Inspection on 22/05/07 for The Willows

This inspection was carried out on 22nd May 2007.

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 02/06/06

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 22nd May 2007 12:30 The Willows DS0000017953.V341166.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.V341166.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.V341166.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.V341166.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the aged of 65 years, who require care by reason of a learning disability (not to exceed 6 persons) 2nd June 2006 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. Accommodation consists of 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. People in residence have lived at the home for more than ten years. A minibus is available for outings. The accommodation fees as at 22nd May 2007 were stated by the manager as being 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 www.csci.org.uk The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection looking at the core standards for the care of adults. This report is based on a range of information that has been accumulated from our inspection records, a site visit to the home that took place on 22nd May 2007 at 12:30pm, a tour of the property, discussions with the registered manager, staff, and people that live at the home, a community nurse, questionnaires issued by CSCI and the records kept at the home. With the same group of people living at the home, there has been little change at the home in terms of the care needs of the people. A single bedroom on the ground has now been refurbished although the room remains vacant, records continue to be comprehensive in detail and up to date, new staff had been employed and work may start soon to upgrade the bathrooms. A visiting community nurse considered the quality of care provided as good. What the service does well: What has improved since the last inspection? What they could do better: The manager was advised at the previous inspection that care records for each person living at the home must not be kept on one file as this breaches peoples rights to confidentiality. Reviews of the service provided at regular intervals by the manager would help to set the objectives for the next year and prioritise those areas that require change and improvement. The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 6 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 DS0000017953.V341166.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.V341166.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 & 4. Quality in this outcome area is good. Information is available about the home and ongoing assessments of needs ensure the type and level of care provided is appropriate. People would have opportunities to visit and see whether the home would meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All five people at the home residents have lived there for over ten years. Again from observation and discussion with the manager, staff and an inspection of the care records, it was evident that the home is able to meet their needs. The home still had one vacancy at the time of the inspection although the manager was clear that assessments would be essential for any prospective person. 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 people. Assessment of each person’s needs is an ongoing process and any changes are recorded and dated. The Willows DS0000017953.V341166.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 & 9. Quality in this outcome area is good. The care plans are sufficiently detailed to enable staff to meet each persons needs. People at the home could be confident that their care plans were sufficiently detailed to ensure staff met their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records of two people were looked at. These contained detailed and up to date information. 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. Staff considered people to be safe, well cared for and that their health care needs were met. None of the people are assessed as being able to access the community without the direct support of staff. The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 10 Care plans and assessments for each person were still kept on one main file. The manager was well aware of the need to provide a separate file for each person and had obtained the new files, but had still not made the changes. The Willows DS0000017953.V341166.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 & 17. Quality in this outcome area is good. People at the home are enabled and supported to access the facilities in the community and to maintain links with family and friends; they also benefit from the provision of a healthy and varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with the manager, staff and the home’s records, it was again evident that staff enable and support people to use the facilities in the home, and the local and wider community. This however, is very dependent on the ability and wishes of the individuals. Staff were well aware of the interests of each person and of those places they prefer and enjoy visiting. None of the people at the home are in any form of voluntary or paid employment or able to access the community independently. They do have the benefit of a mini bus that is available for outings providing the staff are able to drive. Staff spoke of going on picnics and trips to garden centres, The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 12 Hatfield Forest, Southend, Clacton, the hairdressers and swimming and to visit cafes. The home encourages people to maintain contact with relatives and several visit during the year. Three people attend local centres where they are able to meet friends. All 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 family like in appearance. The Willows DS0000017953.V341166.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 & 20. Quality in this outcome area is good. Arrangements are in place to meet people’s physical and health care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation and discussion with the manager and staff it was evident that the home continues to provide people with appropriate levels of care and in a manner that maximises their independence and rights to privacy and dignity. People are supported to determine their own lifestyle according to their level of ability. They were observed to move freely around the home and to choose where they wished to spend their time. Staff were observed to undertake their duties in a friendly and supportive way. It was apparent that staff had established friendly and supportive relationships with people who are encouraged to treat the home as their own. Records showed that the health care needs of people at the home are addressed appropriately. The Medication Administration Record sheets sampled were up to date and well maintained. All medication is kept in a locked cupboard. The home has a policy on the control, administration and safekeeping of medication. None of The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 14 the current people 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 has to ensure that the system used for checking the competency levels of new staff to administer medication safely will need to conform to the requirements of the Skills for Care knowledge sets. The Willows DS0000017953.V341166.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. The home has appropriate arrangements in place to protect people from abuse and to listen to any concerns or complaints. This judgement has been made using available evidence including a visit to this service. 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.V341166.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, 25, 26, 27, 28 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People at the home benefit from being provided with comfortable and reasonably homely accommodation although an upgrade of the bathrooms and lounge area would make the rooms 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 such as the ground floor bathroom and doorways 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. The lounge/dining room has not changed in style or layout for several years and the manager should plan for a refurbishment of the room to make it brighter and more cheerful. A new perimeter fence had been extended. The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 17 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 had been replaced. The shared bedroom has a privacy curtain and the manager is of the opinion that the two people are happy to share the room and would not want to change. The vacant single room has been redecorated and furnished. All bedrooms in use were bright and 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 people with good access to local amenities. All rooms were clean and tidy including the kitchen, which was well equipped. People were observed to have free access to all communal areas within the home when they returned from the day centres. The manager has not managed to upgrade the bathrooms as planned. The Willows DS0000017953.V341166.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. People benefit from being supported by a team of trained and motivated staff that are recruited appropriately. This judgement has been made using available evidence including a visit to this service. 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. To staff files were checked. These contained evidence that two written references and a Criminal Records Bureau (CRB) are obtained. The Willows DS0000017953.V341166.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. 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. People live in a safe environment that is managed by an experienced and qualified manager. EVIDENCE: The owner/manager has the necessary experience and qualifications to manage this home. Evidence was available to show that the manager takes appropriate action to ensure that Health and Safety matters are kept up to date. Services and equipment were serviced at the correct intervals An Envoironmental Health Officer visited the home in May 2007 and considered the standards to be satisfactory. The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 20 A random check of staff files showed that these staff had the necessary statutory training that included the basic health and safety requirements, infection control, first aid, moving and handling and food hygiene. The manager stated that it was difficult to obtain feedback from relatives and other people as part of the home Quality Assurance system. Two responses to a survey carried out in 2006 were positive but there is still no evidence to show that the manager carries out a review of the services provided to help with determining what the objectives are for the following year. The Willows DS0000017953.V341166.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 2 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 3 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 2 X X 3 X The Willows DS0000017953.V341166.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 Care records must be separated to provide an individual file for each resident to ensure confidentiality is maintained. This is a repeat requirement; the previous timescale was not met. 2. YA19 YA24 23 (2) b The manager must plan for the refurbishment of the bathrooms and the lounge/dining room to make them a more welcoming environment for people living at the home. The manager must carryout a review of the home at appropriate intervals that takes people views into account and looks back on the previous year to set the objectives for the next year. 01/11/07 Timescale for action 01/08/07 3. YA39 24 01/10/07 The Willows DS0000017953.V341166.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. Refer to Standard YA27 YA25 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 is assessed in a way that conforms to the requirements of the Skills for Care knowledge sets. 3. 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