CARE HOMES FOR OLDER PEOPLE
Willowbank Residential Home 134/136 Seymour Road South Clayton Manchester M11 4PS Lead Inspector
Michelle Moss Unannounced Inspection 27th February 2007 4:30 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 Residential Home DS0000061407.V331532.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 Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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.V331532.R01.S.doc Version 5.2 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. 24th November 2006 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 8 residents accommodated with 5 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. The fees charged for the home are £358.14 per week. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on the morning of Tuesday 27th February 2007. The inspector spent nearly 3 hours visiting the home. During the visit to the home the inspector: • Met and talked with residents • Spoke with the staff on duty • Looked at some residents’ care plan records. • Looked at how medication was managed. • Looked around the home. • Watched how the residents and staff got a long together. There were some important things the inspector wanted to find out about the care given by the home. These were: • • • • How the health needs of residents were met. How the personal care needs of residents were met. How the staff helped to kept residents safe and promoted community involvement. How the home respected the residents’ rights, diversity and identity. What the service does well:
The residents were seen to be treated as individuals and the staff team provided care that reflected the residents’ rights and preserved their dignity and privacy. This meant that the staff team understood the importance of respecting and seeing the house as the residents’ home. Residents could furnish their individual bedroom’s to reflect personal choice. This respected residents’ diverse needs. Residents’ spoken with were very happy with the care they received. The relationship between the staff and residents was seen as very positive. One relative had commented through correspondence to the home that they were wonderful at caring and kind, described it as a “home from home” and “had a friendly atmosphere”. All of which, showed that residents were happy and felt comfortable and safe around the staff. The home provided a number of activities on a planned and unplanned basis that the residents could join in with if they wanted to. These included gentle exercise, bingo and talking about things that had happened in the past.
Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 6 Residents were supported to maintain community links including attending various community activities. The approach to promoting good health and social inclusion meant residents overall sustained a healthy life style with choices over how to spent their time. What has improved since the last inspection? What they could do better:
Since the last inspection the home had arranged for staff to receive training in meeting the care needs of residents and how to ensure they were protected from abuse. However, this training had not been attended by staff for various reasons. This meant the staff still had limited knowledge about key practices of care. Overall training was not seen to be provided to ensure staff were adequately assessed competent in the different elements of personal care, safe handling and health and safety. Without evidence the home was not showing they offered training to staff that ensured they were sufficiently knowledgeable about care practice. Although care plans had been improved, there were still areas that could be further developed. These included ensuring areas of diversity and health and social care. This would help to confirm care provided was centred around the individual needs of the resident. This included the resident being invited to sign their care plan and hold a copy if they so wished. By improving the care plans the home would demonstrate that the care provided respected the residents wishes and promoted their health, rights, independence and welfare. The home had some radiators that were not covered. By their location they had the potential to cause harm to residents through direct contact. The home needed to carry out a risk assessment to determine the extent of risk to residents. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 7 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 Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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 Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs were monitored through the assessment of needs that evaluated their care and identified any potential risks. EVIDENCE: All residents at the home had an assessment of their needs that was updated monthly to monitor their care and identify potential new risks. Where the home had received new referrals the manager confirmed he completed a needs assessment to ensure that the home was able to meet the needs of the prospective resident. The assessment was discussed with the resident and their representatives. All placements at the home were on an initial trial basis. This was to ensure that the resident was settled there and that the home was able to continue to meet their needs.
Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 10 It was noted that the home had not had a new admission for a while. It was therefore not possible during the visit to case track a new admission. The home did not provide intermediate care. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided an overview of a resident’s care needs. Medication was administered to ensure the health of residents was maintained. Practices of care respected privacy and prompted dignity. EVIDENCE: All of the residents at the home had a care plan that detailed their individual needs and how those needs should be met. Of the 8 residents living at the home 5 of the care plans were looked at. Since the home’s last inspection the individual resident’s care plan had been improved. Some good practices of the plan being person centred was seen. These included acknowledging likes such a TV programmes and indicating that staff needed to ensure the resident was reminded when the programme was on the TV. In addition more details on the various aspects of care had also been identified made. Although the plans were found to be informative further development was recommended. This included looking more at the history of residents’ needs and illnesses that
Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 12 affected their daily lives. The home needed to detail how they respected and promoted the diversity of the residents throughout daily living and care. For example, in a care plan it indicated that a resident needing to be ready for 11am on a Sunday but there was no information to indicate why this was necessary. The care plan did not detail all the health needs of the resident and how this affected them in everyday life. None of the care plans looked at had a signature of the resident to validate their agreement to the plan about them. Development in recording areas of financial safeguarding, nutritional assessment and safe handling were required. With the agreement of individual residents, the home needed to monitor weight as part of promoting health and using body mapping charts where bruising and other body marks including pressure sores were noted by staff. The care plan was seen to be evaluated by the manager on a monthly basis. Medication was stored in a lockable medication trolley that was secured to the wall. Controlled medication was stored in a lockable cabinet away from the medication trolley. Medication Administration Record (MAR) sheets were examined and found to be recorded appropriately. The controlled drugs book was also viewed and overall provided an accurate record of medication administered. It was noted in the care plans that all residents needed to have their medication administered by staff but none stated why. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines in the home demonstrated that residents were encouraged to maintain control over their lives, maintain contact with family and friends and to participate in leisure activities. Meal choices were promoted by the home. EVIDENCE: The home provided a range of activities for the residents on both an informal and formal basis. Each morning the residents undertook a session of gentle exercises. This followed the Age Concerns guidance on promoting good health. Other activities included reminiscence sessions, board games, watching movies, bingo and general discussion groups were also offered. This extended to both home activities and the use of community clubs and events. The manager said that residents all had choice over the activities offered. The home had a four-week menu plan that was discussed with the residents. There was a main choice of meal and an alternative available. The residents were seen to be consulted over the evening meal. The home had a cook who worked 2 hours a day.
Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Polices and procedures were in place to enable concerns to be raised and to protect residents from neglect and abuse. However, staff were not fully trained in adult protection procedures and this could potentially place residents at risk. EVIDENCE: The home had a complaints procedure that was detailed in both the Statement of Purpose and the Service Users’ Guide. The home held a copy of the ‘No Secrets’ document and the Manchester Multi Agency policy and procedure. At the last inspection it had been noted that a number of staff had not received training in adult protection. This raised concerns over the staff adhering to the procedures to make sure the safety of residents was adequately protected. As a result, a requirement was made. On following up the requirement it was found that since the last inspection the manager had secured training for staff through the local authority training section. However, for various reasons the staff had not attended the course and this has resulted in the home continuing to have staff employed that had not undertaken this important training. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy providing residents with a comfortable environment. A programme of refurbishment was ongoing. EVIDENCE: The home was going through a redecoration programme covering the lounge / dining areas and some of the bedrooms. The home had also submitted a capital grants bid through the Local authority for funds to further improvements of the home. This was mainly focused on re carpeting the lounge and corridors and some bedrooms. The residents had been consulted regarding the colour scheme. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 16 Residents were able to personalise their bedrooms to reflect personal choice. Two bedrooms seen were found to be personalised and maintained to a good standard. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment and selection process at the home had been improved. However, staff lacked the training development and skills to meet the care needs of residents and the need to be aware of safe care practices and health and safety. Without the adequate training programme for staff the home was at risk of potentially failing to provide good /safe practices of care. EVIDENCE: At the last inspection it was found that the manager needed to ensure that each member of staff had a personnel file that met with Schedule 2 of the Care Home Regulations to include appropriate application forms, references, enhanced Criminal Record Bureau (CRB) disclosures and evidence of qualifications. Following on from the last inspection two staff files were selected at random and examined. Both were found to hold all the required information. Staff files held some information about training although it related to 2005. From talking with the manager it was acknowledged that training was an area the home still needed to improve on. The manager was a trained nurse and had qualifications and he had been a trainer in the past. The manager planned to develop staff competencies by undertaking awareness training through an in
Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 18 house programme. It was recommended that the competency of staff was established through validated assessments which could be evidenced clarify the training. It was recommended the manager obtained confirmation of his qualifications to formally demonstrate he had the skills to deliver the various training intended to be offered. The manager had started to develop staff supervisions in line with the National Minimum standards for older people and had annual appraisal forms in place. The management team were involved in delivering the care to the residents following a drop in the number of residents the home supported. The management team worked morning and afternoon shifts Monday – Friday. Care staff worked between 5pm and 10pm after which one waking night staff was on duty plus one sleep in staff member. Care staff covered the weekends unless staff were off sick or holiday when the management team would again cover shifts. The provider needed to monitor staff levels as part of the development of the service. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home overall was managed in the best interest of residents. This included the management taking the lead in delivering care. However, the home needed to have a quality assurance system in place that monitored the quality of care provided to validate the home respected the rights and interests of residents it supported. EVIDENCE: The manager was able to demonstrate that he had a good knowledge of the needs of the residents’ living at the home. The manager had previous experience of working as a nurse and was able to demonstrate to staff the requirements of their role.
Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 20 The manager and his wife were taking a primary role in providing the care to residents due to the decreased occupancy. The service had not undertaken a quality assurance survey with residents, relatives and people who commissioned the service. The development of a quality assurance system was discussed with the manager. This was acknowledged by the manager to be a priority for development in 2007 with staff training and care planning. The home did not manage residents’ monies and the manager ensured that a record was maintained of the personal allowance given to the resident each week. Residents or their representatives signed when the allowance had been given. It was recommended that details about financial arrangements were added to the care plan. The manager ensured that equipment was serviced and maintained in accordance with the requirements to ensure the safety of the residents. Fire equipment was checked on a regular basis and training had been provided to staff. The home had in recent months received a visit from the fire authority. The manager stated the recommendations made by the fire officer had been actioned. On the day of the visit the home had also received a visit from the environment health, who were overall satisfied with the hygiene standards within the home. It was noted during the tour of the home that some of the radiators were not covered. The manager was advised that risk assessments were necessary especially where one dining table was against a radiator. The manager stated water temperatures were checked and water safety checks completed. Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 22 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 OP18 Regulation Requirement Timescale for action 30/03/07 18(1)(a)(c The manager and provider must )(i)(ii) ensure that staff have appropriate training relating to the Protection of Vulnerable Adults(POVA) to ensure the safety and wellbeing of the residents’ living at the home. 18 Training must be provided to staff to ensure they are adequately skilled in safe care practices and can meet the needs of residents. The manager and provider must carry our risk assessments for all radiators that are not covered to ensure residents safety is not compromised. 2. OP30 30/04/07 3. OP38 13 30/04/07 Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 23 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 OP7 Good Practice Recommendations It is recommended that the manager continue to develop the care plan. This includes making sure that they are person centred, residents are invited to sign, covers areas of diversity, religious needs, financial safeguarding, nutritional screening, health history and medication care. It is recommended that staffing hours are kept under review to ensure that the needs of the residents are met at all times. It is recommended that the manager monitors residents weight and introduce body maps for recording any bruising, pressure sores or other marks noted by staff. It is reccommended that the manager introduce a quality assurance system. This should include seeking the views of residents and other stakeholders and publishing the findings. It is recommended that the development of in- house training includes obtaining validation of the managers skills/training qualifications which enable him to train other staff. The competency assessments should be formulated to confirm staff have reached a standard of skill / awareness in the various discipline areas. 2. OP27 3. OP8 4. OP33 5. OP30 Willowbank Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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 Residential Home DS0000061407.V331532.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
