Inspection on 21/08/07 for Willowbank Nursing Home

This inspection was carried out on 21st August 2007.

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

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

Other inspections for this house

Willowbank Nursing Home 14/09/09

Willowbank Nursing Home 19/06/06

Willowbank Nursing Home 01/11/05

Willowbank Nursing Home 19/04/05

Willowbank Nursing Home 07/02/05

Willowbank Nursing Home 10/05/04

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Creative Support

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 Key Unannounced Inspection 21st August 2007 10:00 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 Willowbank Nursing Home DS0000022471.V341109.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. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 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 455345 willowbanknh@gmail.com Sage Care Homes (Willowbank) Limited Vacant post Care Home 53 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (47), Mental disorder, excluding learning of places disability or dementia (6), Mental Disorder, excluding learning disability or dementia - over 65 years of age (47) Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 53 service users to include: Up to 35 service users who require nursing care. Up to 47 service users who fall into the category of MD(E) Up to 47 service users who fall into the category of DE(E) Up to 6 service users who fall into the category of MD Up to 6 service users who fall into the category of DE 19th June 2006 Date of last inspection Brief Description of the Service: Willowbank is registered to provide both nursing and personal care for fiftythree 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. The majority of bedrooms are single and some have en suite facilities; others are located near to toilet facilities. There are a number of comfortable lounge and dining room areas and two conservatories. Willowbank 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. Information about the services that the home offers is provided in the form of a service user guide and is available to existing and prospective residents and their relatives. A summary of the most recent inspection report is available within the service user guide. On the day of the key inspection the weekly fees ranged from £361.00 to £514.00. Items not included in the fee include newspapers, hairdressing and personal toiletries. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection, including a visit to the home, took place on 21st August 2007. The inspection process included looking at records, a tour of the home, and discussion with the proposed manager, four care staff and four residents. Information was also included from survey forms filled in by one visiting professional (GP), four visitors and four residents. The inspection also looked at things that should have been done since the last visit and a number of areas that affect people’s lives. There were thirty-four residents living in the home on the day of the inspection. The manager was not yet registered with the Commission for Social Care Inspection although an application was being processed. What the service does well: The home always made sure that people were given enough information about their rights and about the home and the services on offer before they were admitted to the home. This enabled people to make an informed choice about whether the home could meet their needs. Residents were always assessed properly to make sure that staff could look after them properly; this was confirmed in writing before they were admitted to the home. Records supported that resident’s medication was managed safely. Records supported that residents had access to health care and specialist services and appropriate aids and equipment were provided to ensure safety and comfort and to support them with their independence. One GP commented that staff maintained residents’ privacy and dignity during his visits. Residents said they were treated well and looked after properly. Staff were seen knocking on doors and responding to residents and visitors in a friendly but respectful manner. Residents were given a choice of many aspects including mealtimes, routines, activities and choice of clothing. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 6 Residents were provided with activities to meet their social and recreational needs. A daily programme showed exercising to music, ball games, singing, hand massage and baking had taken place. There had been recent outings to local beauty spots, the park and the town centre. One resident said she had enjoyed shopping for clothing. A variety and choice of meals were offered that met residents’ tastes and preferences. Comments included ‘we always get a choice of meals’, ‘ the meals are good, there is a choice and always enough to eat’ and ‘the food is lovely’. The home had a clear complaints system and people were confident their complaints would be responded to appropriately. Staff were aware of action to be taken if they suspected abuse and training had been provided to ensure they were able to recognise abuse and respond appropriately. The staff team were experienced, well supported, competent and provided in sufficient numbers to meet resident’s needs. One resident said ‘I press the call buzzer and staff come quickly’. One relative commented ‘we consider our choice (of home) to be well founded and have complete satisfaction in the care being provided and the competence and professionalism of those providing it’ another said ‘staff show care and understanding to residents and their family. They are always there to listen and support’. People had been encouraged to air their views and opinions about whether their needs and expectations were being met. A resident and relatives survey had been done and meetings with residents and their relatives had been held; staff meetings were held regularly and staff said they were able to contribute. Money was stored safely and securely and staff were supported by a clear procedure to help them to manage residents finances safely. Records showed that servicing and maintenance of equipment in the home were kept up to date and that people’s health, safety and welfare was maintained. What has improved since the last inspection? The home had introduced a new system of medication and had upgraded the medication storage areas to improve safety for residents. Policies and procedures had been reviewed to reflect current practice to guide staff with safe management of residents’ medication. Safe staff recruitment procedures had been followed to ensure residents were protected from unsuitable people. Records showed that staff were provided with training to help them to meet residents’ complex needs. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 7 Each resident had a plan of care that included details about how there care needs would be met. People had been involved in decisions about care and care plans had been reviewed and updated at least monthly to reflect current care needs. During a tour of the home and grounds it was noted that many areas had been improved. There were still some areas in need of refurbishment although it was clear that work was underway to provide a pleasant environment for residents to live in. The standard of furnishings and décor in residents’ rooms had improved and residents were happy with their rooms which were bright, comfortable and clean; some residents had brought in personal items to enhance the homely feel. The gardens were secure, attractive and accessible to residents although the patio area to the rear of the home still remained unsafe for use by residents; a grant had been provided to develop a sensory garden and patio area and work was expected to commence soon. One resident said she enjoyed walking in the grounds and enjoyed the view of the gardens from her window. What they could do better: Policies and procedures needed to be reviewed to make sure they contained up to date information and safe guidance. The information about Willowbank needs minor update to ensure residents and their relatives have all the information about available services and facilities. A range of detailed assessments of any risks were included in the care plans; staff needed to make sure that actions to be taken to reduce any risks were included. Although there had been a number of improvements made to areas in the home the plans to re site and enlarge the kitchen had not progressed since the last key inspection. The environmental health officer had inspected the kitchen in February 2007 and a follow up report indicated that the kitchen was now in urgent need of upgrade. One relative commented that to improve the home the registered provider ‘needs to continue with the refurbishment and building work’. Records to support that further improvements were planned were not up to date. Audit systems need to be introduced to determine whether staff were following policies and procedures and to identify any training needs. The fire risk assessment was due for review to ensure all areas were safe for residents. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 8 The practice of leaving medical hand washing products in residents’ rooms needs to be reviewed, as this could be a risk to residents. 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. Willowbank Nursing Home DS0000022471.V341109.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 Willowbank Nursing Home DS0000022471.V341109.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 and 4. Standard 6 was not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The information that would assist people to make an informed choice about admission to the home was incomplete. Detailed assessments had been completed prior to admission to ensure residents’ needs would be met and staff had been provided with specialist training to ensure they could look after residents properly. EVIDENCE: The information pack about the home was given to residents and their families and people said they were given enough information about the home prior to admission. The information needed to be updated to ensure residents had all the information about available services and facilities. Three residents files were looked at and showed that detailed assessments of Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 11 their care needs had been completed before admission to ensure staff had the necessary skills to care for new residents. Written confirmation that people’s needs would be met had not been sent although there was a template letter available. A training matrix showed staff were provided with training to meet residents’ complex needs. Willowbank Nursing Home DS0000022471.V341109.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ health and personal care needs were met. Staff treated people with respect and maintained their rights to privacy and dignity. EVIDENCE: Three care plans were looked at in detail. Individual care plans had been reviewed since the last key inspection; the plans were clearer, developed from information obtained prior to admission and included details about how residents care needs would be met. People had been involved in decisions about care and care plans had been reviewed and updated at least monthly to reflect current care needs. Relatives said they were kept up to date and one had commented ‘I appreciate the phone calls when she is not well’. Assessments of any risks were included in the care plans although one plan did not detail what action staff would take to reduce the risk of developing pressure sores and injury from falls. Nutritional assessments were not in place although there was evidence that appropriate advice had been sought regarding residents’ nutritional needs. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 13 Records supported that residents had access to health care and specialist services and appropriate aids and equipment were provided to ensure residents safety and comfort and support them with their independence. Survey information from four residents indicated that they had access to medical support when needed and one General Practitioner (GP) commented that residents’ health needs were always met. Residents had key workers who they could build up special relationships with and staff were trained to meet the health care needs of residents. Medication policies and procedures had been reviewed and new procedures were due to be introduced. The procedures needed to cover covert administration, handwritten medication instructions, PRN or ‘as needed’ medications, medicines for leave or day trips and management and safe storage of oxygen to provide staff with safe guidance in all aspects of management of residents medicines. Records were clear and accurate which ensured there was no mishandling although it was recommended that two staff signatures were obtained for medicines for disposal and that medications to be given ‘PRN’ or ‘as needed’ should be supported by clear protocols to assist staff with their decision to administer. Medicines were stored safely and securely. Temperatures of storage areas needed to be monitored to ensure medicines were stored at the right temperature. One GP commented that staff maintained residents’ privacy and dignity during their visits. Three residents said they were treated well and looked after properly. Staff were seen knocking on doors and responding to residents and visitors in a friendly but respectful manner. Privacy and dignity training was provided for all staff and the staff group was well balanced and varied to meet the diverse needs of the residents in the home. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were provided with activities to meet their social and recreational needs and were offered a variety and choice of meals that met their tastes and preferences. EVIDENCE: From observation, looking at records and talking to people it was clear that residents were given a choice of many aspects including mealtimes, routines, activities and choice of clothing. Detailed information had been collated about residents’ preferences and social interests; this assisted staff to provide the right care as a number of residents were unable to make appropriate choices and relied on staff to make decisions for them. There was a record of daily activities that had taken place and of the residents who had joined in. The home did not employ an activities co-ordinator although staff filled in a daily programme that showed exercising to music, ball games, singing, nails and hand massage and baking had taken place. There had been recent outings to local beauty spots, the park and the town centre. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 15 One resident said she had enjoyed shopping for clothing and would be going again next week another said ‘there are things going on’ but she preferred her own company and this was respected. Another said ‘the staff are very sociable, we go on trips, we have hand massage and music’. The manager said one gentleman was interested in bowling and staff were supporting him to become involved in the local bowling association. Residents said their visitors were made to feel welcome and they could visit in the privacy of their bedroom or in the communal areas. A number of residents had access to an advocate to support them or to act on their behalf. The menu offered a varied choice of nutritious and appetising meals. Residents were happy with the meals. Comments included ‘we always get a choice of meals’, ‘ the meals are good, there is a choice and always enough to eat’ and ‘the food is lovely’. Records supported that residents were offered choices and that alternatives to the menu had also been given to ensure residents dietary needs were met. The kitchen staff were familiar with residents dietary preferences and meal preferences had been discussed at resident meetings. The dining areas had improved and tablecloths and condiments were provided. Staff were seen giving sensitive support to residents who needed assistance. One resident said snacks and drinks were provided throughout the day and night if you required. The plans to re site and enlarge the kitchen had not been progressed since the last key inspection. The environmental health officer had inspected the kitchen in February 2007 and the report indicated that the kitchen was now in urgent need of upgrade and further action was being considered. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home had a clear complaints system and people were confident their complaints would be responded to appropriately. Residents were protected by the adult protection policies and procedures and by staff awareness. EVIDENCE: The home had a clear complaints system which was widely distributed around the home. Records supported that complaints and concerns were dealt with according to the procedure. Four relatives had said they were aware of how to complain and that staff had responded appropriately to any concerns they had raised. Eight residents were aware of whom to speak to and were confident that staff would ‘sort things out’. The Commission for Social Care Inspection contact information on the complaints and adult protection procedures needed to be updated. The adult protection procedure was clear and provided staff with clear and appropriate guidance. Staff were aware of action to be taken if they suspected abuse and training had been provided to ensure they were able to recognise abuse and respond appropriately. Recruitment procedures were completed prior to employment and ensured staff were suitable to work with vulnerable people. Procedures were available to support staff with responding appropriately to verbal and physical abuse and dealing with residents’ finances. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The environment had been improved although records did not support that futher improvements were planned to provide a comfortable, safe and homely environment for residents to live in. EVIDENCE: During a tour of the home and grounds it was noted that many areas had been improved. There were still some areas in need of refurbishment although it was clear that work was underway to provide a pleasant environment for residents to live in. The manager had commenced a room-by-room audit to identify areas requiring improvement, however records did not support that further improvements were planned. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 18 The gardens were secure, attractive and accessible to residents although the patio area to the rear of the home still remained unsafe for use by residents; a grant had been provided to develop a sensory garden and patio area and work was expected to commence soon. One resident said she enjoyed walking in the grounds and enjoyed the view of the gardens from her window. Plans to improve the kitchen areas had still not progressed and this had been a concern raised at the Environmental Health Officers visit. A number of communal areas were provided for residents comfort although two of the lounge and dining areas were still in need of redecoration noted at the last inspection; the manager said this was included as part of refurbishment plans. There were aids and adaptations to meet the diverse physical needs of the residents. Call systems were provided in every room to enable residents to call for assistance from staff; not all rooms had ‘wander’ leads and there was no evidence of risk assessment to support non-provision. One resident said ‘I press the call buzzer and staff come quickly’. All rooms were provided with locks to doors and lockable storage and non-provision was supported by risk assessment. The standard of furnishings and décor in residents’ rooms had improved and residents were happy with their rooms although not all rooms contained minimum furnishings. The rooms were bright, comfortable and clean and some residents had brought in personal items to enhance the homely feel. Since the last key inspection a number of rooms had been converted from shared rooms to single rooms with en suite facilities; the remaining two shared rooms were fitted with screens to maintain residents privacy and dignity. Generally all areas were bright and free from any offensive odours; residents said the home was ‘usually’ clean and odour free. There was an odour at the main entrance but the manager was aware of this and the carpet was due to be replaced as part of the ongoing refurbishment. The laundry had been re-sited to the basement area and was clean, fitted with appropriate equipment and organised. Residents were dressed in their own clothes and one resident said her clothing was always returned ‘quite quickly’ and in ‘good order’. One relative commented that to improve the home the registered provider ‘needs to continue with the refurbishment and building work’. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff team were experienced, well supported, competent and provided in sufficient numbers to meet resident’s needs. Safe recruitment procedures had been followed to ensure residents were protected. EVIDENCE: Rotas were clear and showed a good skill mix of staff. Staff generally felt that staffing levels were sufficient and the rotas showed that any shortfalls had been filled with volunteers from the staff list to ensure a continuation of care for residents. Residents said there were enough staff to meet their needs. Information from records and discussions with staff showed that staff were appropriately trained. Staff were able to confirm that they had received induction and update training to help them to meet the needs of the residents who lived in the home. A training plan was available to support the need for training and further development of staff. Three staff files were looked at in detail and showed that a safe recruitment procedure had been followed that would protect residents from being cared for by unsuitable people. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 20 Four visitors commented that staff are skilled and experienced and able to meet residents’ diverse needs. One relative commented ‘we consider our choice (of home) to be well founded and have complete satisfaction in the care being provided and the competence and professionalism of those providing it’ another said ‘staff show care and understanding to residents and their family. They are always there to listen and support’. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was safe and well managed and had improved the quality assurance systems that monitored whether the home met people’s needs and expectations. EVIDENCE: Darren Crossley is the manager although not yet registered with the Commission for Social Care Inspection. An application has been forwarded to register Mr Crossley and he has commenced the registered managers award to support his role of manager. Mr Crossley is a registered nurse with management experience in the private sector. There were clear lines of accountability within the home and one carer said ‘everyone knows what they are doing’ another said ‘things have improved 100 ’. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 22 The business plan was due for review and indicated both short and long term plans for the future. The home had achieved the Investors In People award which is a recognised quality assurance award. People had been encouraged to air their views and opinions about whether their needs and expectations were being met. Audit systems were to be introduced to determine whether staff were following policies and procedures and to identify any training needs. Financial records were looked at for two residents personal allowances. There was a minor discrepancy on one record, which was quickly resolved. It was recommended that two signatures were obtained when dealing with residents’ finances. Money was stored safely and securely and staff were supported by a clear procedure to help them to manage residents finances. Records supported that staff were regularly supervised and appraised to ensure they had the skills to meet residents’ needs. The manager was aware there had been some slippage in timescales but was addressing this. Records showed that servicing and test certificates were kept up to date and that people’s health, safety and welfare was maintained. However the fire risk assessment was out of date and as noted earlier in the report the Environmental Health Department had concerns regarding the standard of the kitchen and a decision would be made regarding further action. It was noted that medical hand washing products were left in a small number of the bedrooms; this could be a risk to residents and should be supported by risk assessment. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 23 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 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 17 X 18 2 2 3 X 2 X 2 X 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 X 3 X 2 3 X 2 Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 24 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. 2. Standard OP8 OP19 Regulation 13 23 Requirement Interventions to reduce any identified risks to residents must be recorded in the care plan. A plan to support ongoing improvements to areas in the home as referred to in the report must be developed. Medical hand washing products must not be left in residents’ rooms without appropriate risk assessment. The fire risk assessment must be reviewed. Timescale for action 01/10/07 01/10/07 3. OP38 13 10/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The statement of purpose should include information as detailed in standard 1 and schedule 1. The service user guide should include information as detailed in standard 1 particularly service users views and the special needs catered for. Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 25 2. OP4 Written confirmation that people’s needs would be met should be sent following completion of the needs assessment. Medication procedures should include guidance on covert administration, handwritten medication instructions, PRN or ‘as needed’ medications, medicines for leave or day trips and management and safe storage of oxygen. The criteria for PRN or ‘as needed’ medication should be clearly defined and recorded. Two signatures should be obtained for medicines for disposal. Temperatures of medicine storage areas should be regularly monitored. The complaints procedure should reflect the correct Commission for Social Care Inspection contact information. The adult protection procedure should reflect the correct Commission for Social Care Inspection contact information. Risk assessments should be in place to support nonprovision of call leads. The registered person should ensure that each room is audited for contents against standard 24 and this is discussed with the resident and their representative, to ascertain their wishes. These wishes regarding furnishing should then be recorded as part of their care plan. The registered person should ensure that 50 care staff have the NVQ level 2 in care, or equivalent. The manager should be registered with the Commission for Social Care Inspection and obtain a recognised management qualification. Two signatures should be obtained when dealing with resident’s personal allowance. 3. OP9 4. 5. 6. 7. OP16 OP18 OP22 OP24 8. 9. 10. OP28 OP31 OP35 Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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. Extracts may not be used or reproduced without the express permission of CSCI Willowbank Nursing Home DS0000022471.V341109.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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