Inspection on 01/11/05 for Willowbank Nursing Home

This inspection was carried out on 1st November 2005.

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

Other inspections for this house

Willowbank Nursing Home 14/09/09

Willowbank Nursing Home 21/08/07

Willowbank Nursing Home 19/06/06

Willowbank Nursing Home 19/04/05

Willowbank Nursing Home 07/02/05

Willowbank Nursing Home 10/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Willowbank Nursing Home Pasturegate Burnley Lancashire BB11 4DE Lead Inspector Mrs Marie Matthews Unannounced Inspection 1st November 2005 09:30 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 Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 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. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willowbank Nursing Home Address Pasturegate Burnley Lancashire BB11 4DE 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) 01282 455426 01282 458009 Sage Care Homes (Willowbank) Limited Mrs Lynne Millar Care Home 53 Category(ies) of Dementia (7), Dementia - over 65 years of age registration, with number (46), Mental disorder, excluding learning of places disability or dementia (7), Mental Disorder, excluding learning disability or dementia - over 65 years of age (46) Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Within the total of 53, no more than 35 service users requiring nursing care can be accomodated. Staffing for service users requiring nursing care will be in accordance with the Notice dated 22 February 2002. Within the overall total of 53 a maximum of 46 service users who fall into the category of either MD(E) or DE(E) can be accomodated Within the overall total of 53 a maximum of 7 service users who fall into the category of either MD or DE can be accommodated 19th April 2005 Date of last inspection Brief Description of the Service: Willowbank is registered to provide both nursing and personal care for fifty three residents with either a dementia or mental health problem. The home is a detached two storey building with a purpose built extension set in 1.5 acres of garden, with attractive lawns, flower beds and patio areas. Willowbank has 29 single and 12 shared bedrooms, a number of comfortable lounge and dining room areas and two conservatories. The home is set in a quiet, pleasant residential area approximately a mile from Burnley town centre. There are shops, a post office, public houses and a convenient bus route near by. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted at Willowbank Nursing and Residential Home on 1st November 2005. The inspection involved looking at records, talking to management, three staff, six residents and three visitors, a tour of the premises and generally looking at what was happening in the home. This inspection looked at things that should have been done since the last visit, in April 2005, and a number of areas that affect resident’s lives. At the time of the visit the manager in charge was not yet registered with the Commission for Social Care Inspection. There were forty-nine people living at the home on the day of the inspection visit. The home was assessed against the National Minimum Standards for Older People. This report should be read with the inspection report of 19 April 2005 for the reader to get a complete overview of the home. Residents and visitors said the staff ‘are a nice bunch’ and ‘lovely, kind people’. Staff were seen offering choices and responding to residents in a friendly but respectful way. What the service does well: Assessments were always completed in detail before new residents were admitted to the home; this made sure that the home was able to meet people’s needs. Residents said they were always offered a choice of meal and the menu showed this was appetising and nutritious. One resident said ‘I always enjoy my food’ another said ‘I can choose what to eat and it always tastes good’. The home had a good complaints system in place and responded correctly and quickly to any concerns and complaints that had been raised. Residents and visitors felt they would be listened to and any concerns responded to. The home was clean and bright and visitors had made positive comments about the home. One resident said ‘it’s a lovely place’. The gardens were tidy and accessible. Photographs showed that staff, residents and their visitors had enjoyed the summer garden party. The way in which the home recruited new staff was thorough and this protected the people living in the home. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 6 Staff meetings had been held regularly and staff felt confident to ‘speak out’ and raise issues. What has improved since the last inspection? What they could do better: The contract/statement of terms and conditions had been reviewed and the manager needed to make sure that all residents were given a copy. Specialist ‘dementia’ training was still needed to help staff to meet some of the residents specialised needs; records showed that this was planned to commence. The care plans had not consistently been generated from the initial assessment information and did not clearly detail the action to be taken by staff to meet resident’s needs. The plans did not yet show that residents and their relatives had been involved in the development or reviews of their care plans. The medication systems had improved but policies and procedures needed to reflect current practice to prevent residents being put at risk. Consideration was being given to changing the way medicines were given to improve the safety of the system. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 7 The home needed to develop a way of seeking and taking action on people’s views about the standard of the services given. Staff meetings had taken place but staff had not had regular meetings with their manager, on a one to one basis, to discuss whether the needs of the residents were being met. Systems were being introduced and this will be looked at again at the next visit. 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. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 8 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 Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. The home provided current and future residents and their representatives with enough information to enable them to make an informed choice about admission to the home. Residents were admitted only when detailed assessments had been completed and when the home was clear their needs could be met. Staff had a clear understanding of residents needs but required specialised training to support them. EVIDENCE: The service user guide contained enough information to ensure that prospective residents and their representatives were able to make a sound choice about admission to the home. Service users views needed to be included in the guide. The contract/statement of terms and conditions had been reviewed and was being given to all residents. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 10 Two residents files were looked at and showed that detailed needs assessments had been completed and written confirmation was given that the home was able to meet their needs prior to admission. Staff had a good understanding of residents needs though they still lacked specialist dementia training. Specialist ‘dementia’ training was planned to commence. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. The care plans had not consistently been generated from the initial assessment information, did not clearly detail the action to be taken by staff to meet resident’s needs and did not yet show that residents and their relatives had been involved in the development or reviews. The medication systems had improved but policies and procedures needed to reflect current practice to prevent residents being put at risk. EVIDENCE: Two care plans were looked at. The care plans varied in detail. One care plan did not include details about care needs as indicated in the initial assessment information. Risk assessments regarding falls were incomplete and the pressure sore assessment was absent. The care plans had been reviewed and updated by staff. A form had been introduced on one care plan to evidence involvement of residents or their relatives in the care planning review process. Access to healthcare services was documented. Medication policies and procedures still did not reflect current practice. The manager said that consideration was being given to changing the system to Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 12 make it safer for residents. The records were clear and had improved. There was evidence that resident’s medications had been reviewed. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. The provision of varied activities to meet resident’s social and recreational needs had improved. The home ensured residents were offered a variety and choice of meals that met their tastes and choices. EVIDENCE: From discussion with residents and staff it was clear that varied, appropriate activities and entertainments were provided. One resident said ‘there is always something going on’ another said they had enjoyed the trip ‘on the bus’. New equipment and games for residents had been purchased since the last inspection. Mealtimes and menus had been reviewed to meet the nutritional needs and preferences of the residents. Residents were always offered a choice of meal that was appetising and nutritious. Residents made positive comments about the meals. One resident said ‘I always enjoy my food’ another said ‘I can choose what to eat and it always tastes good’. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The complaints process in this home is good and residents and their relatives were confident any concerns would be dealt with. The adult abuse procedure provided clear guidance for staff and ensures staff would respond appropriately. EVIDENCE: The complaints procedure was clear and was displayed in the home. The relatives of a recently admitted resident were aware of whom to complain to and had been encouraged to voice any concerns. They were confident that staff would resolve any concerns or complaints to their satisfaction. The adult abuse procedure provided staff with clear information about action to be taken. Staff were aware of whom to report to. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26. The home had a planned programme of redecoration and replacement of furnishings. The appearance of the home was gradually improving and provided comfort and safety for residents. EVIDENCE: A programme of maintenance and renewal was underway. Many improvements to the décor had been made since the last inspection. An audit of the rooms had been completed; a number of carpets and furnishings had been replaced and further refurbishment was planned. The main lounge was due to be re-carpeted and a new fireplace provided to improve the comfort for the residents. The home was clean and bright and visitors had made positive comments about the home. One resident said ‘it’s a lovely place’. The gardens were tidy and accessible. Photographs showed that staff, residents and their visitors had enjoyed the summer garden party. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 16 Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The procedures for staff recruitment were robust and protected the people living in the home. Resident’s needs were met by a well trained and competent group of staff and this had improved quality of life for the residents. Staffing numbers met the assessed needs of the residents. EVIDENCE: The home was staffed appropriately to ensure that the needs of the residents were met. Two staff files were looked at. Both files contained appropriate checks that had been obtained prior to employment. A training and development plan evidenced staff had received appropriate training to help them to meet the resident’s needs. Update training had been planned. A need for specialised ‘dementia’ training has been identified earlier in the report. Staff said there had been a lot of improvements and that they enjoyed working at the home. Residents said the staff ‘are a nice bunch’ and ‘lovely, kind people’. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. The manager had communicated effectively with staff and the registered provider to gradually improve the environment of the home and standards of care for the residents. The systems for consultation with residents and visitors remain poor with little evidence that their views are sought or acted upon. Records had improved to show that safe working practices were up to date and people’s health, safety and welfare was protected. EVIDENCE: The manager was not yet registered with the Commission for Social Care Inspection. An application needed to be completed. Staff made positive comments about the recent changes and how the management team had effectively introduced improvements to the home. The manager was aware of the changes that needed to be made to further help the home to improve its services. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 19 Service users surveys were due to be sent out and the results will be reviewed at the next visit. Staff meetings had been held regularly. Staff felt confident to ‘speak out’ and raise issues. The home had responded promptly and effectively to address requirements and recommendations made at previous visits. The system for financial records had improved and could be audited easily to show that resident’s monies were safeguarded. Staff appraisals had taken place and further one to one supervision sessions were planned. This will be reviewed at the next visit. Examination of records demonstrated that safe working practices were up to date and people’s health, safety and welfare was protected. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 20 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 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 3 Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 21 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 OP2 Regulation 4 Requirement All residents must be provided with a statement of terms and conditions/contract. Timescale 6/06/05 not met. Staff must receive appropriate training to enable them to care for residents with dementia. Timescale 6/06/05 not met. Care plans must be generated from a comprehensive assessment and set out in detail the action to be taken by staff to ensure resident’s health, personal and social needs are met. Residents and/or their representative must be involved in the development and review of the care plan. Timescale 6/06/05 not met. The medication policies and procedures must be reviewed to reflect current practice and guidelines from the Royal Pharmaceutical Society. DS0000022471.V260062.R01.S.doc Timescale for action 20/12/05 2 OP4 18 20/12/05 3 OP7 15 20/12/05 4 OP7 15 20/12/05 5 OP9 13 20/12/05 Willowbank Nursing Home Version 5.0 Page 22 6 OP31 9 7 OP33 24 8 OP36 18 Timescale 6/06/05 not met. The registered provider must 01/12/05 forward an application to register a manager with the Commission for Social Care Inspection. The views of residents, their 20/12/05 representatives and stakeholders in the community about the services offered must be sought. The results of the survey must be published and made available to interested parties. Care staff must receive formal 20/12/05 one to one supervision at least six times a year. Previously a recommendation. 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 Refer to Standard OP1 OP24 OP28 Good Practice Recommendations Resident’s views of the home need to be included in the service user guide. The reasons for not providing minimum room furnishings should be documented in the care plan. 50 care staff should have NVQ level 2 in care or equivalent. Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willowbank Nursing Home DS0000022471.V260062.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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