Inspection on 27/09/05 for The Willows

This inspection was carried out on 27th September 2005.

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 04/07/06

The Willows 28/04/05

The Willows 24/11/04

The Willows 24/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Willows (The) The Willows 40 Searchwood Road Warlingham Surrey CR6 9BA Lead Inspector Kenneth Dunn Announced Inspection 27th September 2005 10:00 Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 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 Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 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. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willows (The) Address The Willows 40 Searchwood Road Warlingham Surrey CR6 9BA 01883 627747 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) Surrey Oaklands NHS Trust Vacant Care Home 14 Category(ies) of Learning disability (14), Physical disability (5) registration, with number of places Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 34-64 and may also have one resident over the age of 65 years Of the 14 (fourteen) people with learning disabilites (LD) accommodated, 5 (five) will have an additional physical disability (PD). Two named individuals up to the age of 75 years may also be accomodated. 28th April 2005 Date of last inspection Brief Description of the Service: The Willows is owned and managed by Surrey and Borders NHS Trust. It is currently registered to provide residential care for up to 14 adults with learning disabilities, some also have physical disabilities. At the time of this inspection the home had only 11 Service Users in residence. The home is a large converted detached property and is located in a quiet residential area within the village of Warlingham. The accommodation for Service Users is provided on two floors, with eleven single bedrooms. The communal space is provided in one good size dining room, a lounge and one room equipped with sensory equipment. Service users have access to a large enclosed garden at the rear, which was laid out in lawns with an area of enclosed trees at the rear boundary. The home has parking space within the forecourt as well as space for the home’s minibus. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the home’s second inspection for the year 2005/2006. This was an announced visit, which meant that staff, service users and their representatives were aware that it was due to happen. The CSCI inspector received feedback from service users families and other professional providing assistance to the home. The returned feedback sheets have been incorporated into the body of this report. Care and health plans were found to provide a good level of information about each individual, based upon a sound assessment of their needs and aspirations. This was a positive inspection and the manager has embarked on a process of redeveloping the ethos of the home to be service user focussed. 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. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5 The Willows was found to be operating effectively in respect of these standards. In line with requirements made in the previous inspection report standards 2 & 3 have been reviewed and now follow the guidance established in the National Minimum Standards. EVIDENCE: The manager has established a sound process of assessing residents’ needs and aspirations and this was being enhanced by the development of person centred planning. All other documents relevant to the care of the individual were reviewed with the manager and follow the National Minimum Standards. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 8 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, 8 & 9 A review of these documents indicated that these standards were now being met effectively. There is evidence that the individual needs and aspirations of the service users were now recognised and plans are in place to ensure that they continue to develop still further. EVIDENCE: The manager has now ensured that all the service users have received a full review to ensure that the care provisions offered to them meets their changing needs. There is clear documentation on file of the process of review and individual needs assessments being carried out under a multi disciplinary partnership which includes the manager/key workers, care management, the service users and or their representatives and health care professionals. The manager informed the inspector that there was an ongoing process of reevaluation of the care and support offered to the individual service users by the service. As a consequence of the review the manager has introduced monthly supervision for all staff. As a direct result of staff supervision appropriate training has been sourced where gaps have been identified and a detailed training matrix has been developed to ensure that all staff offer consistent care to the service users. The manager explained that it was hoped by ensuring the staff were appropriately trained all of the service users would Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 9 benefit from an enhanced ability to make choices suitable to their individual needs. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12 & 14 The Evidence gathered during this inspection confirmed that the home now meets each of the assessed standards. The manager was able to demonstrate that the service users were encouraged and supported to lead as independent and fulfilling life as they were able. EVIDENCE: At the time of this inspection 3 service users with the support of staff were on holiday at a leisure camp on the south coast of England. On the day of this inspection the service users were being supported and encouraged by the staff on duty to engage in activities. The staff were seen to be communicating effectively and offering the correct levels of support to the service users ensuring that they had alternative choices if they did not want to be with the main group. The service users are now actively encouraged and assisted to participate in appropriate activities. In compliance to a request from care management the manager now records all occasions when service users are unable to or do not wish to attend day care or any other event organised for them. This has helped highlight areas where further training and support would benefit the service and to ensure that staff are aware of measures and protocols for engaging appropriately with individual service users. The manager has reviewed the staffing arrangements and the training previously offered within Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 11 the service. As a result of this review a system has been introduced to offer further opportunities to the staff for their personal development and ultimately ensuring the service users receive the correct support and encouragement to allow them to participate at home and in the greater community. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 12 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 & 20 The staff have developed a better understanding of the service users support needs and are further developing good interpersonal relationships with the service users. The health needs were being met with evidence of multi disciplinary working taking place. EVIDENCE: Feedback from service users / representatives and external care professionals indicated that the support offered by the staff was now appropriate to meeting the needs of the individuals. All service users are assisted when they are in the bathroom or toilet although the amount of support needed varies from each individual. The staff stated that they have had further impute from the manager and medical professionals regarding appropriate care for the service users. The inspector witnessed staff and service users engaging effectively and care being offered in a sensitive and professional manner. The service users care and health plans have been reviewed and updated and the manager and staff have worked hard to ensure that the service users health and personal care needs are being consistently met. The staff spoken to during the inspection stated that they have received further training to ensure that the service users health and care needs are being meet fully. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 13 Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 14 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 & 23 The home has a full set of policies and procedures in place to ensure the continual protection of the service users. EVIDENCE: In line with a requirement from the previous inspection report a review has been completed regarding the way the service responds to concerns, complaints and issues around protection. The manager has instructed all staff to ensure that they record any event involving service users, which may affect only one specific service users or others within the home. One member of staff stated that they have to be “the eyes and ears of the service users because they cannot communicate their concerns or worries”. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 15 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 & 30 Generally the service offers a safe environment for the service users. The bedrooms are of a good size and represent the service users occupying the room. EVIDENCE: The manager has embarked on a process of temporary redecoration of the home, at the time of the inspection all of the public areas had been painted in bright primary colours. The choice of colours was explained to be an effort to move the home forward and offer a fresh new start for the service. The manager is awaiting a confirmation of budget allocations for a full programme of redecoration. The service recently took delivery of new dining room furniture purchased for the specific needs of the service users. The service users bedrooms were more representative of the individuals occupying them. The personnel items and choice of colours are now more reflective of the individual service users and their cultural identity. During the inspection one service user managed to look herself in her bedroom and it took some time for a member of staff to attend to her and let her out. The inspector discussed this with the manager at the time and the manager stated that was not a normal occurrence and that they should always be left unlocked. The manager must ensure that the door locks on the bedroom doors are not locked while service users are in the bedrooms. It is further recommended that the manager undertakes a full risk assessment on the style Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 16 of locks used and reviews the overall need for bedroom to be locked in such a way. On the day of this inspection the refrigerator was not functioning al as a result was unable to maintain the contents at a safe temperature. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 36 Staff recruitment policies currently ensure that appropriately competent staff are employed by the organisation. The heavy reliance on agency staff has slowly been minimised by an active recruitment plan. EVIDENCE: The staff spoken to stated that there are appropriate training opportunities in place for them and the manager has made accessing them easier by discussing options during supervision or by displaying information on the staff notice board. There is a commitment from the organisation to provide staff with NVQ training. After a recent recruitment drive by the organisation the service has employed sufficient staff to meet the needs of the service user group, who are all of high dependency. The manager informed that inspector that it is the plan to be fully in house staffed by the end of the 2005. Two written references are required for all staff and Criminal Records Bureau checks will be carried out on all future staff. The manager is involved in all aspects of staff recruitment and staff induction programmes. Staff are able to work on a one to one basis with Service Users. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 18 Service Users in this service are unable to communicate verbally and therefore it is of crucial importance that newly recruited staff can be fully understood by Service Users. There is good evidence to indicate that all staff are now well supported by the manager. Presently all staff receive supervision on a monthly basis and supervision records fully substantiate this. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 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): 37, 38 & 42 After an initial settling in period the manager is now fully aware of the needs of the Service Users in the home and as such is able to communicate this to staff through regular staff meetings and individual supervision sessions. The manager now provides good leadership and consistent direction to staff in this home to ensure that Service Users receive consistent quality care. EVIDENCE: Training, development and the recruitment of staff have been given a high priority and this has resulted in a more stable and restful home. The manager has not yet been registered with the CSCI but plans have been made for him to be interviewed during the month of October. The manager has actioned a full review of care provisions and was able to show that further improvements had been made to the care plans and in the revision and development of policies and procedures. The inspector reviewed all health and safety checks recently completed by the manager. Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 X X X X 2 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willows (The) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000013832.V253567.R01.S.doc Version 5.0 Page 21 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 Standard YA25 Regulation 16(1), 23(2)(e,f) Requirement Timescale for action 27/09/05 2 YA30 2 YA30 cont. The manager must risk assess all locks on the bedroom door and reassess the necessity of locking them. 13(3)16(2)(e,j,k) The service must have a 27/09/05 suitable method of keeping foodstuff at a safe temperature. 23(2)(d)(5) 27/09/05 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 Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Willows (The) DS0000013832.V253567.R01.S.doc Version 5.0 Page 23 - 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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