Inspection on 10/03/06 for The Willows

This inspection was carried out on 10th March 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Willows 20/01/09

The Willows 23/03/07

The Willows 05/09/05

The Willows 16/11/04

The Willows 10/06/04

The Willows 11/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Willows Summer Lane West Wick Worle North Somerset BS24 7TF Lead Inspector Paul Grey Unannounced Inspection 10 of March 2006 09:30 th The Willows DS0000020373.V281200.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 The Willows DS0000020373.V281200.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. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Willows Address Summer Lane West Wick Worle North Somerset BS24 7TF 01934 510404 0117 9699000 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) The Brandon Trust Mrs Gladys Jill Marshall Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 7 Adult Patients with learning difficulties/physical disabilities Staffing Notice dated 30/03/1998 applies Manager must be a RN on Part 5 or 14 of the NMC register Date of last inspection 5th September 2005 Brief Description of the Service: The Willows is a small, homely provider offering care for up to 7 service users with severe learning, physical and sensory disabilities. The Willows is a pleasant bungalow situated in a quiet cul-de-sac on the outskirts of Worle.The home has single rooms and has been extensively adapted to meet the needs of service users. The team strive to provide a broad range of life experiences both inside and outside of the home environment. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over 3 1/2 hour period in the absence of the manager. The Inspector spoke with staff, met two service users, audited care files and conducted a tour of the premises. The Inspector noted that the homes administration was excellent, service users present were well presented and appeared content. The environment was clean, comfortable and very pleasant. The Inspector commends the home and the manager on a pleasant environment and a good standard of care. The Inspector noted that there had been insufficient fire drills at the home. The nurse in charge agreed to remedy this with staff having a fire drill shortly after the Inspectors departure. As a consequence this was not made a requirement. What the service does well: What has improved since the last inspection? 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. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 6 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 The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 7 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): 1, 2, 3 Potential service users are provided with the information they need to make an informed choice about the home prior to moving in. The home can demonstrate its ability to assess the needs and aspirations of prospective service users. Prospective service users know that the home can meet their needs and aspirations. EVIDENCE: During inspection, the Inspector noted the home has maintained an up to date statement of purpose. This outlines the purpose of the home, describes support and facilities available and gives a reasonable description of the individual accommodation available. The statement of purpose also contained a complaints procedure with contact details for CSCI. The Inspector audited 3 files. The Inspector found evidence of a clear and comprehensive assessment procedure. This was well documented. The Inspector noted evidence that the assessment procedure is used to develop the individual service user plan. Where possible the service user is involved in this process. Given the degree of disability experienced by the service users this input is often minimal. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 8 The Inspector noted clear evidence from his observation of care, audit of care records and staff statement evidence that the home can demonstrate their ability to meet service users assessed needs. The Willows DS0000020373.V281200.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, 9 The home reflects service users changing needs and personal goals in their individual plan of care. The home assists service users to make decisions about their lives. The home support service users to take reasonable risks is part of an everyday lifestyle. EVIDENCE: The Inspector audited 3 plans of care during inspection. The Inspector noted evidence from both staff statement and auditing records to indicate that the assessment process is used to generate a clear plan of care. The Inspector noted the plan of care sets out how any service users specialist requirements will be met. The plan of care also mentions any potential restrictions on the service users choice or freedom. The Inspector noted that there were no undue restrictions on the service users. The Inspector noted that staff had gone to great lengths to take service users rights into account when making decisions for service users who may be an able to express a preference. This was good practice. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 10 The Inspector noted the home had a range of comprehensive and up-to-date risk assessments. These reflected a clear risk management strategy on the part of the home and the manager. Where potential risk was identified and nominated course of action was also identified to reduce risk to reasonable levels. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 11 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, 14, 15 The service supports service users with opportunities for personal development. The home helps service users exercise choice and control over their own lives. The home support service users to have appropriate personal and family relationships. EVIDENCE: The Inspector noted that staff supported and encouraged service users to develop practical day-to-day skills for themselves. Given the service users profound disabilities this in itself presented a challenge to staff. Staff spoken with were able to inform the Inspector as to how service users were encouraged to be involved in a room care and how they were supported with involvement in their own personal care. Should service users have an identified spiritual need the service would attempt to support the service user to meet at. The Inspector noted from staff statement evidence, care records and the diary that service users are supported and encouraged to participate in leisure The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 12 activities. This may involve anything from listening to music, watching videos, trips out as a group, visits to the cinema, or supported activities at the home. Staff at the home help support service users to maintain links with family. This may entail phone calls, birthday cards, Christmas cards etc or supported visits to or from family. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 13 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 The home supports service users with personal care in a manner they prefer and require. The home supports service users meet their physical and emotional health needs. EVIDENCE: The Inspector noted evidence from service user files and statement evidence regarding the way in which personal care is delivered. The Inspector noted evidence to indicate that sensitive and flexible personal support is provided to service users. On inspection and after touring the premises, the Inspector was able to meet a service user in receipt of personal care. The Inspector noted at the time of inspection, service users were able to get up and go to bed as they wished with support. The Inspector noted that service users had appropriate technical aids and equipment in order to support their independence. Technical equipment provided, such as beds and lifting equipment, had been assessed by the appropriate professional and implemented with full risk assessment. Service users are supported to be involved in their own health care as much as is practical. Service users have support and access to local National Health The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 14 Service facilities, a local GP and specialist input as needed. Service users health is carefully monitored by the staff team, which includes trained nurses. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 15 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): 23 The home protects service users from abuse, neglect and self harm. EVIDENCE: The Inspector noted the home has robust procedures for the reporting of all detecting potential abuse. The Inspector noted at the time of inspection a range of documents and procedures, including is North Somerset is no secrets were present. New staff are checked by a POVA list. Staff receive appropriate training to understand and learn how to deal with aggression from the service users and understand its potential causes. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 16 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, 27, 28, 30 Service users live in a homely, comfortable and safe environment. Service users are provided with sufficient toilets and bathrooms to meet their needs. Shared spaces complement and supplements service users rooms. The home is clean and hygienic throughout. EVIDENCE: The home is a pleasant modern bungalow with large gardens and ample space. The Inspector noted that the premises were suitable for their intended purpose, well maintained and were able to meet service users needs. The home generally has a pleasant domestic feel to it. The premises were safe, bright, cheerful, and very clean throughout with no offensive odours. The home had sufficient bathroom and toilet is to meet service users needs. These were clean, well equipped and had sufficient space to manoeuvre service user and wheelchair if necessary. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 17 The Inspector noted the home had a range of comfortable communal areas. This included areas outside of the premises, such as the patio. It also included a large pleasant and flat garden for service users use. The home had ample communal space for service users. The premises were clean and hygienic throughout. The Inspector noted evidence of infection control procedures. The laundry facilities were sited so that soiled items were not carried through the kitchen. The Inspector noted that hand washing facilities were available in prominent areas for use by staff or visitors. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 18 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): 31, 34, 36 Service users benefit from clarity of staff roles and responsibilities. Service users are protected by the homes recruitment policy. Service users benefit from well supervised staff. EVIDENCE: The Inspector reviewed the staff the job descriptions during the inspection. The Inspector noted these to be comprehensive and in-depth. Staff job descriptions were linked to achieving service users goals. The Brandon trust operates a recruitment policy based on equal opportunities. Appropriate references, POVA and see CRB checks are obtained by the trust. These are not stored on the premises. The Inspector noted evidence of regular staff supervision. This was clearly documented. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 19 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): 38, 40, 41 Service users benefit from the leadership and management approach of the home. Service users rights and best interests are safeguarded by the homes policies and procedures. EVIDENCE: The Willows maintains the feel of a pleasant home to live in or work in. Staff feedback indicates staff feel involved with the management process and understand the management process. The Inspector notes the feedback from staff and relatives is consistently good. Staff spoken with belt the management processes of the home were clear, open and fair. The Inspector sampled to written policies and procedures at random. Both policies and procedures were present, up-to-date and were in line with current professional standards. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 20 The Inspector also reviewed the homes records. These were well maintained, accurate and up-to-date the exception to this being the record of fire drills. The Inspector spoke with staff about this. Staff have remedied this and as a consequence the Inspector has made no requirement regarding fire drills. The Inspector noted that the individual care records of the service users were maintained up-to-date and kept in good order. The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 21 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 3 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 X 36 3 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 X 13 X 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X x X 3 X 3 3 X x The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 22 YES 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Willows DS0000020373.V281200.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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