This inspection was carried out on 31st January 2006.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Willowbank Rest Home 42 Lancaster Lane Clayton Le Woods Leyland Lancashire PR25 5SP Lead Inspector
Della Lovell Unannounced Inspection 31st January 2006 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 Rest Home DS0000005900.V280959.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 Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Willowbank Rest Home Address 42 Lancaster Lane Clayton Le Woods Leyland Lancashire PR25 5SP 01772 435429 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) jjc@johncairns.co.uk Willowbank Rest Home Limited Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The home is registered for a maximum of 20 service users in the category of OP (Old Age, not falling within any other category). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 9th August 2005 Date of last inspection Brief Description of the Service: Willowbank is situated on the outskirts of Leyland, close to junction 28 of the M6 motorway, in a quiet residential area. Local amenities are close by. Accommodation is provided on two levels in eighteen single rooms and one shared room. There are spacious lounge areas available, where a variety of activities take place. The home has a dining room although service users may dine in the privacy of their own homes if they wish. Willowbank does not provide nursing care. Willowbank Rest Home DS0000005900.V280959.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 over one day in January 2006. The Inspector spoke to the provider, acting manager, three staff members and a number of service users. The inspector examined a number of records, toured the home and observed the staff on duty. The registered manager left the post at the end of December 2005 and Mrs Ann Geddes has been employed to provide management cover. What the service does well: What has improved since the last inspection?
Since the last inspection the management team ensure that all information about a service users health and social care needs are recorded on the care plans and met. Both an environmental and fire risk assessment were in place to ensure the continued safety of service users living in the home.
Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 6 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 Rest Home DS0000005900.V280959.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 Rest Home DS0000005900.V280959.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): 3 The home had a good assessment procedure, which ensures service users needs are assessed and met. EVIDENCE: One new service users file was looked at as part of the assessment process. The home had undertaken a full and comprehensive assessment of the service users needs and the service users confirmed that she had been involved in the process and had been made aware of what care she could expect to receive at Willowbank. The service user confirmed that she had received information and documentation about Willowbank and had been offered a trial stay at the home before making the decision to stay permanent. During the inspection the inspector noted that one-service user had been admitted to the home under the age of 65 years. It is a condition of the homes registration that all service users are to be aged 65 years and above. This was discussed with the manager and provider on the day. Clarification and advice was given by the inspector and appropriate action was immediately taken by the home to address this matter.
Willowbank Rest Home DS0000005900.V280959.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 8 The health and personal care needs are met by the homes assessment and care planning process. EVIDENCE: Each service user had an individual plan of care, which sets out in detail the action needed to be taken by the care staff to meet their needs. Each service user had a daily record sheet, which recorded the care given and any significant events. Files contained information in relation to NHS entitlements such as dental and eye sight tests and one new service users file contained literature for staff with reference to a specific health condition. All service users spoken to felt their needs were being met and said that they were very happy with the care and attention provided by the staff team at Willowbank. Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 10 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): 13 and 14 The homes procedures and practises enable service users to exercise choice and control over their lives and contact with family and friends are actively encouraged. EVIDENCE: Service users and staff were able to confirm that there were no restrictions on visitor to the home. One service user said that they can take their relative to their own room or use one of the communal lounges if they so choose. Observations made confirmed that service users had control over their lives. Staff were seen consulting with service users over their daily routine and all service users said that the staff in the home treated them with respect. One-service users showed the inspector her bedroom and told the inspector how she had brought some of her personal possessions in from home. The staff at the home encourage the service users to maintain their independence. One service user said I like to dress and bath my self, the staff only assist me to get in and out of the bath because I can be unsteady. Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 11 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): 18 The home had robust procedures in place to safeguard service users from abuse and harm. EVIDENCE: The home had a policy and procedure in place for the Protection of Vulnerable Adults and all new staff are made aware of this information through the home induction procedure. Both the manager and staff were aware of the correct procedure they would follow to protect service users. Service users told the inspector that they did not have any concerns and would speak with the manager or the provider if they did. Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 12 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 Service users live in a safe, well maintained home. EVIDENCE: The home is well maintained and cleaned to a high standard with good quality furnishings and fittings. At the time of the inspection all service users told the inspector that they were very happy living at the home and happy with their accommodation. One service user told the inspector how the staff at the home always keep her room clean and tidy. The home does not provide sluicing facilities however policies and procedures are in place to ensure that infection control is maintained. Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 13 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): 29, 30 The policies and procedure for recruitment of staff are robust and provide safeguards for the protection of service users. Staff are provided with training to ensure they are competent to meet the needs of the service users living at the home. EVIDENCE: The home had a robust recruit policy and procedure in place, which ensured the Protection of Vulnerable Adults. The file of one newly appointed staff member was looked at. All the appropriate checked had been undertaken by the home prior to the staff member starting and an induction programme was in place to ensure the staff member was competent and confident to do the role of a carer. Staff on duty told the inspector that they felt well supported by the training provided and one staff member said that she was enjoying the current training being provided by the home on dementia care. Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 14 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): 31,35 and 38 The home is well managed which ensures the service users interests are safeguarded. The home promotes safe working practises, which ensures that the health and welfare of service users and staff are promoted and protected. EVIDENCE: All staff receive training in health and safety practises. There were certificates on staff files to show that staff had received training with regards to moving and handling and food hygiene however a number of staff were awaiting their moving handling certificate. There was evidence that one new staff had completed an induction programme and all staff are provided with on going training to ensure they are competent in their job. The home appropriately records all accidents and there is a fire and environmental risk assessment in place that is reviewed every 6 months. Infection control measures are in place and all staff are provided with protective clothing when undertaken specific tasks. On the day of the visit general maintenance certificates where in place and up to date.
Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 15 Service users or their families manage the finances. The home provides a lockable storage area in all the bedrooms and payments are generally made via a relative. The home holds a small amount of money for some service users. All written records were seen maintained and up to date. Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 16 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X x STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Timescale for action Section 24 The registered person must 01/02/06 CSA 2000 ensure that service users are admitted in the age category the home is registered for. Regulation Requirement 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. 4. Refer to Standard OP26 OP28 OP30 OP38 Good Practice Recommendations The registered person should consider installing a sluicing facility in the home. The registered person should continue to work to having 50 of its workforce achieve an NVQ Level 2 All staff should have a minimum of 3 paid days training a year. The registered person should ensure that staff are kept up to date with moving and handling certificates. Willowbank Rest Home DS0000005900.V280959.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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