Inspection on 27/06/07 for Willow Brook House

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willow Brook House 16/12/09

Willow Brook House 02/09/09

Willow Brook House 12/09/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Willow Brook House 77 South Road Corby Northants NN17 2XD Lead Inspector Unannounced Inspection 27th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Brook House DS0000065185.V339442.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.V339442.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 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.V339442.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 19th January 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 provided by the acting manager as being current at the time of the inspection: Fees range between £331.31and £348.55 dependent on assessed needs for those funded by local authorities. Residents funded by the local authority will be asked for a ‘top up’ fee, which varies according to their ability to pay. Fees for self-funded residents range between £500 and £550 dependent on the room. The fees include personal care, accommodation, meals and laundry. Chiropody and hairdressing services can be arranged and are charged separately. Other Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 5 costs would include personal expenditure such as newspapers, clothing and toiletries. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. 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 the information held by the Commission for Social Care Inspection as part of the pre-inspection planning and an unannounced inspection visit to the service. The pre-inspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls, letters, and details of any complaints and concerns received. The report from the last key inspection carried out on 19 January 2007 and the random inspection carried out on 22 March 2007 were reviewed and the findings taken into account when planning this inspection. The random inspection was carried out to check compliance with requirements made at the January inspection. The information gathered assisted with planning the particular areas to be inspected during the visit. Prior to the inspection an annual quality assurance assessment (self assessment) was requested by the Commission for Social Care Inspection. Some reference to part of this has been made in this report, however this is a new document and advice has been given regarding the level of detail and evidence required for the future. Following the inspection and prior to completion of the report two questionnaires were received from residents and another two from relatives. These views and the views of residents’ and relatives spoken with during the inspection have been incorporated in the report. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting residents’ and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. Some of the residents’, particularly those with dementia were unable to express their views on the care provided, therefore observations were made of their general well being. The inspector also spoke with other residents’ who were not part of the case tracking process. A sample of staff files were reviewed to check the adequacy of the recruitment procedures. Communal areas and a sample of residents’ bedrooms were viewed and observations were made of residents’ daily routines. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 7 Some feedback on the inspection findings was given to a senior member of staff at the time of the inspection. The findings were also discussed with the Acting Manager in a telephone call the day after the inspection. What the service does well: What has improved since the last inspection? Comments received from relatives and residents indicate that standards of care have improved. This was confirmed by observations during the inspection. Care plans that guide the care provided to residents were more reflective of residents’ needs, assisting staff in meeting individual needs. Comments from relatives, residents’ and staff are that there has been an improvement in the quality of the meals provided. Problems with the lack of hot water in some en-suite bathrooms have been resolved since the last key inspection. Staffing levels had improved and there had been a reduction in the number of agency staff used resulting in residents’ getting the help that they needed. The morale of staff had also improved which helped to create a more relaxed atmosphere in the home. Assessments were in place to determine the suitability and safety of bed rails for individual resident’s prior to use Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Willow Brook House DS0000065185.V339442.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.V339442.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, 2, 3, standard 6 was not assessed as intermediate care is not provided. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process establishes the homes ability to meet the needs of people admitted to the home, prior to admission. However the lack of written information prevents prospective residents from making an informed choice about admission to the home. EVIDENCE: At the time of inspection the statement of purpose and service user guide were waiting to be revised. The importance of developing a statement of purpose, which provides residents and their relatives with clear information about the services provided, has been raised before. The Operations Manager has confirmed that the statement of purpose and service user guides, which are being revised, will contain information specific to Willow Brook House, rather than just the corporate information. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 11 Discussion with a recently admitted resident and their relative identified that they had been invited to visit the home before moving in, and that some verbal information had been given during the visit. However they had not received a copy of the statement of purpose or service user guides or other key information such as the range of fees and arrangements for payment. They had also not had access to a copy of the last inspection report. The information is particularly important in helping prospective residents and their families and any professionals who assist to choose a care home. Responses received in questionnaires, discussion with relatives and a sample check of residents’ records indicate that some but not all have contracts or a statement of the terms and conditions. A sample check of residents’ records confirm that prior to admission to the home a detailed assessment of their needs is carried out. This helps to ensure that their needs can be met. Willow Brook House DS0000065185.V339442.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. The overall care provided appears to be good, however arrangements for ensuring residents’ prescribed medication is available need to be improved to ensure they are not put at risk. EVIDENCE: Comments received from residents’ and their relatives in questionnaires, and through discussion during the inspection indicate that the majority are happy with the care provided. One relative stated “very impressed with the excellent care”. Another relative, and a resident though generally happy with the care, felt things could be improved if residents’ were able to have a bath or a shower more regularly than once a week. Observations during the inspection confirmed that residents’ care needs were being met. There had been an obvious improvement in the standards of care received by residents’ since the last inspection. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 13 Review of a sample of residents’ care plans confirmed that improvements had been made since the last inspection and that these are now much more reflective of residents’ individual needs. Care plans are important tools in guiding staff in providing consistent care according to residents’ needs. Records show that the care plans are reviewed regularly and updated when needs change. Where required risk assessments were in place to determine the suitability and safety of bed rails for individual resident’s prior to use. Health care assessments are carried out to determine risks in relation to falls, the risk of developing pressure ulcers and nutritional risk. These are reviewed regularly and records identify that any necessary action such as the use of pressure relieving equipment is taken to reduce the risks. Residents records and comments received from relatives and residents’ confirm that health care services are accessed appropriately on behalf of residents’ Visits from General Practitioner’s, District Nurses and a Chiropodist are evidenced within the records. A sample check of medication held on behalf of residents’ identified that there was in some cases no clear audit trail, making it difficult to carry out an accurate stock check. Advice was given to ensure that where medication has not all been used within the ordering cycle, that any carried forward is clearly recorded on the medication administration record. A stock check of the controlled drugs held confirmed that these were clearly and accurately recorded. There were no discrepancies between the stock and the records. A sample check identified that in most cases residents’ prescribed medication was available. However records identified that a particular medication for one resident had not been administered for three days and there was none in stock, putting this resident at risk. The senior member of staff on duty confirmed that contact had been made with the pharmacist and the General Practitioner and that the medication was to be delivered that day. The need to resolve ordering problems and ensure that residents prescribed medication is always available was discussed with the Acting Manager following the inspection. Some of the eye drops, which have a short shelf life once opened, were not marked with the date of opening and therefore potentially out of date, reducing their effectiveness. Staff were observed to treat and speak to residents in a respectful manner. This was supported by comments received from residents and their relatives. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 14 Willow Brook House DS0000065185.V339442.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. Residents’ are supported in their daily routines, the majority are happy with the meals and activities and visitors are welcomed, enhancing their daily lives. EVIDENCE: Discussion with residents’ and staff and observations during the inspection identified that improvements had been made in supporting residents’ with their preferred daily routines. Staff confirmed that staffing levels have improved, which has helped to resolve the problem. There is a planned activity programme, which includes activities such as bingo, music, films, art and craft and baking. The newsletter shows that outside entertainers such as singers and keyboard players are also used. The newsletter also contained information and a picture of a celebration of a residents’ birthday, which had been organised jointly with relatives indicating an acknowledgment of the importance of the recognition of individuals. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 16 Observations and comments from residents confirm that activities actually take place. On the day of inspection some residents’ were taking part in a bingo session and later a resident was enjoying painting and craft work. Some impromptu activities take place, for example on the dementia unit two residents’ were enjoying some music in a residents room which then encouraged other residents to enjoy some dancing in the corridor. Residents’ records include residents’ religious needs. Staff advised that at the time of the inspection the Christian church service, which is held in the home once a week, meets the needs of current residents’. Visitors and a resident confirmed that there are flexible visiting arrangements and that they are encouraged to visit and made welcome by staff. This helps to enhance the daily lives of residents’. There is a four week rotating menu in place, which confirms that there is choice and variety in the meals. The majority of the residents’ spoken with were happy with the meals provided. Discussion with staff indicated that there had been an improvement in the quality of meals provided and the cook advised that they had changed their meat supplier and were now receiving better quality meat. A questionnaire from a relative included the comment “good food”. On the day of inspection the lunchtime meal was pork and apple casserole or cheese and potato pie with potatoes and carrots. A sample taste confirmed that the meat in the casserole was very tender and tasty. Observations of the service of the lunchtime meal on the dementia unit confirmed that staff were supporting and assisting residents’ with choices. Staff were flexible in their approach to residents’ with dementia who did not want to sit at the dining table and were happy to accommodate a resident’s wish to eat at a desk in the corridor ensuring that the resident had their meal. Staff demonstrated their awareness of residents’ individual needs and were monitoring the food intake of residents’ who have a tendency to wander away from the table. Willow Brook House DS0000065185.V339442.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 dealing with concerns and complaints, which residents and relatives are aware of and staff are aware of their responsibilities for protecting the people in their care. EVIDENCE: A record of complaints received directly by Willow Brook House was reviewed; one of these had been copied to the Commission for Social Care Inspection (CSCI) for information. No other complaints had been received directly by CSCI since the last inspection. The complaints received by Willow Brook House included issues such as missing items, laundry, lack of cleaning staff at a weekend and care issues. A sample check of the records indicated that action had been taken to address the concern. Feedback in questionnaires received from two residents’ and two relatives and discussion during the inspection confirmed that the majority are aware of the complaint procedure and feel able to raise any concerns. There is also now a comments book, which is available in the foyer, which provides relatives with another avenue for raising any concerns. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 18 Staff spoken with were clear about their responsibilities for safeguarding residents’ in their care. Residents’, relatives and staff spoken with had no concerns about how residents’ were treated. A staff member confirmed that she had also received some training in safeguarding adults. Willow Brook House DS0000065185.V339442.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ have a comfortable place to live in with most areas being clean. However standards of cleanliness need to be monitored to ensure they are maintained for the benefit of residents. EVIDENCE: Residents’ are able to spend there time in their rooms or in the shared lounges and dining rooms. Bedrooms and shared areas were comfortably furnished and residents’ and relatives spoken with were happy with their rooms. Outstanding requirements relating to the environment have now been met. These related to a lack of hot water in some en-suite bathrooms and smoke from the designated smoking room permeating the corridor. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 20 Discussion with the maintenance man and a sample check confirmed that hot water was available and he confirmed that the thermostatic valves were now being replaced where necessary. Staff advised that prospective residents’ are told that Willow Brook House is a no smoking home. There is no longer a designated smoking room and a ‘smoking shelter’ has been erected in the garden for the small number of residents’ who smoke. This reduces the risk to residents’ who do not smoke, however advice was given to monitor the impact of the arrangement on the small number of residents’ who smoke. There is an enclosed patio area with some seating, which is accessible from the lower ground floor dementia unit. Although the weather was fine, it was rather breezy and not used during the inspection. However staff confirmed that residents’ do wander outside freely when the weather is good. A resident on the other floor was observed to be enjoying sitting outside the front of the home watching and chatting to people coming and going. The resident was able to access the outdoor area independently as it is accessible for wheelchair users. An annual quality assurance assessment (self assessment) submitted to the Commission for Social Care Inspection identifies that one of the planned improvements is to relocate the laundry as it is noisy and vibrates. This would be an improvement as the laundry is currently located on the top floor. Residents and relatives have commented on how noisy the machines are. The assessment also states that the cleanliness has improved over the last twelve months and is being maintained. However the findings of the inspection indicate that standards of cleanliness are variable. A relative stated, “rooms kept very fresh and clean”, while a resident felt that additional housekeeping staff were required to do extra cleaning. On the day of inspection a sample check identified that areas such as the kitchen, bathrooms, floors and residents’ bedding were kept generally clean. There were no offensive odours, however some of the bedroom carpets were dirty and stained and appeared in need of replacement. Furniture in the lounge on the dementia unit was noted to be particularly dusty. A visitor was overheard to comment on the condition of the fridge on the upper floor in the dining room, which was found to be very dirty with spilt and dried food. The Acting Manager has advised since the inspection that a re-decoration programme has commenced which includes painting and decorating on the dementia unit, which will improve the general appearance of the area. The Acting Manager has also confirmed that some bedroom carpets have been replaced following the inspection. Willow Brook House DS0000065185.V339442.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. There has been an improvement in the staffing levels, providing better care for residents, however a more thorough recruitment process is needed to provide better safeguards for residents. EVIDENCE: Observations and discussions with staff, residents’ and visitors during the inspection indicated that there has been an improvement in staffing arrangements to meet residents’ needs. Staff said that staffing levels had increased and when fully staffed they were more able to meet residents’ needs. Observations during the inspection confirmed this. However feedback in questionnaires from relatives and residents’ and discussion during the inspection indicated that there is a need to monitor this closely. Discussion with staff and a sample check of staff rotas indicate that the shortages are less frequent and that in most cases absences are replaced by current staff rather than agency staff improving the consistency of care. Positive comments were received about the staff team such as “care staff always very helpful and considerate to both residents and relatives.” and “staff work hard”. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 22 The Acting Manager has acknowledged the need to enrol more staff on a National Vocational Qualification (NVQ) course. She hopes to increase the number of staff with this qualification, which provides staff with a basic understanding of care practices to fifty percent by the end of the year. The training matrix was not available at the time of the inspection, however discussion with staff confirmed that some training has taken place since the last inspection, which includes dementia care training. This helps to provide staff with a better understanding of the needs of people with dementia. Records show that the need for staff to attend mandatory training has been emphasised through staff meetings. Two staff files were reviewed to check the adequacy of the recruitment process. This identified that although references and criminal record bureau clearances had been obtained there was a need to be more rigorous in checking information to ensure that residents’ are properly protected. Shortfalls included, gaps in employment histories, which had not been checked, and a health questionnaire, which had not been fully completed. The interview checklist indicated that the only discussion had been around the smoking policy and the shift pattern. In one application there were discrepancies in the information supplied to support the criminal record bureau application, which had not been picked up. Following the inspection the Acting Manager was asked to investigate this in order to protect residents’. Willow Brook House DS0000065185.V339442.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): 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements have been very inconsistent, however staff morale is now improving, which is helping to raise standards of care to residents’. 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 and had not been one for some time, 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.V339442.R01.S.doc Version 5.2 Page 24 Willow Brook house has had a succession of temporary managers. At the time of the inspection in January 2007 a new manager had been in post for just a few weeks. There was another change of manager in April 2007. It was evident through previous inspections that the changes have had an unsettling effect and affected standards of care. However this inspection identified that there is a calmer atmosphere and staff morale has improved which has a direct effect on the care and well being of residents’. Staff, residents and relatives confirm that the current Acting Manager is approachable and will act on issues raised. 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. As part of the quality assurance system, the organisation has systems where various audits are carried out to measure compliance with regulations and identify shortfalls. A sample check confirms that these are carried out regularly and indicate similar findings to the inspection with some improvement since the last inspection. There was evidence that views on the standards of care are sought. For example, through relatives meetings, managers ‘surgeries’ and through the comments book which has been introduced. Review of the comments book identifies some areas for improvement and also positive comments, such as “food improved”, “thanks for saving life – choking”. Small amounts of money are held on behalf of residents’ to assist them with paying for things such as chiropody and hairdressing. The money is held securely and records of transactions kept. In most instances two people sign the record of transactions, which provides better safeguards for residents’ and staff. Advice was given that where a resident requests that money is held on their behalf and they are able to sign themselves, this should be the first consideration. No health and safety concerns were identified during the inspection in relation to the premises. Staff spoken with had received appropriate training in safe working practices and records showed that action was being taken to ensure that all staff attend mandatory training, which includes training in safe working practices. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 25 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 (1) (a, b, c) Requirement A statement of purpose which includes all required information about the facilities, services and fees must be made available to prospective and current residents’ and their families to help them make informed choices. Arrangements must be made to ensure that residents’ prescribed medication is always available to reduce the risk of a deterioration of their health. Information supplied, as part of the recruitment process must be checked to ensure there are no discrepancies, reducing the risk to residents’. Timescale for action 31/08/07 2. OP9 13 (2) 31/07/07 3. OP29 19 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 27 No. Refer to Standard Good Practice Recommendations Willow Brook House DS0000065185.V339442.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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