Inspection on 04/01/07 for Willowbank Rest Home

This inspection was carried out on 4th January 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 Rest Home 11/10/07

Willowbank Rest Home 31/01/06

Willowbank Rest Home 09/08/05

Willowbank Rest Home 27/01/05

Willowbank Rest Home 21/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Willowbank Rest Home 42 Lancaster Lane Clayton Le Woods Leyland Lancashire PR25 5SP Lead Inspector Mrs Janet Proctor Key Unannounced Inspection 09:00 4th January 2007 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.V308373.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 Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 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) hazelhousecare@btconnect.com Willowbank Rest Home Limited Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (1) of places Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 20 service users in the category of OP (Old age not falling within any other category). One named service user in the category PD (Physical Disability under the age of 65 years of age) may be accommodated with the overall number of registered places. 31st January 2006 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 rooms if they wish. Willowbank does not provide nursing care. Information on the home is available in a Service User’s Guide, which explains what is provided at the home. In January 2007 the fee charged was £395-00 to £405-00 per week. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Willowbank Rest Home on the 4th January 2007. The previous inspection was done on the 31st January 2007 and information on the findings of this can be obtained from the home or from www. CSCI.org.uk. No additional visits have been made since the previous inspection. Prior to the inspection information had been submitted in a pre-inspection questionnaire. Surveys had also been returned by some residents and relatives. On the day of the inspection there were 16 residents at the home, Information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to residents, the Manager, and staff members. A tour of the building took place. Wherever possible the views of residents were obtained about their life at the home and their comments are included in the report. What the service does well: Arrangements were made to make sure that the health of the residents was looked after. At the time of the inspection a number of people were suffering from coughs and colds and the GPs had been called in to monitor this. From the surveys forms returned five residents said that they always receive the care and support that they needed and three said that they usually did. A resident spoken to said, “I feel quite healthy – they call the Doctor if I’m not well.” There were good relationships between the staff and residents. They interacted in a pleasant way. Residents spoken to said, “They’re friendly staff, nice with you”, “I’m very happy, it’s a real home from home” and “The staff treat us with respect”. All of the relatives surveys returned said that they were made to feel welcome at the home. Medication was stored and given out in a safe manner. This ensured that residents received the right medication at the right time and that their health was protected. Residents received a nutritious and balanced diet that promoted their health. All of the residents spoken to praised the food at the home. They said, “The food’s marvellous – I really enjoyed my dinner” and “The food’s good, always something you can eat”. One of the resident surveys returned included the comment “The food is excellent, if possible please pass congratulations and appreciation to the chef.” Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 6 A programme of activities was done so that residents were occupied and entertained. A resident said, “There’s some activities – bingo, knitting, exercises. That’s good, it loosens you up. We have some trips out.” One of the resident surveys said, “ I would appreciate more trips out in the mini-bus”. The home was clean and tidy, and the furnishings were of a good standard. Repairs were done as needed. This meant that residents lived in a safe and pleasant place. All of the resident surveys returned said that they thought the home was clean and fresh. The Management team had ways of measuring the quality of care given at the home. This let them know if there were any shortcomings in care and management and they could then take steps to rectify this. One of the systems used was a resident survey form. This was last done in August 2006 and showed that residents were very pleased with what was provided at the home. What has improved since the last inspection? What they could do better: Following the assessment of a proposed resident’s needs they must receive confirmation in writing that these can be met at the home. This is so that they can be confident that they will receive the right care once they are admitted. A care plan should be started as soon as possible after a resident is admitted. This is so that the staff have the information they need to given the right care. When the plan is reviewed there should be some comment made as to whether the aims are being met or not. This shows whether the care being given is Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 7 right and effective. There should be some information in the plan of care about how to meet the resident’s social needs. This is to ensure that they receive the recreational activities that fit in with their diverse interests and needs. If a resident is assessed as being at risk of developing a pressure sore there must be some direction for staff in the plan of care about this. This is so that they know the right actions and equipment to use to prevent a sore from occurring. Any handwritten entries to the Medication Administration Recording charts should be signed and witnessed. This is to ensure that no errors have been made in writing the instructions. Residents who take care of their own inhalers must keep these in a safe place. If they are left out in view of others, they may get misused. The locks on bedroom doors must enable the resident to be able to open these from inside the room without the use of a key. This is so that they never get accidentally locked in their room. There must be a fire detection system in all areas where flammable items are stored. This is to ensure that a timely warning is given if a fire should start. Two residents thought the temperature of the stairs and corridors was cool and this should be monitored to ensure that it is comfortable for residents. In order that staff remain knowledgeable and competent they must receive regular training updates. This must include moving and handling and training in Safeguarding Adults. An application for registration must be submitted for the new Manager. This is so that the Commission can begin the process of registration. 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.V308373.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 Rest Home DS0000005900.V308373.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had their needs assessed before moving into the home. This meant that their needs were known and arrangements could be made to meet these. EVIDENCE: The files for three residents were examined. These showed that an assessment of their needs had been done before they were admitted. The form used for the assessment had been amended so that it clearly stated the age of the proposed resident. This had been done so that it would be apparent if any resident under 65 years of age were to be admitted. The fact that needs could be met at the home had not been given to the proposed resident in writing. This meant that they could not be fully confident that their needs could be met. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 10 A resident who had been recently admitted said, “My daughter went and had a look round a lot and then she brought me to look around and meet the staff. My first impressions were that it was clean and the staff were nice.” Intermediate care was not provided at Willowbank Rest Home. Willowbank Rest Home DS0000005900.V308373.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 at least once during a 12 month period. 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 this service. The care plans identified the personal and health care needs of residents. This meant that staff knew what they had to do to meet these. Medication practices safeguarded residents’ health and welfare. Residents were treated with respect and their privacy and dignity protected. EVIDENCE: The care plans for three residents were examined. One resident had been admitted over two weeks previously but a plan of care had not yet been completed. The documents for the other two residents were in individual folders and were well organised. There was a sheet that had been signed by the resident or their relative to show that they had been consulted about the content of the plan. The plans had been reviewed, but the review did not always give an indication of the progress that was being made to meet the needs. For example, one care plan had identified nutrition as a need and the aim of this was to increase the resident’s weight. This resident had actually lost Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 12 eight pounds since November 2006, but this had not been considered in the review as to whether the plan of care was actually working or not and should be amended. There were assessments for health. These included: moving and handling; nutrition; risk of falls; and risk of developing pressure sores. If the resident was identified as being ‘at risk’ this was usually included in the care plan. However, two of the residents were identified as being at ‘high risk’ of developing pressure sores but this was not in their plan of care. This meant that staff had no directions on what actions to take to reduce this risk. There was evidence that pressure mattresses and cushions were used appropriately. A full risk assessment for the use of bedside rails was used. This gave a clear indication whether the bedside rails were in the best interests of the resident or not. It was not clearly evident what the score on the falls risk assessment meant, whether they were at high, medium or low risk of falls. This could result in staff not taking sufficient care when tending to the resident. A record was kept of the resident’s weight. Not all residents could use the stand-on scales and arrangements were to be made to obtain sit-on scales so that the weight of all the residents could be monitored. There was good evidence that other health professionals were consulted when needed. These included: chiropodist; optician; dietician; and GP. Residents spoken to all said that they were well looked after. There were some good practices in respect of the control of medications. These included appropriate storage and records of medicines ordered, received, administered and disposed of. Prescriptions were seen before the medicines were dispensed. There was a photograph of the resident for identification purposes. A criteria sheet was used for ‘as required’ medications. This meant that all staff would be giving them in a consistent manner. Controlled Drugs were correctly stored and recorded. The balance of drugs kept was checked and agreed with the records. The method of counting Controlled Drugs would be easier with a proper tablet counter. Handwritten entries on a Medication Administration Recording chart had not been signed or witnessed. This meant that there was the potential for error if the original instructions had been written incorrectly. Glycerine and lemon mouth swabs were available. It is not good practice to use these as they can reduce the moisture in the mouth and contribute to dryness. Inhalers were in view in one bedroom. The resident to whom these belong must ensure that they are kept securely so that no-one else can access these. Residents were seen to be treated with dignity and respect. The preferred term of address was noted in the plan of care and used by staff. Privacy was Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 13 respected by staff knocking on doors before entering their rooms. The subjects of privacy and dignity were covered in the Induction training given to staff. Willowbank Rest Home DS0000005900.V308373.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 at least once during a 12 month period. 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 this service. Residents’ social and recreational needs were met by activities being available and contact with visitors. The daily routines for residents matched their preferences and choices. Residents received a balanced diet and enjoyed their meals. EVIDENCE: There was a programme of activities that included: gentle exercise; bingo; hand massage; dominoes; cards; church services; neck and shoulder massage; and crafts. There was a Hobby Therapist who worked 25 hours a week specific for activities. The social care needs of residents were assessed prior to admission but this information was not apparent in the plan of care. This meant that staff might not know the best way of ensuring how the resident’s diverse social and recreational needs were to be met. Residents spoken to said they could get up and go to bed when they wished. They said they could use their rooms as and when they wanted. They could have meals in their rooms if they wished to. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 15 Residents and staff were able to confirm that there were no restrictions on visitors to the home. One resident said that they can take their relative to their own room or use one of the communal lounges when their visitors came. All of the residents spoken to said that they enjoyed the food served at the home. The dining room was decorated and furnished in a pleasant manner and residents were encouraged to make the meal time a social occasion. There was a four-week rota of menus. There was a choice of meal at teatime and alternatives could also be had at any meal. The day’s menu was displayed in the dining room so everyone was aware of what was on offer. The Cook went around and asked residents what they wanted for their teas. Night staff had access to foodstuffs so that they could make snacks if anyone was hungry. There was a sufficient stock of food on the premises, including fresh fruit and vegetables. Records were kept of fridge, freezer, trolley and cooked temperatures. Willowbank Rest Home DS0000005900.V308373.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 inspected at least once during a 12 month period. 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 this service. Residents were confident that any concerns or complaints would be listened to and acted upon. Residents were protected from abuse. EVIDENCE: There was a complaints procedure that was on display on the notice board. This was also in the Service User’s Guide given to residents. Records were kept of the complaints made. This record included the result of the investigation. The forms were in a loose-leaf style but were numbered so it was apparent if any were lost or mislaid. Only one complaint had been received by the home in twelve months. No complaints had been made direct to the commission. Residents spoken to said that they had no complaints. One resident said that there had been some ‘blips’ but they had been sorted out when something was said. This implied that staff responded appropriately when issues of concern were brought to them. There were Prevention of Abuse procedures and a Whistleblowing procedure available for staff. The reporting of abuse was covered in the Induction procedures when staff started work. This meant that they had directions on what to do should they witness or suspect anything was wrong and safeguarded residents. A member of staff spoken to was aware of the correct action to take. The training on Prevention of Abuse was not updated annually, Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 17 which meant that these directions were not reinforced to staff on a regular basis. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 18 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 and 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 well maintained and provided a pleasant environment for residents. The lack of a smoke detector in the medication storeroom and the use of inappropriate locks on some doors may put residents at risk. EVIDENCE: All areas of the home were clean, tidy and well maintained. The rooms were homely, comfortable and nicely decorated. There were two lounges and a dining room for the use of residents. Sufficient bathrooms and toilets were provided on each floor. Two residents said that they felt that the temperature of the stairs and corridors felt cool. They said that their bedrooms were warm and they could control their own heating. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 19 18 of the bedrooms were for single occupancy and there was one double bedroom. The bedrooms contained sufficient furniture and there was a call system for requesting staff attention. Chubb locks seen were seen on some bedroom doors. The use of these is unsafe as there is the potential for someone to be locked in their room. There was no smoke detector in either the medication storage room or the attached storeroom where combustibles were stored. This meant that a fire could be well established before a warning was given to staff. There was a separate laundry room, with a washer and dryer. The laundry had hand washing facilities and plastic gloves so that good hygiene could be maintained. The laundry was done by the care staff. There was liquid soap and paper towels in all areas around the home. Plastic gloves and aprons were available and seen to be used by staff. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty met the needs of the residents. Recruitment practices safeguarded residents. Lack of regular training updates may lead to staff not remaining knowledgeable and competent. EVIDENCE: There was a duty rota that gave the name, designation and hours worked by each member of staff. There was a Cook and a domestic every day. Administrative support was also available. There were sufficient staff on duty to meet the needs of residents. All pre-employment checks were in place and these ensured that residents were safeguarded. All proposed staff completed an application form and had a face – to –face interview. A Criminal Records Bureau check was done and two references requested, one from the previous employer. All new staff were given a copy of the GSCC code of conduct and practice. A contract of employment was issued at the end of the probationary period. There was an equal opportunities policy and an anti-discriminatory practise policy. Attitudes to this was explored on interview. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 21 All new staff received an Induction course and the topics they learnt were recorded in a booklet. This gave them the basic knowledge and competency they needed to do their work. Although some further training had been arranged not all staff were attending these sessions, especially night staff. This meant that their skills and knowledge may not be up to date. There were 19 carers, of which 10 had the National Vocational Qualification Level 2 in care. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed. There were systems to monitor quality and ensure that the home was run in the best interests of the residents. Health and safety of staff and residents may be affected by the lack of regular training updates. EVIDENCE: A new Manager had been recruited before Christmas. She had the necessary skills, experience and qualifications for the job. Two residents had been on the interview panel and their opinion of the candidates valued and taken notice of. All of the residents and staff spoken to said that the new Manager was approachable and they felt easy about approaching her. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 23 The home used good quality assurance systems. An external review on this had been done in November 2006. The home also had the Investors In People award. Resident surveys were done annually. These could be completed by relatives as well as residents. The last survey was done in August 2006. This showed a 70 - 99 satisfaction level. Any issues arising were dealt with, for example, laundry problems identified were dealt with by new equipment and training. Residents meetings were held. Relatives were also invited to attend these and share their views. Meetings were held for different grades of staff. Residents could look after their own money if wished to. Staff at the home did not take responsibility for managing any benefits or bank accounts of the residents. Small sums of money were kept on the premises for day-to-day expenses. These were stored in a secure manner. Records were kept that showed the date, the transaction, the balance and a signature. These were checked against a random number of cash balances and found to be correct. Receipts were kept of any item purchased on behalf of a resident. There were records to show that maintenance was done as and when it should be. A new Oxford hoist had been purchased in April 2006. This had not been checked after six months as required by LOLER. Reports were made and kept of any accident occurring on the premises. Not all staff were receiving regular update training in safe working practices. This may mean that their skills and knowledge are not up to date. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 24 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1)(d) Requirement It must be confirmed in writing before a resident is admitted that their needs can be met at the home. The locks provided to bedroom doors must be appropriate for the needs of residents. They must be able to be opened from inside the room without the use of a key. The Lancashire Fire and Rescue Service must be consulted about the provision of a smoke detector in the medication storeroom. Their advice must be followed. All staff must receive regular training in safe working practices to ensure that they have the necessary skills and knowledge to do their work. An application for registration must be submitted for the manager when her probationary period is compete. Timescale for action 31/01/07 2. OP19 23(2)(a) 28/02/07 3. OP19 23(c)(i) 31/01/07 4. OP30 18(1)(c) 31/03/07 5. OP31 8 31/03/07 Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 26 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. 5. 6. 7. 8. 9. 10. 11. 12. Refer to Standard OP7 OP7 OP8 OP8 OP9 OP9 OP9 OP9 OP12 OP18 OP19 OP38 Good Practice Recommendations A plan of care should be started as soon as possible after the resident has been admitted. The review of needs/problems in the plan of care should given an indication of the progress made. The plans of care should tell staff what to do if a resident has been identified as being of ‘high risk’ of developing pressure sores. The falls risk assessment form should clearly indicate whether the resident is at high, medium or low risk of falls. The use of a tablet counter should be considered for checking the amount of Controlled Drugs. Handwritten entries to the Medication Administration Recording charts should be signed and witnessed. The use of glycerine and lemon mouth swabs should be discontinued. Residents who administer their own inhalers should ensure that these are kept in a secure manner so no-one lese can access them. The social and recreational needs of residents should be identified in the plan of care. All staff should receive regular updates on Prevention of Abuse The temperature of the corridor and stairs should be monitored to ensure that this is comfortable for residents. The hoist should be examined every six months to ensure that it is fit for purpose. Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willowbank Rest Home DS0000005900.V308373.R01.S.doc Version 5.2 Page 28 - 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. 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