Inspection on 12/09/08 for Willow Brook House

This inspection was carried out on 12th September 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willow Brook House 16/12/09

Willow Brook House 02/09/09

Willow Brook House 27/06/07

Willow Brook House 19/01/07

Willow Brook House 04/10/06

Willow Brook House 01/02/06

Extracts from inspection reports are licensed from CQC, this page was updated on 14/11/2008.

CARE HOMES FOR OLDER PEOPLE Willow Brook House 77 South Road Corby Northants NN17 2XD Lead Inspector Kathy Jones Unannounced Inspection 12th September 2008 08:15 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 House DS0000065185.V371355.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 House DS0000065185.V371355.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Brook House Address 77 South Road Corby Northants NN17 2XD 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) 01536 260940 01536 260941 willowbrookhouse@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Vacant post Care Home 48 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No person falling within the OP category can be admitted where there are 25 people of the OP category already in the home. No person falling within the PD(E) category can be admitted where there are 25 people of the PD(E) category already in the home. No person falling within the DE(E) category can be admitted where there are 23 people of the DE(E) category already in the home. The total number of Service Users in the home must not exceed 48. Date of last inspection 27th June 2007 Brief Description of the Service: Willow Brook House is a care home providing personal care and accommodation to forty eight older people over the age of sixty five years. Up to twenty five people may have a physical disability and up to twenty three people may have dementia. The registered provider is Ashbourne (Eton) Ltd, which is owned by Southern Cross Healthcare. Willow Brook House is a purpose built facility located in the Old Village area of Corby Northampton, with local community shops nearby. There are two floors; residents with dementia are located on the lower floor and residents with a physical disability on the upper floor. All bedrooms are for single occupancy and have en-suite facilities. There are 23 bedrooms on the lower floor and 25 bedrooms on the top floor. Communal dining rooms, lounges and bathrooms are located on both floors. The following fees were detailed in the ‘scale of charges’ provided as being current at the time of inspection: Fees range between £341.55 and £570.00. The scale of charges states the fee will be determined by the assessed needs and the room chosen. The service user guide identifies that fee rates are negotiated with the local authority on an annual basis based on the number of people they place. The guide states that fees may vary for people who are self funding and that these people may have different or additional facilities. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 5 The fees include personal care, accommodation, meals and laundry. Chiropody and hairdressing services can be arranged and are charged separately. Other costs would include personal expenditure such as newspapers, clothing and toiletries. Information about the service including the most recent inspection report are available in the foyer. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the service, collating information received in surveys received from relatives, people who use the service and staff and drawing together all of the evidence gathered. Surveys were forwarded to eight named people who use the service, eight named staff randomly selected and the General Practitioner. Two surveys from people who use the service, which had been completed with the help of their relative, and a survey from a member of staff were received. The pre-inspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact and correspondence with the home and previous inspection reports. The last full inspection (this is called a key inspection) took place in June 2007. Information from this inspection was taken into account as part of the planning. This unannounced inspection visit was carried out over a period of a day. There were two inspectors for most of the day. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. Observations of the homes routines and care provided were made and views on the care provided were sought from people who use the service, visitors and staff. Because Willow Brook House provides care for people with dementia and they are not always able to tell us about their experiences, we have used a formal way to observe people to help us understand their experiences. We call this method of observation a Short Observational Framework for Inspection (SOFI). This involved us observing up to five people who use services for two hours and recording their experiences at regular intervals. This included their state of well-being, and how they interacted with staff members, other people who use services, and the environment. The management of residents’ medication was checked through reviewing prescribed medication for a sample of people. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 7 A sample of staff files were reviewed to check the adequacy of the recruitment procedures in protecting people who use the service. Communal areas and a sample of bedrooms were viewed and observations were made of people’s general well being, daily routines and interactions between staff and people who use the service. Verbal feedback was given to senior staff throughout the inspection and some to the new manager who arrived towards the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Care plans were not in all cases reflective of people’s needs and did not provide staff with sufficient information to be able to provide consistent care appropriate to people’s needs. Linked with the required improvements in the care plans there needs to be better systems for monitoring people’s health where concerns and risks have been identified. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 8 Improvements are needed to the management of people’s medication to ensure that they are receiving it as it has been prescribed. Staff training needs to be arranged to ensure that all staff have received up to date training to enable them to meet the specific needs of people who use the service. This should include dementia care and movement and handling. Recruitment procedures need to be more rigorous to ensure that people who use the service are properly safeguarded. 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 House DS0000065185.V371355.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 House DS0000065185.V371355.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. Standard 6 is not applicable, as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a thorough assessment process, which provides assurances that the needs of people admitted to the home can be met. EVIDENCE: Information is available to people considering using the service and their families in the form of a statement of purpose and service user guide. A copy of the documents and a copy of the most recent inspection report are also available in the foyer. We spoke with one person who had been admitted to the home in the last few months who said that she had visited the home prior to admission. She was unable to recall if she was given a statement of purpose but her comments indicated that her expectations were being met. “I like spending time in my Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 11 room. I have my own belongings with me” “I am happy here” “Staff are all nice and helpful” “I’ve settled in well” We also met someone who had just arrived with their family who were helping her to move in. Family members confirmed that they had visited Willow Brook House while their relative was in hospital and had been given a brochure containing some information but did not recall being made aware of the statement of purpose or service user guide which provide more detail about Willow Brook House and the services provided. It is important that people have as much information about the services provided to help them make an informed decision when choosing a care home. A sample check of people’s care files confirmed that an assessment of their needs is carried out prior to admission. The information gathered as part of the assessment, which also included information from the placing authority was sufficiently detailed to make this decision. This is important in helping to ensure that people’s needs are known and can be met, helping to avoid unnecessary moves for people. Willow Brook House DS0000065185.V371355.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. While some people are happy with, and appear to receive a good standard of care, the shortfalls in the care planning, monitoring of people’s health care needs and management of their medication in some instances puts people at risk. EVIDENCE: Two surveys from people who use the service were received which had been completed with the assistance of a relative. One responded that they usually get the care and support that they need and the other that they always do. Each person had his or her own individual plan of care that was contained within a file. Not all files contained a photograph of the resident, which is important in helping new or agency staff to easily identify people. This is particularly important with people who may not be able to communicate very well and are not always able to introduce themselves. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 13 Care plans varied in the level of information about residents individual preferences such as their preferred name, where they preferred to eat, food likes and dislikes and what time they liked to get up in the morning and retire at night. They would however benefit from being more person centred. It was evident that staff are working to include people’s preferences and some were very specific, however others contained very general statements such as “offer choice from menu”, “ensure has regular access to hairdresser and chiropodist”. On initial viewing of the individual care plans they appeared to contain basic information that staff require in order to meet peoples’ health and personal care needs. There was also evidence that care plans were reviewed and updated on a regular basis. However when talking to staff about people’s individual needs it was apparent that more detailed information is needed to ensure that care plans are reflective of people’s individual needs and support their care. One example of this was a movement and handling plan did not include the specific movement and handling needs of someone with Parkinsons disease. Individual plans of care contained risk assessments that were reviewed regularly and covered areas such as pressure care, moving and handling and risk of falls. It was not clear in all cases how the risks identified were being managed. For example one assessment relates to the risk of constipation, and for one person whose care files were reviewed they had been identified as being at medium/high risk. This person was also prescribed medication where one of the side effects is the risk of constipation. There was no care plan in place or evidence of a consistent monitoring system. Personal care record sheets showed when people had received help with basic personal care tasks. There were however some gaps within these making it difficult to identify whether people were receiving the necessary support in this area. People’s records showed involvement from other professionals such as general practitioners, opticians, chiropodists, continence advisors, audiologists and district nurses. One person who uses the service spoken with during the inspection confirmed that staff arrange an appointment with the General Practitioner when asked. Staff were also heard reporting health changes which they had noticed to senior staff and making appointments with the General Practitioner. We looked at a sample of medication administration records and medication to see how well people’s medication is being managed. A requirement had been made at the previous inspection about the need to make sure that people’s prescribed medication is always available. We checked this for two people and found that all of their medication was available. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 14 We were however concerned that in one case medication was not being given as prescribed. The medication is generally prescribed for pain relief and was in the form of slow release patches, which were to be applied every seven days. Medication administration records were marked with the code ‘N’ which is described as “offered PRN not required” (PRN is a term used to describe medication that the General Practitioner prescribes to be given as and when required). There was no care plan for pain management or indication of the specific condition or pain the medication is prescribed for and no evidence of consultation with the General Practitioner prior to changes to the administration of this medication. The person whose care plan is referred to above told the inspector that they had an appointment with the General Practitioner that day to review their pain relief. A sample check of daily records shows various entries where complaints of pain have been made. The Manager was informed of the concerns on the day of inspection and asked to ensure that the medication was given as prescribed. A requirement was also made in an urgent action letter sent following the inspection and prior to completion of this report. Staff were observed to treat people with dignity and heard to speak to them in a respectful manner. Residents all looked well presented and as if they were able to express their individual preferences and personality through their style of dress. A hairdresser visits the home on a weekly basis and residents can use her services if they wish to do so. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 15 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. People are supported in their daily routines, the majority are happy with the meals and activities and visitors are welcomed, enhancing their daily lives. EVIDENCE: Observations were carried out of people’s daily routines during the inspection and where possible people spoken with. As detailed in the introduction because people with dementia are often not able to tell us about their experiences we observe their routines for a period of time and the interactions they have with staff and others. These observations identified that staff were engaging and interacting positively with people. Staff appeared vigilant to residents needs for example checking whether television was audible and checking if residents were comfortable with temperature of lounge. One person spoken with was enjoying visiting a friend of over 50 years who staff had identified as living on another floor within the home. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 16 On the day of inspection some people who use the service were observed enjoying a bingo session. A lady commented that she enjoyed watching a film in the lounge after lunch and then liked to watch the news in her room in the evening. Confirmation that activities are usually provided was received from a relative in a survey “my mother is enjoying the activities and company. The activities are well organised and appropriate to the residents needs”. On the dementia unit there was sensory equipment that comprised of a bubble tube, fibre optic cables and a projector that displayed colourful images onto the wall. One person was observed sitting and watching these images. Another person had a baby doll, which she appeared to derive comfort from looking after. There is a flexible visiting policy and people were seen to enjoy visits from family and friends. Breakfast on the ground floor looked appetising, a cooked breakfast of scrambled eggs and tomatoes was offered, with some people choosing to have just cereal and toast. People who use the service said that the breakfast menu changes which gives some variety. The tables in the dining room were nicely laid with clean cloths and cutlery. Staff were observed gently encouraging residents on the dementia unit to eat and drink more. Meal time observed was a sociable time with staff encouraging social interactions with residents. The cook explained that the residents have one choice of main meal each day but other options are available to cater for individual preference or special dietary requirements. On the day of inspection a cooked breakfast or toast and cereal was available for breakfast, fish and chips was the main course at lunch time and ravioli and sandwiches was available for tea. The food looked and smelt appetising. One person who uses the service commented, “I like the food”. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 17 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. There are procedures for reporting and investigating concerns and complaints, which people who use the service and their relatives are aware of. There is evidence that complaints are taken seriously and shortfalls acknowledged. EVIDENCE: The Commission for Social Care Inspection (CSCI) have received no recent complaints about the service. Information supplied within the annual quality assurance assessment submitted to CSCI confirms that complaints have been received directly by the service. A sample check of the complaint record kept at Willow Brook House during the inspection confirmed that complaints are investigated, shortfalls acknowledged and plans put in place to address any concerns. One incident was referred to social services under the safeguarding vulnerable adults procedures and social services were satisfied that this was addressed appropriately. A review in one persons file contained concerns raised by her relative about the décor and cleanliness of her bedroom. An inspection of the bedroom showed that these concerns had been addressed. Review of information on another persons file about an incident between people who use the service suggested that the incident was a one off and had been managed appropriately. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 18 Information about how to make a complaint is detailed in the service user guide. Contact details are provided for managers at different levels within Southern Cross in case people are not satisfied with how their complaint has been dealt with in the home. Information provided in surveys confirms that people who use the service know how to make a complaint and staff know what to do if they do. A relative stated “Mum doesn’t feel there is anything to complain about but does know who to talk to.” Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 19 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, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have a comfortable and clean environment to live in. EVIDENCE: A sample check of the premises, which included shared areas such as lounges and dining rooms and some people’s bedrooms found that these areas were clean and hygienic and that there were no unpleasant odours. Information received in surveys confirms that this is generally the case. The kitchen was also seen during the inspection and this presented as clean and hygienic. The walls in the dementia unit had been painted with colourful murals depicting amongst other things shop fronts, a bus stop and cats sat on a window sill. One person who uses the service said, “It looks lovely” A staff member said that people who use the service really like the pictures and Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 20 interact with them. This was evident with the picture of the cat, which a staff member said had been regularly stroked. The lounge on the dementia unit was light and comfortable, creating a pleasant place for people to sit. Bedrooms were clean and had been decorated and furnished to reflect people’s individual preferences. Each bedroom has an en-suite toilet and wash basin. All of the bedroom doors had locks on, which staff could override in an emergency. While talking to someone who uses the service he said that the maintenance man was fitting an additional lock to the en-suite bathroom following his request for extra privacy. There was an attractive garden area, which contained some bird boxes that residents had painted. Staff and residents fed the birds. This garden area is easily accessible from the dementia unit on the lower ground floor. People from the ground floor were noted to sit in a small space outside the front door which leads on to the car park. There is a grassed area, however it is quite a steep slope and therefore not accessible. The Manager advised that she was exploring the possibility of creating a suitable garden area for people on the ground floor. Information submitted in the annual quality assurance self assessment and discussion with the maintenance man confirmed that there is a programme for regular servicing and checking of equipment to ensure it is safe and properly maintained. There was evidence in an audit action plan developed by the Operations Manager following a visit on 03/09/08 that maintenance records are checked as part of the auditing process. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 21 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. People who use the service are positive about the staff team who care for them, however a more thorough recruitment process and more training is needed to provide better safeguards and meet the needs of people. EVIDENCE: Discussion with staff and information received in a survey identified that there are usually enough staff. One person who uses the service said, “sometimes there are staffing problems”. Two members of staff said there was sometimes a problem when staff call in sick at short notice but that everything is done to try and find a replacement and that staff work hard to meet people’s needs. Discussion with several staff throughout the inspection indicated that there has been an improvement in staff morale, which has helped to reduce sickness levels. Observations indicated that staff including those not directly involved in care, are working as a team and supporting each other, which in turn supports the people who use the service. Staff interactions with people who use the service demonstrated empathy, respect and a good knowledge of peoples individual communication needs and preferences. Staff were observed giving clear explanations to people about what they were doing and offering individuals choices within their capabilities. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 22 One person who uses the service was observed being verbally abusive to staff. The staff involved dealt with the situation in a calm and sensitive manner giving the person a clear, concise explanation for their actions. A survey completed by a member of staff confirmed that training is provided relevant to their role, which helps them to understand the different needs of people and keeps them up to date with new ways of working. They also said that they had received induction training, which covered everything they needed to know. Review of the matrix of staff training identified that approximately half of the care staff have achieved a National Vocational Qualification at level 2 or 3. This qualification provides staff with an understanding of the needs of older people and care practices. The training matrix identifies a number of shortfalls in staff training and discussion with the new manager following the inspection confirms that some action is being taken to arrange further training. It is important that staff have training appropriate to their role and the needs of the people who use the service. Given that Willow Brook House have a dementia unit, training in this area is considered to be particularly important in helping to ensure that people’s needs are fully met. Review of the training matrix against the staff rota identifies several staff working on the dementia unit who have had no training in dementia care. A member of staff confirmed in a survey that before they started work criminal record bureau checks and references had been carried out. The annual quality assurance self assessment stated that there is a robust recruitment process. However a sample check of two staff files identified that criminal record bureau checks are made, but there are concerns about the recruitment procedure in that a full employment history had not been confirmed and satisfactory references had not been obtained prior to people starting work. A similar requirement about recruitment was made at the previous inspection. A rigorous recruitment procedure is an important part of helping to protect people who use the service. The manager confirmed that she would review all staff files and undertake further checks if necessary. A requirement was made in an urgent action letter following the inspection to confirm the expectations for safeguarding people who use the service. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 23 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, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are positive signs of improvement, however consistent management arrangements and oversight by the organisation are needed to improve and sustain standards of care and safeguard people who use the service. EVIDENCE: Standard 31 relates specifically to the registered manager and their experience and qualifications. At the time of the inspection there was no registered manager in post, therefore this standard was not inspected as such. However it is considered from the perspective of the adequacy of the management arrangements, as this is considered a key aspect of ensuring that residents receive appropriate care. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 24 Willow Brook house has had a succession of managers. The manager in post at the time of the last inspection in June 2007 has since left and the current manager has been in post for just a few weeks. A survey completed by a member of staff stated that at the time of completion the current manager had just been in post for one month but that so fare she had been very helpful and supportive and acts on any queries or concerns. This view was supported by discussion with other staff during the inspection. Staff morale appeared to be good which has a positive impact on people who use the service. It is the expectation of the Commission for Social Care Inspection that an application for registration of a manager is submitted without delay and efforts are made to maintain consistent management arrangements to improve and sustain standards of care. As part of the quality assurance system, the organisation has internal systems where various audits are carried out to measure compliance with regulations and identify shortfalls. The Operations Manager also carries out an unannounced visits at least once a month to check on and report to the organisation on standards of care. A recent report appears more thorough and discussion with staff during the inspection confirmed that action is taken based on these findings. For example the content of the planned medication training had been revised to take account of shortfalls identified. It is important that these systems are in place to review and improve standards of care for people who use the service. Some people leave small amounts of money for safekeeping to assist with paying for services such as hairdressing and chiropody. This is kept in a central bank account, which accrues interest and is added to each individual account. A sample check confirmed that records are kept of all transactions and receipts kept to verify these. This helps to safeguard people. In a small minority of cases additional assistance is given to people with managing their finances. Advice was given regarding improving the safeguards for staff and people who use the service and to ensuring that the arrangements are part of an agreed care plan. Observations during the inspection were that staff were carrying out safe practice in relation to the movement and handling of people who needed assistance. Training records identify that staff do receive training in safe working practices, however the training matrix identifies some staff who have not received recent training in some areas including movement and handling. This is important to ensure that staff have the necessary knowledge and skills to reduce the risk for people who use the service. During the inspection cleaning staff were observed to have cleaning products on an open trolley. While staff appeared to be fairly vigilant and careful to keep these products close to them it was difficult when mopping a bathroom Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 25 and possible to remove a product unnoticed. This presents a particular risk to some people with dementia. Advice was given to look at either different working practices or a different type of trolley. Following the inspection the manager has advised that a different trolley is now in use. Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 26 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 Requirement Timescale for action 05/12/08 2. OP8 12 (1) (a & b), 3. OP9 13(2) Care plans must be reflective of people’s needs with sufficient information to guide staff in the care to be provided. People’s health and well being 31/10/08 must be monitored in accordance with the assessed risk. This must include the risk of constipation for those people unable to express a problem. A medication audit must be 26/09/08 carried out to ensure that people are receiving medication as prescribed. This requirement was made in an urgent action letter sent following the inspection. People must receive medication 31/10/08 in accordance with the prescriber’s instructions. A review of staff files must be 29/09/08 carried out to ensure that appropriate references and checks have been obtained to enable you to be satisfied that all people employed are fit to work with vulnerable people. This requirement was made in an DS0000065185.V371355.R01.S.doc Version 5.2 4. 5. OP9 OP29 13 (2) 19 Willow Brook House Page 28 urgent action letter sent following the inspection. 6. OP29 19 The recruitment procedure must include obtaining a full employment history and ensuring that employment references have been obtained before people start work to protect people who use the service. A similar requirement was made following the last inspection. Staff must receive training appropriate to their role and responsibilities to help them meet the assessed needs of people who use the service. This must include dementia care training. Staff must receive up to date training in safe working practices including movement and handling. 31/10/08 7. OP30 18 (1) (c) (i) 15/01/09 8. OP38 13 (4) (c) 13 (5) 05/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willow Brook House DS0000065185.V371355.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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