and a mentor from Leicester, and is at present in the process of applying for registration as manager. The quality rating for this service is one star. This means people who use this service experience adequate quality outcomes. What the service does well: Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 7 The home is clean and well maintained, with regular tests and servicing of equipment at the suggested intervals, to make sure staff and residents have their health and safety protected. The activities Co-ordinator takes a life history of each resident, creating a picture of their personal preferences, religion, culture and wishes, to try to maintain their individuality, and this is used to form part of the home’s plan of activities, which helps with the day to day well-being of residents. Residents said the activities organised have been “fantastic, we’ve had trips out as well as things going on in the home.” There is an information board which is easy to see on the wall, in the reception area for visitors, letting them know what’s going on and also about the relatives’ meetings, and helps them and their families to feel involved in what is happening in the home. The home has, according to one resident, “A warm, homely feeling.” Vases of fresh flowers were placed around the home, enhancing the homely atmosphere. Regular checks of medication administration are made by senior staff to ensure that residents received medicines correctly and staff take time to administer medicines with a drink in a dignified way. What has improved since the last inspection? What they could do better: Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 8 Care plans must include input from the resident, or their representative, when being developed, or reviewed, to ensure care is carried out in the way they prefer. Residents’ moving and general mobility must be assessed within the care plans and the use of wheelchairs, or other mobility equipment needed, identified, to make sure aids to mobility are suitable for residents and not for the ease of staff moving people around. Improvements need to be made to the process for receipt of medication to ensure medicines are put away correctly and that records are completed to ensure staff know that medicines are available. Details must be completed fully to ensure that staff know what strength of medicine and how to give medicines correctly, when entries are handwritten on the Medicines Administration Records. Fridge storage temperatures are taken regularly but staff must take appropriate action when temperatures are regularly outside the recommended range. This needs improvement to ensure residents receive medicines that have been stored appropriately to reduce the chance of deterioration Staff training must be undertaken and recorded, to make sure they have the necessary skills to care for the home’s residents. In particular new staff require thorough induction, as well as longer serving staff requiring updated training, to include current procedures in medicines administration and storage. Staff appraisal and supervision must be undertaken regularly to make sure their skills and personal development requirements are dealt with, so they provide a competent service to residents that promotes their protection and well-being. 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 Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 9 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.V359722.R01.S.doc Version 5.2 Page 10 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): 1, 3, 6, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available for people to make a decision about the suitability of the home to meet their needs. Assessments are carried out which identify the person’s history and needs and information is passed to staff when new residents move into the home. There were no residents receiving short term care at the time of this visit. EVIDENCE: Comprehensive information booklets were on display and provided to new residents who may wish to move into the home to help them make a decision about the suitability of the home and its facilities, to meet their needs. A resident spoken with said they had got a copy of the information and was given the opportunity of visiting the home before moving in. “They answered all my questions and showed me round.” Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 11 A completed pre-admission assessment for a person who may be moving into the home was seen. This was thorough, included personal history, as well as particular cultural and religious preferences and identified the care needs and support the person needed. Staff had potted histories of new residents, which they said helped them to start conversations with them, helping them to settle. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 12 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, 10, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents’ care plans focus heavily on clinical aspects and tasks and are not person centred, nor do they identify the person’s individuality and diversity. Care plan reviews did not contain evidence of any input from the residents, leading to reviewed plans continuing to be clinically focused. Medication Administration Records (MAR) were generally up to date. Policies are in place for the management of medication but staff do not always follow them. EVIDENCE: The four care plans case tracked had assessments containing information about the person’s health care needs. The assessments had a number of gaps in particular in the areas of religion, individual preferences and wishes, which led to care plans focused mainly on the clinical needs of residents, and were not person centred. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 13 Information provided in the Annual Quality Assurance Assessment stating what the home does well described, “a comprehensive suite of policies and procedures and the Royal Marsden manual of Clinical Nursing Procedures.” “Any pressure ulcers are recorded,” and “all residents have a nutritional screen,” which reflected the clinical nature of the care planning. There was no indication of how residents’ diversity was addressed. A pre-admission assessment completed for a resident about to be admitted though was completed thoroughly, and identified the person’s history, preferences and culture, as well as care needs. There was evidence in the care plans of reviews having taken place, but there was no evidence of any input from the resident. One plan review said, “on and off with eating,” and another said, “on and off with scratching when being hoisted.” Comments that did not adequately describe, or address the changing needs of residents, which could create a negative impact on the well-being of residents. The nurses spoken with said they were responsible for care plans and their reviews, but with the shortage of staff it had become difficult to maintain reviews and care staff spoken with also said they didn’t get involved with care planning. Relatives said they had never been asked to be involved with care plans, and one said they were unaware of a care plan. During the visit I spent time in the lounge and dining areas of the home and noted there was a high number of people who were sitting in wheelchairs and at lunchtime this number increased as people were wheeled to the tables for their meals. On speaking to some of the residents in wheelchairs, they said they would prefer to be in what one lady called, “proper chairs.” Another said he was able to walk, but the staff preferred to use the chair, “In case I fall.” Two residents spoken with had their own wheelchairs, and said they preferred to stay in the chairs. None of the care plans seen had any indication of the mobility capabilities of residents, or equipment needed to support their movements safely around the home. None contained any information about the use of wheelchairs, which could indicate a lack of choice by the residents, and that wheelchairs were being used for staff convenience and not resident need. Residents spoken with said they were satisfied their care needs were being met and staff treated them with respect. The interactions between staff and residents were observed to be positive and supportive and the activities co- Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 14 ordinator was particularly dynamic in respectful interactions with residents, who were observed responding cheerfully to her. Improvements had been made in signing Medication Administration Records (MAR) and recording reasons why medicines had not been given. Senior staff regularly check records and medication to ensure that staff are administering medicines correctly. Full information of allergies, service users ‘preferred’ names and GP’s name were not recorded on the MAR. This information needs to be completed to ensure medicines are given correctly, appropriately and to the right person. Handwritten entries on MAR could be read clearly although some details were incomplete for example full administration instructions were not always recorded. Records can be improved by ensuring they are an exact copy of the dispensing label, which is then double-checked and countersigned. The dosage, quantity or the number of units was not always the same on the MAR and dispensing label. The community pharmacy or prescriber should be contacted to rectify any changes or errors on medicine labels. There was no documented risk assessment in the relevant care plans for residents with creams stored in their bathroom cabinets. Documented risk assessments are essential to ensure residents are fully supported and protected. There was a lack of organisation of medicines received from the community pharmacy. Medicines were not always handled and recorded in a timely manner on receipt into the home. There was shortage of staff to receive and put medicines away promptly, no clear work surfaces and insufficient storage facilities. The Pharmacist Inspector found medicines received from the community pharmacy from the day before still remained unchecked and not put away correctly. This was confirmed when observing and speaking to care staff. A resident had not received medicine on the day of the visit because it was still in bag of medicines received from the community pharmacy and staff thought it was not in stock. A review of these arrangements is required to ensure care staff receive and handle medicines efficiently. Staff did not make full use of patient information leaflets when supplied, that gave information, for example about correct storage and possible side effects. There was confusion in storage requirements of medicines for the fridge and dating medicines when first opened. Administering medicines not as instructed by the patient information leaflets and manufacturers specification can affect Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 15 the way they work and can increase the chances of service users being placed at unnecessary risk All medicines were locked in dedicated cupboards that were secure. However fridge and storage temperatures were not appropriate for all medicines in the home. Records showed that injections had been kept at temperatures below freezing that may have caused the medicine to be less effective. When this was raised with the manager a new fridge was ordered immediately and steps were taken to ensure correct storage until the fridge arrived. Previously there was an error reported of an injection administered to another resident. Several injections were in use and there was a risk that they may be administered incorrectly to another resident. Staff confirmed that in future these injections would be kept in correctly labelled closed containers for separate residents. Arrangements for the recording and storage of controlled drugs were in place. However the CD cabinet contained an item of jewellery and should be used for storage of controlled drugs only. The Nurse in charge of medicines said all relevant carers had recently received medication training and were waiting for their certificates. However it was evident that some carers were not following the policies and best practice, regarding basic handling of medicines. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 16 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, 15, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ activities have improved, with an interesting array of activities, using life maps and individual’s interests to help develop them and relatives and friends are kept informed to help maintain contact and a sense of belonging. Meals are nutritious, healthy and choices are provided. EVIDENCE: The activities co-ordinator, who has been in post since September, works 5 hours each day and observing her with the residents, she demonstrated her enthusiasm for the work. She was in the dining and lounge areas with residents, was very bubbly and motivated. I was shown a number of photographs from parties, and activities throughout the year. Burns night was celebrated with bagpipes and also a valentine’s celebration A visit to Chatsworth house to see the Christmas decorations and have a meal out had also been organised and photographed. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 17 Residents spoken with about activities said they were really good, interesting and fun. Relatives spoken with said, “Activities had greatly improved since the coordinator came on the scene. The trip to Chatsworth was very cold, but lots of fun for everyone.” There was information for relatives and residents on the notice board in the reception area, and minutes of the last resident and relative meeting were seen. The next meeting scheduled for 15th April 2008. Relatives said they were aware of the notice board and that it kept them up to date with what was going on. They also said they were always made to feel welcome at the home, offered drinks and could also have something to eat if they asked. Everyone spoken with said they were satisfied with the food and the lunchtime meal looked appetising and nutritious. The dining area was clean and pleasantly set up with table decorations and flowers around the room, to enhance the social aspect of meals. Meal times are set, but people can choose when to eat. One lady, who said, “I like my bed and prefer to stay there,” arrived for her breakfast at 11:30, and this was provided for her in a dignified, pleasant manner, providing evidence that this was not an unusual episode, supporting the freedom to choose for this person. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 18 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, 18, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns through the home’s complaints procedure, and are protected from abuse. EVIDENCE: A copy of the complaints policy was available in all residents’ bedrooms, and also in the reception area of the home and complaints records were seen, which showed the system in place to deal with and monitor complaints. Residents spoken with said they would speak to staff if they had any problems. One said, “It is much easier to say things now, the new manager is very approachable and listens to what I say. Things are much better now.” Another stated there had been an issue about staff not contacting them to let them know there was a problem, and the new manager had sorted this out very quickly. Staff said they were aware of their role in safeguarding adults, what abuse was and who to report it to, safeguarding residents from harm. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 19 Records showed that not all staff had received training in safeguarding and whistle blowing, but the matrix was seen demonstrating this was being undertaken by BUPA, to make sure residents remain in safe hands. Residents said they felt safe with staff, who treated them with respect and relatives said they felt their relative was in good hands, with the home’s staff looking after them well. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 20 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, 22, 23, 24, 25, 26, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained and comfortable environment, with personal possessions around them. EVIDENCE: The home was clean, warm and well lit. There was a homely atmosphere, and vases of fresh flowers were scattered around all the communal areas, which provided pleasant fragrances, as well as being pleasant to see. Residents said the flowers were changed regularly, and “they make the place very springlike.” All bedrooms had en-suite facilities and were well maintained, with residents’ personal possessions around them reflecting their individuality. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 21 Specialist beds and hoists being used to support the care needs of residents were seen to be in good condition and the Annual Quality Assurance Assessment supported this with evidence of the date of servicing. Residents said they liked their bedrooms, that they were comfortable and were able to have as many possessions around them as they wished. One resident, who stayed in their room all the time said, “I’ve got my room just as I like it and I have a lovely view out of the window.” The bedrooms seen, of those people who were being case tracked, were well maintained, each had a cupboard with a lockable drawer to provide security for valuables. Personal photographs, ornaments, televisions and radios were amongst the possessions residents had in them. The outside of the home was pleasant and accessible to all residents if they wanted to go into the garden area. The communal lounge and dining areas were clean and well maintained with the television lounge in one area, so people who did not wish to see the television did not have to, as the second lounge area had armchairs scattered around in small groupings to encourage socialisation. Residents were observed playing dominoes, reading and chatting with each other in this area, supporting their well being. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 22 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, 30, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing levels have increased to meet the care requirements of residents, and a training programme undertaken to make sure staff are skilled and competent in their role as carers. EVIDENCE: Before the new manager took up her post, the Commission was provided with information by the service that there were severe shortages of staff. The duty rota was inspected and there were now sufficient staff working to meet the care needs of residents. Agency carers and nurses were included in the rota to ensure sufficient carers were working during each shift. Residents said there had been some difficulties around Christmas, but, “things had got much better since the new manager came into the home.” Discussions with the manager explored the strategies she was using to try to encourage potential recruits of the right calibre and there was evidence of the Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 23 service trying to recruit new staff, also a banner on the outside wall of the home displayed dates of recruitment days. Staff files were inspected and they contained all the information and documentation needed to make sure residents were properly protected. Criminal Records Bureau checks were in place, as well as proof of identity, professional references and previous training and experience. There was though, a lack of evidence of training. One new carer, with no previous experience, who started work earlier in the year, had no records of any induction or other training, including moving and handling, fire training, or first aid. Another file showed there had been no training since Fire training in March 2007. None of the files contained any evidence of induction training. I spoke with 3 carers during the lunchtime and they all said they were very anxious about the staffing levels over Christmas when they were severely understaffed, and without any agency carers. They also said there was a severe lack of training, one had been working at the home for 3 years and had had no training, and had not had any appraisals either. However, they said they felt the new manager was listening to them. Trained nurses spoken with said they had found it difficult with staff shortages to keep up to date with things, particularly care planning and reviews, but felt they had been able to make a start since the new manager came into post. They said they felt supported by the manager. The manager explained how she had organised the training and the training matrix with dates organised was seen. Training was being supported by BUPA, which included helping staff to achieve their National Vocational Qualifications, as well as moving and handling, basic food hygiene, fire procedures. Other training was programmed to follow this. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 24 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, 36, 38, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, with quality assurance systems developed to maintain, or improve, the health, safety and wellbeing of residents and staff. EVIDENCE: The new manager has been in post for seven weeks and during this period has demonstrated her skills with improvements put in place, which include, raising staffing levels, carrying out thorough pre-admission assessments which were seen to be person centred and being open and approachable to staff and residents. The manager is in the process of applying to become the registered manager. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 25 A resident said, “The manager is a good person to me. She is very caring and always listens.” Another said, “Things are beginning to get a bit better since she started. She is very approachable and will listen if we have a problem. The staff have been very overworked and at Christmas there was a lot of carers not here.” Residents said they felt the home was now being run in a way that helps them feel in control. Staff also expressed that they thought the new manager had, “brought a sense of order into the home since she became manager.” However, as mentioned previously in this report, there was a high proportion of residents in wheelchairs, not mobilising independently, and this could have a negative impact on their choices, as there was no evidence within the care plans to indicate the need for wheelchair use, any other mobility aid, or other interventions to support their independent mobility. Residents remain in control of their finances, where possible, and personal money and valuables are kept securely, to reduce the risk of personal, valuable items going missing. They have access to their own funds whenever they wish and the administrator keeps written records of all financial transactions, which were checked at this visit and found to be up to date and accurate. Residents said they were comfortable with the way their money was taken care of and, “I can get my money whenever I need to.” None of the staff files contained any information about staff supervision, and staff said they had not had appraisal, or supervision, over the last year. The new manager discussed how this was to be addressed, with the new deputy, due to start shortly, being involved in staff training and supervision, and training had been organised for April for nursing staff to supervise carers. However, this had not yet been implemented. BUPA Care Homes has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts to support the quality assurance system and annual plan for the home, with resident, family and staff questionnaires continuing to form part of the process. The Annual Quality Assurance Assessment contained good information which was supported by evidence gathered during the inspection visit, and demonstrates a high level of awareness by explaining the areas still needing improvement and detailing ways in which these improvements can be made. Evidence was seen of routine checks carried out by the maintenance person, such as fire safety system checks, and maintenance records, including evidence of maintenance of equipment, such as specialist baths, hoists and Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 26 special beds, as well as general maintenance issues around the home being dealt with, supporting the health and welfare of residents and staff. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 28 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(2) Requirement Care plans must include input from the resident, or their representative, when being developed, or reviewed, to ensure care is carried out in the way they prefer Residents’ moving and general mobility must be assessed within the care plans and the use of wheelchairs, or other mobility equipment needed, identified, and risk assessed, to make sure aids to mobility are suitable for the individual resident Systems must be put in place to ensure medicines are ordered and received into the home appropriately so that prescribed medicines are available at all times to administer according to the prescribers instructions Medication must be stored according to the manufacturers specification to ensure that medicines do not deteriorate or become contaminated. Staff training must be undertaken and recorded. Including medicines DS0000026427.V359722.R01.S.doc Timescale for action 23/06/08 2. OP7 13(5) 23/06/08 3. OP9 13(2) 30/05/08 4. OP9 13(2) 30/05/08 5. OP30 18(1)c 23/06/08 Willow Brook Care Home Version 5.2 Page 29 6. OP36 18(2) administration and new staff who require thorough induction appropriate to the work they perform, to make sure they have the necessary skills to care for the home’s residents. Staff appraisal and supervision 23/06/08 must be undertaken regularly to identify their skills and personal development requirements to make sure they can provide a competent service to residents that promotes their protection and well-being 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. 5. Refer to Standard OP9 OP9 OP9 OP9 OP9 Good Practice Recommendations Additional Patient Information Leaflets should be kept in a file for up to date information on medicines to enable staff to store and administer medicines correctly. Any medicines left in the resident’s room should be risk assessed and regularly reviewed. Securely store individual service users containers for injectable medicines in preparation for administration by District Nurses. The policy and procedures for handling medicines should be included in the induction of both new and agency staff. Ensure any known allergies are recorded on the Medicines Administration Record (MAR) or “nil known” where appropriate. To liaise with the supplying pharmacist, to include both resident’s full name, “preferred” names and GP. Willow Brook Care Home DS0000026427.V359722.R01.S.doc Version 5.2 Page 30 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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