Inspection on 23/03/07 for The Willows

This inspection was carried out on 23rd March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Willows 20/01/09

The Willows 10/03/06

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 23 March 2007 09:30 rd The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 1 The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 2 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.V320532.R01.S.doc Version 5.2 Page 3 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.V320532.R01.S.doc Version 5.2 Page 4 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) www.brandontrust.org 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.V320532.R01.S.doc Version 5.2 Page 5 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 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.V320532.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector conducted this unannounced inspection over the period of 4 hours. During this time the Inspector completed a tour of the premises, met staff, day-care support staff and reviewed documentation and care files. The Inspector found a well cared for service user group living in a homely pleasant environment. The staff team were positive, well motivated and well trained. The Inspector noted the environment has been improved further and been redecorated. The Inspector made no requirements on this inspection. 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 summary of this inspection report can be made available in other formats on request. The Willows DS0000020373.V320532.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 DS0000020373.V320532.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): 1, 2 Quality in this outcome area is good The home understands the importance of having sufficient information when choosing a Care Home. It has innovative ways of helping prospective individuals to choose a home that will meet their needs and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector reviewed the statement of purpose and the assessment process used to assess service users needs. The Willows has 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 2 care files to review the assessment process. There was evidence of a clear and comprehensive assessment procedure. This was well documented and was focused the whole needs of the individual. The Inspector noted that the assessment procedure is used to develop The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 9 a person centered individual plan. Where at all 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.V320532.R01.S.doc Version 5.2 Page 10 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 service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Management and staff understand the importance of residents being supported to take control of their own lives, and to encourage and enable them to exercise their rights and make their own decisions and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector audited 3 plans of care, met the service users and spoke with staff. Evidence from staff statement and care records indicate that a comprehensive assessment process is used to generate a clear plan of care. The Inspector noted the plan of care sets out how any specialist requirements will be met. The plan of care also mentions any potential restrictions on the service users The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 11 choice or freedom. The Inspector noted that there were no undue restrictions on the service users. Staff have gone to great lengths to take service users’ preferences into account. The inspector found documented evidence outlining how service user’s preferences were identified. This was good practice helping the team make decisions based on the service users preference. 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, a nominated course of action was also identified to reduce risk to a reasonable level. The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 12 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): 11,13, 14,15, Quality in this outcome area is good The service has a strong commitment to enabling residents to develop their skills, including social, emotional, communication abilities. Service users are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; they have been fully involved in the planning of their lifestyle and quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 12 was not assessed on this inspection. Given the profound nature of disabilities experienced by the service user group, none of service users work or are enrolled in an external educational programme. 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. The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 13 Staff were able to inform the Inspector how service users were encouraged to be involved in 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 it. The Inspector noted from staff statement evidence, care records and the diary that service users are supported and encouraged to participate in leisure 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 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.V320532.R01.S.doc Version 5.2 Page 14 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 Excellent Efficient systems are in place to ensure service users receive effective personal and healthcare support. The Statement of Purpose sets out the competencies and specialisms the home offers and is able to deliver these effectively through a highly skilled, trained and knowledgeable staff group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector reviewed evidence from service user files and staff statements about how personal care is delivered. The Inspector noted evidence to indicate that sensitive and flexible personal support is provided to service users. This was documented and observed by the inspector in staff/service user interactions. 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 The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 15 service users had appropriate technical aids and equipment in order to maximize their independence. Technical equipment provided, such as beds and lifting equipment, had been assessed by the appropriate professional and implemented with full risk assessment. There was evidence of servicing and regular safety checks present. 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 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.V320532.R01.S.doc Version 5.2 Page 16 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, 23 Quality in this outcome area is good The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and robust complaints procedure. Complaints will be investigated by the manager, who will respond within 28 days. At the time of inspection there were no complaints about the service. The Inspector noted the home has robust procedures for the identification and reporting of potential abuse. Policies and procedures are in place to guide staff. Staff receive appropriate training to understand and learn how to deal with aggression from the service users. The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 17 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): 24,27,28,30 Quality in this outcome area is excellent The manager has ensured that the physical environment of the home provides for the individual requirements of the residents who live there. The home is appropriate for the needs of service users, is homely, clean, safe and comfortable. It is a very well maintained, attractive home, which is accessible to community facilities and services. It has the specialist equipment and adaptations needed to meet individual service user’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Willows 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 premises have undergone recent redecoration and are in excellent condition. The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 18 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 move a service user and wheelchair if necessary. 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.V320532.R01.S.doc Version 5.2 Page 19 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 35 Quality in this outcome area is good Residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. Staff members undertake external qualifications beyond the basic requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector reviewed the staffing and job descriptions against the assessed needs of the service user group. During inspection, the Inspector observed the staff team communicating well with one service user. The Inspector noted evidence that service users are supported by a staff team who have received specialist training to meet their needs. Documentation at the home highlighted a wide range of training offered by the Brandon trust for staff The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 20 members. In excess of 50 of the care staff at the home have achieved NVQ to or higher. Staff records are held at the Brandon Trust Central office. The Inspector will be assessing staff records after visiting the Brandon trust Central office. Service users are supported by a well trained staff. The Brandon Trust provides training facilities and courses in excess of that required by the sector skills Council workforce. The home has a documented training and development plan and access to ample training from the Brandon trust. This is good practice. The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 21 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, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s registered manager is a qualified nurse with in excess of 20 years experience in management. The home manager has consistently demonstrated her ability to meet the written aims and objectives of the home. The Inspector reviewed the home’s quality assurance processes. The manager at the Willows has used the Brandon Trust quality assurance programme. The Inspector found evidence of a regular review of quality issues at the home using this tool. The Inspector also noted that the tool appeared incomplete although there was evidence that the quality assurance had been implemented. The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 22 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.V320532.R01.S.doc Version 5.2 Page 23 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 x 4 x 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 4 25 x 26 x 27 4 28 4 29 x 30 4 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 3 12 x 13 3 14 3 15 3 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 x 3 x x 3 x The Willows DS0000020373.V320532.R01.S.doc Version 5.2 Page 24 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. 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.V320532.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 DS0000020373.V320532.R01.S.doc Version 5.2 Page 26 - 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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