CARE HOMES FOR OLDER PEOPLE
Willowbank Residential Home 134/136 Seymour Road South Clayton Manchester M11 4PS Lead Inspector
Ann Connolly Unannounced Inspection 13th January 2006 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 Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 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 Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Willowbank Residential Home Address 134/136 Seymour Road South Clayton Manchester M11 4PS 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) 0161 370 9080 Nageeb Aubdool Nazmah Aubdool Nageeb Aubdool Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The numbers of service users accommodated must not exceed thirteen (13) service users who require personal care only by reason of old age (OP). Staffing arrangements at the home must be maintained in line with minimum levels specified in the Residential Forum guidance ` Care Staffing in Care Homes for Older People`. The home must employ, at all times, a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 20th July 2005 Date of last inspection Brief Description of the Service: Willowbank is a residential care home offering accommodation and personal care for up to 13 elderly persons. At the time of the inspection there were 9 residents accommodated with 4 vacant places. The home is situated in Clayton in the north of the city in a quiet residential area close to local amenities.The home was previously two semi-detached houses, which have been adapted to form one property with ramp access to the front of the building. The home has small well-maintained gardens and a patio area accessed by patio doors from the lounge. Parking is available on the road and at the side of the building. The home offers accommodation in 3 double and 7 single bedrooms. There are two lounges with combined dining space. The designated smoking area is situated in the hallway. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 13th January 2006.During the course of the inspection, time was spent talking to residents, visitors and the manager. The residents were consulted about their views of the home and on their experiences of living there. Time was spent examining records, documents, the residents and staff files. A brief tour of the building was also conducted. There was evidence that the home was continually working to develop the service and the requirements from the previous inspection had been addressed. The home had not received any complaints made directly to them, however, the Commission for Social Care Inspection had received one complaint about the service. This was fully investigated during this inspection and was not upheld. During this inspection only a selection of the National Minimum Standards were assessed therefore in order to gain a full picture of how the home meets the needs of residents in the home, this report should be read with the previous and any future reports. What the service does well:
There was a warm and welcoming atmosphere in the home. All residents spoken to seemed relaxed and settled and spoke highly of the way the staff supported them. The good thing about the home was the positive comments made by residents about the staff. One resident said, ‘ I really like it here. My brother took me to look at a few places, but this is the tops for me’. All residents spoke highly of the meals served in the home and said there was always an alternative meal available if they did not like the menu choice. One resident said, ‘the food is alright, I have no complaints’. Another resident said, ‘You get lovely hot meals, I like the food’. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 7 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 Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 8 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): EVIDENCE: These standards were not assessed on this occasion. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 9 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 and 9 Care plans ensured that the health care needs of residents were identified and included the interventions required to meet needs. Some shortfalls were identified in the management and handling of medication which could potentially place residents at risk. EVIDENCE: Since the last inspection there had been an improvement in care plans. Care plans were detailed and set down the care needs, goals and the intervention required to meet needs. There was evidence on files that care plans were reviewed monthly. The manager said training was given to staff to ensure they used care plans effectively to monitor changes in care needs. Medication was administered using a monitored dosage system. Medication stock levels in the blister packs balanced with the medication administration records (MAR), however, there were some errors in loose medication stored in their prescribed package. Two lots of medication showed inaccuracies. Paracetamol, which was prescribed for one resident, was also used generally as a ‘homely remedy’ and used as required for residents in the home. The
Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 10 manager must audit all medication kept in the home and ensure accurate records of stock levels are maintained. Prescribed medication must only be administered to the individual for whom the medication is prescribed. There was no record of the receipt and disposal of medication received into the home. A record must be maintained and accurately record the receipt and disposal of medication. A record of the signatures of staff who are responsible for the administration of medication must be kept with the medication records. Since the last inspection, the previous requirement to secure the medication trolley to the wall when not in use had been addressed. There was evidence of good practice and all medication records had a photograph of individual residents attached to the Medication administration Records. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 11 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): 15 Residents receive a wholesome appealing diet. EVIDENCE: Ten residents spoken to expressed satisfaction about the meals served in the home. One resident said, ‘The meals here are very nice and if you don’t like something they will give you something else’. The menu on the day of inspection consisted of roast chicken, fresh vegetables, carrots, cabbage and new potatoes. The meal was served in the dining room and seating arrangements were in small groups of four. This arrangement provided a relaxed social setting for residents to enjoy their meals. There was an ample supply of groceries and provisions providing evidence of a wide range in menus. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 12 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 Policies and procedures were in place, which enabled residents to raise any issues of concern. EVIDENCE: The home had a comprehensive complaints procedure which included the address and telephone number of the Commission. A copy of the complaints procedure was made available in each bedroom. Residents spoken to said they felt confident in approaching the manager and staff with any issues of concern and a relative visiting the home also echoed this. One resident said, ‘If there was a problem , I’d tell the manager, but we have nothing to complain about. There had been no complaints made direct to the home. One complaint about the home had been direct to the Commission. The issues of concern were fully investigated during this inspection visit and were not upheld. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 13 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): 25 and 26 Overall satisfactory standards of hygiene were maintained throughout the home but some decorating standards in the home were poor. Some cleaning materials and wheelchairs were stored inappropriately and could potentially place residents at risk. Faulty equipment in the home could place residents at risk. EVIDENCE: A large lounge and dining area is located on the ground floor. A passenger lift provides access to all floors. The building was clean and tidy throughout. The requirement made in the previous inspection to repair the damp wall in bedroom 10 had been addressed. A number of the bedrooms were in need of decorating in order to maintain a pleasant environment for residents in the home. The manager must provide a programme of renewal for the fabric and decorating throughout the home. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 14 Some of the alarm call cords were missing in some of the bedrooms. This equipment is designed to ensure the safety and well being of residents in the home and must be repaired in order to provide an effective and functional system. A number of wheelchairs were stored inappropriately causing obstruction and several had missing footrests. Cleaning and chemical products stored in the building were stored inappropriately and caused a potential hazard for residents in the home. All products must be stored appropriately in a locked cupboard or room to comply with COSHH requirements . None of the bedroom doors had privacy locks capable of being overridden in the event of an emergency. The manager must arrange for the fitting of appropriate locking devices and provide residents with the opportunity to have a key to their own rooms which will promote privacy and dignity for residents in the home. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 15 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): 30 Training was provided to staff in the home. EVIDENCE: Training records provided evidenced that staff received appropriate training. Staff received training in health and safety. Three members of staff had completed NVQ’s level 2 and 3 and one member of staff had commenced NVQ level 2. The manager demonstrated a commitment to provide ongoing training for staff in the home, and this was demonstrated in the training plan. All staff were scheduled to attend a course in the safe handling of medication. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 16 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): EVIDENCE: These standards were not assessed on this occasion. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 17 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X x X X X X 2 2 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 13 Requirement The manager must audit all medication and maintain accurate records of medication in the home. Medication must only be administered to the individual for whom the medication was prescribed. The manager must provide a programme of renewal for the fabric and decorating throughout the home. Alarm cords must be repaired in order to provide an effective and functional system. Wheelchairs must be stored appropriately and must be repaired. Timescale for action 13/01/06 2 OP25 23 13/05/06 3 OP25 23 13/05/06 4 OP25 23 23/04/06 5 OP25 23 Cleaning and chemical products 13/01/06 must be stored appropriately in a locked cupboard or room. Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willowbank Residential Home DS0000061407.V277195.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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