Inspection on 02/06/06 for The Willows

This inspection was carried out on 2nd June 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 22/05/07

The Willows 05/12/05

The Willows 01/12/04

The Willows 20/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Willows 30 Hunnable Road Braintree Essex CM7 2NU Lead Inspector Brian Bailey Key Unannounced Inspection 2nd June 2006 10:45 The Willows DS0000017953.V297194.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 DS0000017953.V297194.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 DS0000017953.V297194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 30 Hunnable Road Braintree Essex CM7 2NU 01376 550669 01376 550779 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) Mrs Linda Samaranayake Mrs Muriel Howe Mrs Linda Samaranayake Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the aged of 65 years, who require care by reason of a learning disability (not to exceed 6 persons) One female, over the age of 65 years, who requires care by reason of a learning disability (not to exceed 1 person) 5th December 2005 Date of last inspection Brief Description of the Service: The Willows is a care home providing personal care and accommodation for six adults with learning disabilities. Mrs Muriel Howe and Linda Samaranayake who is also the registered manager, privately own the home. The property is a detached house that has been adapted and is situated in a residential area close to Braintree town centre and is on a regular bus route to Chelmsford and Colchester. Local amenities include supermarkets, church, library, post office, bank and building societies and newsagents. The Willows is a two-storey building with residents occupying four single and one shared bedroom, which is on the ground floor. There are two bathrooms, a separate WC and a lounge/dining room and an activities room. There is a secure private rear garden with a patio. All residents have lived at the home for more than ten years. A minibus is available for outings. The accommodation fees as at 6/6/06 were disclosed by the manager as up to a maximum of £750 per week. Extras to the fees include chiropody, hairdressing and toiletries. Inspection reports are available from the home and the CSCI website. The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of The Willows was carried out on 2/6/06. This report is based on a range of information that has been accumulated from our inspection records, a site visit to the home, discussions and observations with the manager, staff and residents, comments cards returned to CSCI and a check of the records kept at the home. Twenty-six standards were assessed, of these twenty-two were met and four partly met. What the service does well: What has improved since the last inspection? What they could do better: The home needs to be able to demonstrate how and when they consult with residents and or a relative about any changes to residents’ care plans to ensure there is agreement on how care needs are to be met. The manager must ensure that individual care files are created for each resident rather than having all information on one file, which represents a potential breach of confidentiality. The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 6 The carpet in a first floor bedroom is of a poor quality and needs replacing and a bathroom should be up-graded. The home has the basis of a Quality Assurance system in place and surveys are carried out at periodic intervals. The manager must make available a report that reflects the results of any survey and of how the outcomes will contribute towards setting the objectives for the next year. 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 DS0000017953.V297194.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 DS0000017953.V297194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available about the home and ongoing assessments of needs ensure the type and level of care provided is appropriate. Prospective residents would have opportunities to visit and see whether the home would meet their needs. EVIDENCE: All five residents have lived at the home for over ten years. From observation and discussion with the manager, staff and an inspection of the care records, it was evident that the home was able to meet residents’ needs. The home had one vacancy at the time of the inspection although the manager was clear that assessments would be essential for any prospective resident. The manager stated that this would be necessary to ensure the home could meet their needs and that the person was compatible to live with the existing residents. Assessment of each person’s needs is an ongoing process and any changes are recorded and dated. The Willows DS0000017953.V297194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to take risks and act independently as assessed within an agreed care plan, although more involvement in the development and review of plans by residents and relatives would ensure they are all in agreement with care plan objectives. EVIDENCE: The care records of two residents were looked at. These were detailed and covered a wide range of information that was up to date. Care plans were easy to follow and evidence was available to show they had been reviewed at regular intervals. Information included dates of all appointments with health care professionals, up to date monthly weight checks and a daily record. There was no evidence however that residents and/or their relatives are in the development of care plans. Staff considered residents to be safe, well cared for and that their health care needs were met. The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 10 None of the residents are assessed as being able to access the community without the direct support of staff. Care plans and assessments for each resident were still kept on one main. These need to be separated into a file for each resident to ensure confidentiality is maintained. The Willows DS0000017953.V297194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 , 14, 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. Residents are enabled and supported to exercise their rights to access the facilities in the community and to maintain links with family and friends. Residents benefit from provision of a healthy and varied diet. EVIDENCE: From discussion with the manager, staff and the home’s records, it was again evident that staff enable and support residents to make use of the facilities in the local and wider community. This is however, dependent on the ability and wishes of individual residents. Staff were aware of the interests of each resident and of those places they prefer and enjoy visiting. None of the residents are in any form of voluntary or paid employment or able to access the community independently. They have the benefit of a mini bus that is always available for outings providing staff are able to drive. Staff spoke of going on picnics and trips to garden centres, hairdressers and swimming and of walks into town to go shopping for the home and themselves The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 12 and to visit cafes. All residents had been on holiday at Easter for a week to Hunstanton, which two residents indicated they had enjoyed. The home encourages residents to maintain contact with relatives and several visit during the year. Three residents attend local centres where they are able to meet friends. All residents have a weekly activities programme that is flexible according to the needs and wishes of residents. Evidence was available to show that a varied and nutritious diet is provided. Good food stocks were available that included fresh fruit. The normal pattern is for cooked breakfasts at weekends and during weekdays a choice of cereals; a cooked meal is served in the evening. Meals are served in the dining area, which is a homely and family like in appearance. The Willows DS0000017953.V297194.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 at least once during a 12 month period. 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. Arrangements are in place to meet residents’ physical and health care needs. EVIDENCE: From observation and discussion with the manager and staff it was evident that the home continues to provide residents with appropriate levels of care and in a manner that maximises their independence and rights to privacy and dignity. Residents are supported to determine their own lifestyle according to their level of ability. They are able to move freely around the home and to choose where they wish to spend time. Staff were observed to undertake their duties in a friendly, open and supportive way, using appropriate language. It was apparent that staff had established friendly and supportive relationships with residents who were empowered to treat the home as their own. Records showed that residents’ health care needs were addressed appropriately. The Medication Administration Record sheets sampled were up to date and well maintained. All medication is kept in a locked cupboard although the locking mechanism was not very effective. The home had a policy on the control, The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 14 administration and safekeeping of medication. None of the current residents were assessed as being able to retain their own medication. Staff that administer medication had received training from the supplying pharmacist and the manager, which it was stated included an assessment of their competency. The manager was advised that the system for checking the competency levels of new staff will need to conform to the requirements of the Skills for Care knowledge sets. The Willows DS0000017953.V297194.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 at least once during a 12 month period. 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 appropriate arrangements in place to protect residents from abuse and to listen to any concerns or complaints. EVIDENCE: The home had an appropriate complaints procedure. No complaints had been received by the home or CSCI. A clear policy and procedure on the protection of vulnerable adults from abuse was available to all staff. Staff training had been provided to ensure they were aware of the main issues and definitions of abuse. The Willows DS0000017953.V297194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being provided with comfortable and homely accommodation although an upgrade of the first floor bathroom would make the room a more welcoming and attractive environment. EVIDENCE: The home blends in well with the neighbouring properties. This is a property that had been adapted to accommodate six people and as a consequence, some areas are rather small and not ideal for people with a physical disability. Accommodation consists of a lounge/dining room and a separate music/activities room that overlooks the rear garden, which is private and secure. A new perimeter fence had been erected. There are three single bedrooms on the first floor and a single room and one shared bedroom on the ground floor. A carpet in a single bedroom on the first floor is worn and requires replacement. Although the shared bedroom has a privacy curtain the manager should consider discussing with the service users the option for a single room, converting the room for single use and utilising the spare room, which continues to be unoccupied. All bedrooms in use were bright and The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 17 cheerful and had been personalised. The front door has a step that would present a difficulty for wheelchair users. Unrestricted car parking is available in the road at the front of the property. The home has a mini bus that provides residents with good access to local amenities. All rooms were clean and tidy including the kitchen, which was well equipped. Residents were observed to have free access to all communal areas within the home. The manager intended to upgrade the first floor bathroom during the past year but this was not achieved, although the doors were replaced on the ground floor bathroom and toilet, which has improved privacy. The Willows DS0000017953.V297194.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 at least once during a 12 month period. 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. Residents benefit from being supported by a team of trained and motivated staff that are recruited appropriately. EVIDENCE: Evidence was available to show that there were sufficient staff on duty and staff are aware of a system for seeking guidance and/or assistance should the need arise. The manager has obtained a National Vocational Qualification (NVQ) at level 4 in management. Of the staff employed, five have an NVQ at level 2 and one staff member has a nursing qualification, the home therefore meets the target of 50 of care staff requiring a NVQ 2 qualification. One member of staff is working towards an NVQ level 3. One new member of staff had been employed at the home since the last inspection in July 2005. The manager confirmed that an up to date CRB disclosure at enhanced level had been obtained for all staff. The Willows DS0000017953.V297194.R01.S.doc Version 5.2 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe environment that is managed by an experienced and qualified manager. EVIDENCE: The manager has the necessary experience and qualifications to manage this home. The manager has the basis of a Quality Assurance system and a survey of relatives and other interested people such as the GP was carried out in 2005. The results of the survey need to be published and made available and a copy sent to the CSCI. There was no evidence that the manager carries out an annual review of the services provided to ascertain the objectives for the following year. The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 20 Evidence was available to show that the home takes the necessary precautions regarding health and safety matters. All equipment and systems were being serviced at the appropriate intervals and were up to date. All staff had received training in the basic health and safety requirements that include infection control, first aid, moving and handling and food hygiene The Willows DS0000017953.V297194.R01.S.doc Version 5.2 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 15 Requirement Timescale for action 01/11/06 2. YA6 15 3. 4. YA19 YA39 23 24 The manager must whenever possible consult with the resident, or a relative with any revisions of the care plans. Care records must be separated 01/09/06 to provide an individual file for each resident to ensure confidentiality is maintained. The manager must replace the 01/09/06 carpet in the first floor bedroom. 01/12/06 The manager must submit a copy of the home’s latest 2005 Quality Assurance survey summary report to the CSCI local office. An annual review must be undertaken that looks back on the previous year, which helps to establish objectives for the future year. The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 23 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 Refer to Standard YA27 YA25 YA20 Good Practice Recommendations The manager should upgrade the bathrooms during 2006. The manager should investigate whether the current occupants of the shared bedroom on the ground floor would prefer to have their own single bedroom. The manager should ensure that the competency of staff responsible for administering medication are assessed in a way that conforms to the requirements of the Skills for Care knowledge sets. The Willows DS0000017953.V297194.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 The Willows DS0000017953.V297194.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. 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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