Inspection on 16/10/06 for The Willows

This inspection was carried out on 16th October 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 31/01/06

The Willows 25/08/05

The Willows 15/12/04

The Willows 16/06/04

The Willows 28/01/04

The Willows 03/09/03

The Willows 23/10/02

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

CARE HOME ADULTS 18-65 The Willows No 1 The Willows Bungalows Gas House Lane Morpeth Northumberland NE61 1SW Lead Inspector Anne Brown Key Unannounced Inspection 16th October 2006 11:00 The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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 DS0000000647.V304899.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 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 DS0000000647.V304899.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address No 1 The Willows Bungalows Gas House Lane Morpeth Northumberland NE61 1SW 01670 395850 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) pauline.carr@nmht.nhs.uk Newcastle, North Tyneside & Northumberland Mental Health NHS Trust Mrs Pauline Carr Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: The Willows is small home in Morpeth that provides care and support for younger adults and older people who have mental health problems. There are three separate bungalows within the attractive and well-maintained grounds. Each bungalow has four bedrooms, dining area and lounge. This home is close to a number of good local amenities and transport services. The fees are £819.08 per week. Inspection reports and information about the home are readily available. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over four and a half hours. A tour of the premises took place and a sample of records was inspected. These included care plans, fire log, accident book, complaints and medication records. Five staff members and seven service users were spoken to during the inspection. Eleven service users and four relatives returned questionnaires. What the service does well: What has improved since the last inspection? What they could do better: The care plans should be evaluated at the agreed intervals to ensure any changes to the service users’ needs are recorded. Photographs should be placed on the staff files to confirm the staff member’s identity. Documentary evidence of relevant qualifications should be available as stated in Schedule 2 of the Care Home Regulations 2001. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 6 Items stored in the boiler cupboards should be kept well away from electrical wiring to ensure fire safety. 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 summary of this inspection report can be made available in other formats on request. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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 The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their individual needs assessed prior to admission. This ensures that the staff are aware of all their needs and are able to meet these. EVIDENCE: The service continues to carry out a thorough assessment before people are admitted. These are completed by a variety of professionals. The staff at The Willows carry out their own assessments that lead to detailed care and support plans for the people who live here. Service users are involved in this process. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are care plans that contain guidelines for dealing with complex needs, which explain what staff need to do. Service users are encouraged to make decisions. The care staff support the service users to take risks as part of their lifestyle. EVIDENCE: Each person has a service user plan that describes their individual needs and how the home will meet them. The plans state what staff need to do to care for and support people. The service users sign the care plans to confirm they have been involved. The plans are reviewed and revised on a regular basis, The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 10 either as a matter of routine, or at the person’s request. However some evaluations had not been carried out at the agreed intervals. The staff on duty were well aware of the needs of the service users and were observed consulting and communicating with them. Meetings are held when service users are asked their opinion of the services offered in the home. Minutes are taken but could not be found in the absence of the acting manager. These will be examined at the next inspection. Risk assessments are available on the case files. These assist the service users to lead fulfilling lives and they are well supported by staff to take calculated risks as necessary. The staff have knowledge of equality and diversity issues and these are carefully considered when writing the care plans. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with the community and opportunities to participate in social and personal development activities are good. The service users are encouraged to mix with other people and participate in worthwhile activities. Service users are supported to have personal relationships and keep in touch with family and friends. Staff respect the service users’ rights. Well-balanced menus are in place and alternatives are offered. EVIDENCE: The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 12 Each person is able to take part in activities of their choice. Some people attend a day service that offers a range of things to do, and one person is involved in a work placement. Some people choose not to be involved in services or activities outside of the home, and they confirmed that this was their personal preference. Staff support people to keep in touch with others who are important to them, such as relatives and friends. Three service users visit their relatives on a regular basis. People have opportunities to mix with people who do not have disabilities, through the use of what the local community has to offer. Some service users enjoy swimming, watching football and rugby matches, shopping, going to the pub and the Christian Fellowship. Activities in the home include playing pool and darts. A party is being arranged in the home for November 5th. Each person is offered the opportunity to go on holiday every year to a place of their choosing. The housekeeper cooks main meals, although service users are encouraged to do some shopping and to help with the cooking. The service users said they had enjoyed their lunch and confirmed the food is always enjoyable. They also confirmed that they enjoyed takeaway meals on a regular basis. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical and emotional health care needs of the service users are well met and recorded in the care plans. The staff give the service users the personal support they require and according to their preferences. An appropriate system is in place for dealing with medications, which protects the health of service users. EVIDENCE: Matters that affect people’s mental wellbeing are very well recorded. Any signs that people may not be well are identified and staff have clear instructions on how to act in such situations. Each person’s care and support is regularly reviewed and action is taken on any changes. The service works The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 14 closely with a range of other professionals to ensure that any specialist needs are met. The staff on duty were aware of the individual needs of the service users and confirmed they had been given appropriate and specialised training. The questionnaires from the service users confirmed they were always treated well by the staff. A random sample of medication records and the system for storage and handling medication was looked at and found to be appropriate. Service users are assessed and encouraged to keep their own medication if they are able. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system and a whistle blowing policy is in place, which helps to protect the service users from abuse. EVIDENCE: A suitable complaints procedure is in place. This is displayed in the home. The service users said they would not hesitate to complain if they were unhappy, and felt they would be listened to. The staff on duty were aware of the whistle blowing policy and said they would use it necessary. Some qualified staff have undergone training in the protection of vulnerable adults and all others have been booked on a course. Appropriate records, receipts and signatures are retained when dealing with money held on behalf of the service users. There are good guidelines available for staff to meet the needs of people whose behaviour may challenge the service. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes are comfortable, pleasantly decorated and well maintained. There is a good standard of hygiene. EVIDENCE: The three bungalows are well presented and accessible for the people who live there. Each bungalow has a programme of ongoing repairs, decoration and replacement of worn items. The housekeeper said that new kitchen units had been ordered for one kitchen as the surfaces on the shelves were becoming worn. She also felt an electric The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 17 insect killer should be provided, as flies can be a problem because the kitchen is located next to trees. There is sufficient communal space for service users to enjoy. Gardens are well maintained and there is suitable garden furniture. The service was clean, hygienic and free from offensive smells. The staff confirmed that information on infection control is available from the Health and Safety Manager from the Trust. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are well trained and competent to support the service users. The recruitment policy and practice supports and protects the service users. The needs of the service users are met by appropriately trained staff. The staff team are well supported and supervised, so that they are able to do their job well. EVIDENCE: The staff on duty had a good knowledge of each person’s individual needs and how they should be met. They were observed to be treating the service users with respect and demonstrated good values and attitudes. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 19 The service users said they enjoyed good relationships with the staff team. Comments were made about how good some staff members were and how they never let people down. One relative said they could not thank the staff enough for what they do. There is a good staff training programme that includes all statutory training, as well as training in subjects that relate directly to the needs of residents. There are also opportunities for staff to continue professional development. An appropriate recruitment and selection process is in place. Three staff files were examined at the Human Resources Department and confirmed that appropriate checks are carried out prior to people being employed in the home. However not all files contained a photograph and documentary evidence of relevant qualifications. A programme is in place to ensure all staff receive formal supervision at regular intervals. Some staff confirmed that these sessions had taken place. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run with a focus on the service users. The management and staff team respect the service users’ views regarding the running of the home. The health, safety and welfare of service users are protected by the systems the home has in place. EVIDENCE: The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 21 The service users said they were consulted on all aspects of their lives and on the day-to-day running of the home. Both staff and service users said the management were supportive and approachable. The staff receive necessary health and safety training on a regular basis. All accidents are well recorded. The fire logbook was examined. Tests to the fire detection and fire fighting equipment were up to date. The fire alarms were being tested during the inspection. The fire officer had recently visited the premises to up date the fire instructions for the staff. The boiler cupboards in bungalows 1 and 2 contained lots of clothing and bedding. This could be a fire safety hazard if the items are near to electrical wiring. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 22 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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 23 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 2 3 Standard YA6 YA34 YA42 Regulation 15(2)(b) 4(b), Schedule 2 4(c)(v) Requirement Evaluations of the care plans must be brought up to date. Photographs and proof of relevant qualifications must be available on the staff files. Items must not be stored close to electrical wiring in the boiler cupboards. Timescale for action 30/11/06 31/12/06 23/10/06 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 YA24 Good Practice Recommendations An electric insect killer should be provided in the main kitchen. The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 The Willows DS0000000647.V304899.R01.S.doc Version 5.2 Page 25 - 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. 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