Inspection on 09/08/05 for Willowbank Rest Home

This inspection was carried out on 9th August 2005.

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 04/01/07

Willowbank Rest Home 31/01/06

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 Della Lovell Announced 09 August 2005 09:30 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 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 F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Willowbank Rest Home Limited Mrs Debra Styles Care Home 20 Category(ies) of OP - Old age registration, with number of places Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 20 service users in the category of OP (Old Age, not falling within any other category). 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3. 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. Date of last inspection 27 January 2005 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. A dedicated team of care staff provide long term or respite care for up to 20 elderly people aged 65 years and above. There is a daily menu and alternatives are always available. Special diets are catered for. Willowbank does not provide nursing care. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over one full day in August 2005. The management team in the home are committed to raising standards and issues raised at the last inspection had been addressed. The inspection involved discussion with the people who lived and worked at the home, examination of records, a tour of the home and information received from questionnaires sent to relatives and service users. A separate pharmacy inspection was carried out by the Pharmacist Inspector. The outcome of this inspection, together with any requirements and recommendations has been sent in a separate report. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that the service users care plans provide detailed information in the way of written instructions and action required by staff to ensure all assessed needs are fully met. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 6 Each service user had a comprehensive file, which contained various documentation. The registered person must ensure that all visit to NHS services are documented and recorded for each service user. The must ensure that a thorough fire and environmental risk assessment is undertaken which includes all service users bedroom windows and action appropriate action to minimise any risks identified. 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 F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 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 standard(s) 1,2 and 3 The homes statement of purpose and service user guide provides service users and prospective service users with the information they need to make an informed choice about where to live. EVIDENCE: All service users and prospective service users are provided with a service users guide. The home ensures there is a copy available in the entrance hall for all visitors or family’s. The home had a good admission procedure to ensure service users needs are assessed and planned for. Observation of service users files showed that all new service users are admitted only on the basis of a full assessment and for individuals referred through social services the registered manager had obtained a local authority assessment. One service users told the inspector that since moving into the home her health and physical ability had greatly improved because of the care and support provided by the home. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 and 10 Individual care plans were in place, however more attention and detail is needed to ensure care staff have adequate information and instructions to meet the assessed needs. Documentation held on service users files did not ensure that service users have access to NHS enttilements. Service users are cared for in such a way that ensures the service users dignity and privacy. EVIDENCE: The files of a number of service users were viewed in detail as part of the inspection process. The service users care plans had been generated from the initial assessment and service users and or their families had the opportunity to be involved in the process. On the day of the visit one care plan did not provide written instructions in accordance with each identified assessed need and the action required by care staff to meet the needs. Two service users files lacked information on whether or not service users had access to NHS entitlements such as hearing and sight test and dental care. The manager and service users were able to confirm that these needs were being met although they had not been recorded. The Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 10 manager told the inspector that all files would be reviewed and information up dated. Service users spoken to throughout the day were happy with the care they receive and told the inspector that the staff were very kind and treat them with respect and dignity. The inspector saw examples of staff caring and speaking to service users in a sensitive manner. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 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 standard(s) 12 and 15 The meals in the home are very good offering choice and variety and catering for special dietary needs. Social activities are well managed and provide interest and variety for the people living at the home. EVIDENCE: All service users told the inspector the food in the home was excellent and that a choice is always offered. One service users said that the cook can make any thing and if you do not want what is on the menu she will make you some thing different. The home has a four weekly menu, all the food is prepared and cooked from fresh produce by the cook. The cook was very aware of service users likes and dislikes and was able to accommodate all the different tastes. The cook was able to explain how special diets are catered for which ensures that choice is provided. One staff member takes responsibility for arranging activities and there is a monthly programme, which includes trips out on the homes own mini bus, a selection of board games and visits from external entertainers. One service user said that she had especially enjoyed the last trip out to a garden centre. The home ensures that service users needs and disabilities are taken into consideration and individual one to one support is provided for service users who are unable to participate with out assistance. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 12 On the day of the visit some service users were sat in the garden enjoying the nice weather and others were enjoying a board game with the care staff. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16 and 18 The home has a complaints procedure, which ensures that all complaints would be acknowledged and investigated. The home had robust procedures in place to safe guard 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 spoken to confirmed that they had received training and was able to explain the correct procedure they would follow to protect service users. The home had not received any complaints. A complaints policy and procedure was in place and is made available to all service users in the service users guide. One service users told the inspector they had no complaints but knew who they could speak to if they had any concerns. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19,20 and 26 The home was clean comfortable and homely and provided an environment that was suitable for its stated purpose. Risk assessments were needed to ensure the continued safety of the service users. EVIDENCE: The home was accessible to all service users. Ramps allowed easy access to the out side and a passenger lift and stair lift was provided to access all floors. Out side the grounds were tidy and well maintained, providing a pleasant area for service users and their visitors to enjoy if they wished. A handy person is employed by the home to attend to all repairs and maintenance. The home was cleaned to a high standard and furnishing and fittings was of a good quality. One service users told the inspector that Willowbank was very homely and that she liked her bedroom and felt she had enough furniture and space. Since the last inspection a number of improvements had been made, the drive way had been renewed, the dining room and ground floor bathroom had been refurbished and bedrooms are redecorated once vacant. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 15 The laundry was clean and tidy but was getting ready for re-decorating. The washer provided a sluicing facility for laundry but the home did not provide a sluicing facility for commodes. The provider discussed the future plans with regards refurbishment and the possibility of installing a sluicing facility. At the time of the inspection the inspector noted that not all windows had been fitted with a restrictor and a fire risk assessment had not yet been completed. One door, which provided a fire escape route was seen to be bolted. The registered manager addressed this matter on the day. A risk assessment should be undertaken of the environment and action taken to minimise any identified risk. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The policies and procedure for recruitment of staff are robust and provide safeguards for the protection of service users. Staff at the home are provided with training to ensure they are competent to do the job. EVIDENCE: The home had a robust recruitment procedure in place, which ensured the Protection of Vulnerable Adults. Personnel files showed that a thorough recruitment and selection process had taken place and all new staff had undertaken induction training. There was a training matrix in the home, which clearly showed what training had been undertaken by staff and certificates were seen on the staff files. Staff were provided with mandatory training and other more specialised training such as dementia which equipped them with the necessary skills to carry out their role confidently and competently. Staff said that they felt well supported by the management team and training. Since the last inspection a number of staff had completed the NVQ Level 2 qualification and number of staff were working towards the qualification. Staffing levels in the home were sufficient for the number of service users living in the home. Staff spoken too said that they felt they had enough staff on duty to meet the needs of the current service users. There was a rota available in the home showing which staff are on duty at any one time. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 The home is well managed which ensures service users interests are safeguarded. Staff are appropriately supervised to ensure they are confident and competent in the work they do. EVIDENCE: There is a clear management structure in the home and the management team are well supported by the registered provider. Service users and their families are provided with the opportunity to be involved in the running of the home through the process of surveys. The surveys are analysed and the findings published. Staff confirmed that they receive appraisals and supervision sessions and this was also documented on the staff files. Staff have the opportunities through regular staff meetings to raise any issues with regards to the running of the home. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 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 x 14 x 15 4 COMPLAINTS AND PROTECTION 2 3 x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x x Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 19 no Are there any outstanding requirements from the last inspection? 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 7 Regulation 15(1) Requirement Service users care plans must be in sufficient detail to provide clear instructions and guidance to staff on the actions to be taken to meet their assessed care needs. The registered person must ensure that service users their entitilements to NHS services and that is documented on their individual files. The registered person must ensure that a fire risk assessment is completed for the home and take approprate action to minimise any risks. The registered person must undertake an enviromental risk assessment of the premises which includes all service users bedroom windows and take appropraite action to minimise any identified risks. Timescale for action 31/10/05 2. 8 12(1)(a) 13(1)(b) 31/10/05 3. 19 23(4)(a) 13(4)(a) 31/9/05 4. 19 13(4)(a) 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 20 No. 1. 2. 3. Refer to Standard 26 28 30 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 a minimum of 3 paid days training a year. Willowbank Rest Home F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road, Chorley, Lancashire PR7 1NW 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 F57 F08 S5900 Willowbank V234504 090805 Stage 4.doc Version 1.40 Page 22 - 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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