Inspection on 20/02/06 for Willowbrook

This inspection was carried out on 20th February 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willowbrook 18/10/06

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

CARE HOME ADULTS 18-65 Willowbrook Willow Crescent Oakham Rutland LE15 6EH Lead Inspector Fiona Stephenson Unannounced Inspection 20th February 2006 10:40 Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 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 Willowbrook DS0000066433.V280034.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 Adults 18-65. 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. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willowbrook Address Willow Crescent Oakham Rutland LE15 6EH 01572 771001 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) Rutland House Community Trust Ltd Position Vacant Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Care Home will provide personal care to service users who fall within the following service user categories; Learning Disability (LD) Physical Disability (PD). Maximum number registered 10. No person falling within the category PD may be admitted to the home unless that person also falls within category LD i.e. dual disability. 13/04/05 Date of last inspection Brief Description of the Service: Willowbrook is a care home for people with learning difficulties, some of who also have physical disabilities. The accommodation was purpose built in 1995 and is ground level only. The home has ten single bedrooms, a large lounge/dining room, a ‘quiet’ lounge and a small conservatory and atrium. The home has gardens with seating areas and the administration of the home is undertaken in a mobile unit located within the grounds. Willowbrook is approximately one mile from the centre of Oakham, which has a range of amenities including a swimming pool, churches, shops, pubs and a library. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two inspectors, starting at 10:40am and finishing at 1:45pm. It was the second statutory inspection of the home for the year 2005-2006 and as such, the inspectors focused on the ‘core’ standards that were not checked during the previous inspection. To do this, the inspectors used a method called ‘case tracking’ where the care and quality of life of one resident was checked by talking to staff, looking at records, and by checking parts of the premises the resident uses. What the service does well: What has improved since the last inspection? Staff have training in delegated healthcare duties, which is now documented and signed by the appropriate authority, thereby providing evidence that the training is of an acceptable and appropriate level to keep residents safe. Staff in ‘overnight’ charge of the home, now meet the criteria of Regulation 18, and have sufficient experience and knowledge to support the care and well being of residents in their care. All bedrooms have been re-decorated in the last year, and reflect the individuality of the residents living in them. Willowbrook DS0000066433.V280034.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. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not checked on this occasion. EVIDENCE: Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Residents’ individual needs and choices are well supported by staff. EVIDENCE: Through discussion, staff demonstrated to inspectors a good understanding of the needs of the residents living at the home. The inspectors were also informed of a recent situation involving a resident where staff are to be commended for their actions and their work as advocates for the resident concerned. Each resident has a care file that on the whole provides information about the care needs of each person. The information in the files is however, not always easy to track – for example, when checking changes to a resident’s medication regime, the staff member couldn’t find the evidence to support the change to medication; not all changes to care practice are dated, thereby providing no evidence as to whether the care changes are recent or requiring review, and there is no system available to show that reviews of care, for example with regard to skin care, have been carried out. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15 Residents are given good opportunities to engage in lifestyles suited to their needs and preferences. EVIDENCE: The residents have a range of activities both within the home and outside of the home environment, and the activities are arranged in consultation with residents to ensure they meet their individual aspirations and requests. Residents were noted to be involved in both leisure related, and work related activities. Residents who were able to communicate, declined the opportunity to speak to inspectors, although it was noted that one resident who declined to talk was fully involved in painting a picture at the time. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Care provision is good, however medication administration is not always accurate. EVIDENCE: Discussion and written information provided good evidence that staff provide personal care in the way that residents prefer and require. Medication was checked and although generally medication was administered appropriately and accurately recorded, there were a couple of serious errors noted i.e. the information from a medicine bottle had been incorrectly hand written onto the resident’s medication record sheet, and correcting fluid had also been used to amend a mistake. Also prescribed items such as dressings were not being documented as being administered, and nebulisers were not being put back in the prescribed boxes. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not checked on this occasion. EVIDENCE: Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30. Residents live in a homely, clean and safe environment. EVIDENCE: Inspectors looked at the bedrooms and communal areas of the home and found them all to be in a clean and tidy state. Bedrooms have been redecorated in the last year, and reflect the personalities of each resident. Specialist equipment is used to support the needs of residents, however staff are also mindful of using non-specialist equipment when appropriate. For example one resident was found to enjoy the use of a bean bag whilst at an activity outside the home, and a bean bag was purchased for him to use within the home so that he could have a change from being in a wheelchair or in his bed. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not checked on this occasion. EVIDENCE: Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not checked on this occasion. EVIDENCE: Willowbrook DS0000066433.V280034.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 Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x X X X X X X X Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 17 None 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 YA20 Regulation 18 (1)(2) Requirement Provide an action plan detailing how staff will be trained and supervised to ensure medication is recorded and administered appropriately. Timescale for action 06/03/06 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 YA6 Good Practice Recommendations Consider revising care records to ensure that all areas of care have individual care plans which are dated and reviewed at appropriate intervals, and where changes to care can be easily identified and tracked by staff. Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Willowbrook DS0000066433.V280034.R01.S.doc Version 5.1 Page 19 - 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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