CARE HOME ADULTS 18-65
The Willows Halvarras Park, Halvarras Road Playing Place Truro Cornwall TR3 6HE Lead Inspector
Lynda Kirtland Unannounced Inspection 30th November 2007 10:00 The Willows DS0000009122.V343700.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 DS0000009122.V343700.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 DS0000009122.V343700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Willows Address Halvarras Park, Halvarras Road Playing Place Truro Cornwall TR3 6HE 01872 865588 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) mail@dcact.org Spectrum ****Post Vacant**** Care Home 3 Category(ies) of Learning disability (3) registration, with number of places The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th July 2006 Brief Description of the Service: The Willows is a home providing personal care and accommodation for up to three adults with a learning disability. The registered provider is Spectrum, an organisation that provides specialist care in small units for people with autism. The aim is to provide them with specialist support in a domestic style environment. There is a manager in charge of the home on a day-to-day basis. A team of care staff assists them. Senior managers from within the organisation are available to provide specialist support and assistance where necessary. The home is located in the village of Playing Place, close to the city of Truro. There is reasonable access to public transport and the home has its own vehicles to assist service users to access the local community. The home is a single storey building, set in its own grounds and is set off the main road. There are three single bedrooms for use by the service users. The home has a combined lounge and dining room, a kitchen, separate laundry room and two bathrooms. There is a lockable office, which also functions as a sleeping in room for staff at night. The home has a large garden and some offStreet parking space. There have been some adaptations, with the provision of grab rails to assist people with specific physical disabilities to access the building. Fees range from £908.17 to £2104.50 per week, according to information provided by the manager at the time of the inspection. There are additional charges for hairdressing, private chiropody, personal newspapers, dry cleaning, alcoholic beverages, off-site entertainment, confectionary and stationary. The costs of these are variable. Information about the home is contained in the home’s statement of purpose and inspection reports, which are available on request. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place on 30 November 2007. It lasted for approximately six hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that the needs of people who use the service are appropriately met in the home, with particular regard for ensuring good outcomes for them. People who use the service were met and observation of their daily life and care provided occurred. There was an inspection of the home’s premises and of written documents concerning the care and protection of the people who use the service and the ongoing management of the home. Discussions with staff and observations in relation to their care practices occurred as well as discussions with the home’s acting manager. The principle method used was case tracking. This involves examining the care notes and documents for a select number of people who use the service and following this through with interviews with them and/or their relatives and staff working with them. This provides a useful, in-depth insight as to how their needs are being met in the home. At this inspection, two people who use the service were case tracked. The Commission received the Annual Quality Assurance Assessment, which is a questionnaire that the previous registered manager completed. The AQAA describes the services and facilities that The Willows provide and identifies what areas they do well in and where they want to make further improvements. What the service does well:
People who use the service have lived at The Willows for sometime and know each other and the facilities that the home offers well. It is not anticipated that there will be a change of resident group at The Willows. However if there were any new admissions to the home a detailed assessment of individual care needs would be undertaken. People who use the service have individual care plans, which set out generally how the home will meet their personal, health and social care needs, including needs relating to their individual backgrounds and culture, age, sex, religion, individual abilities and sexual orientation. Staff help them to make important decisions about their lives and enjoy a good quality of life. They are supported and encouraged to take risks to develop their skills, independence and confidence, but in ways which are safe for them and other people.
The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 6 People who use the service enjoy a good quality of life in the home. Staff support them to take part in a wide range of activities in the community. They are encouraged to go out to a local social club and to maintain valued relationships with their friends and families outside of the home. Staff support people who use the service with their personal care so that they look smart and fashionably dressed, which they appreciate. They are helped to access a range of NHS healthcare providers, such as doctors, opticians and community nurses so that they maintain good general health and receive any specialist services they need. It was observed that the people who use the service appeared relaxed and comfortable in staff presence. It was observed that there is a genuine commitment among the staff team to ensure their welfare and protection from abuse is paramount. The staff team is selected fairly and on the basis that people employed to work in the home are fit and suitable to work with vulnerable adults in a care setting so that service users and their representatives can have confidence in the people caring for them. What has improved since the last inspection?
The improvements that have been made to the service since the last inspection are that people who use the service are now provided with clear information about the costs of their placements, including more detailed and accurate information on how their personal contributions are calculated. The newly appointed manager has brought with her knowledge and experience from working within another Spectrum home. She has therefore introduced to staff new documents to work with for example care plan review documents and activity rotas that will benefit the care that people who use the service receive. People who use the service are assisted to access the healthcare services they need, when they need them, with particular reference to dental care. One staff member is now designated to be responsible for administering medication on shift. This has lead to less medication errors. There has been a review of staffing levels at night with a trial period of having one staff member on a waking night plus a sleeping in person. This has now ceased and one person sleeps in. However staff expressed concern that a person who uses the service may have a fall at night if he gets up due to mobility difficulties. The manager has agreed to review nighttime staffing in respect of this individual. The home had a fire risk assessment on the day of inspection.
The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 7 What they could do better:
A new manager has been appointed to the service and this inspection, plus her induction has highlighted that there are some areas of improvement to further benefit the care that people who use the service receive. These are as follows: The homes Statement Of Purpose and Service Users guide must be updated to accurately reflect the services that The Willows provides. It was noted from case tracking two peoples files that care plans need to be updated and cover all of the individuals care needs and inform, direct and guide staff as to what actions are needed to provide consistent care to the individual. Regular reviews must also be held and documented. The manager acknowledged this and stated that she is in the process of reviewing and updating all the care plans. The manager has introduced the updated format of Personal Care plans which provide service users with specific goals to work towards, and inform and direct staff in how to support the person to achieve this goal to encourage them to fully maximise their skills for independent living. The RSA area must be reviewed urgently. They are currently used for when People who use the service need ‘time out’. This area is outdoors, and is open to the elements. The Commission raised concerns regarding the health and safety risks these areas posed. In addition staff needed to guide individuals out to these areas and it was of concern as to how this is managed in a safe way for the individual and for those who witness the incident. The manager and staff acknowledge that the range of activities needs to be reviewed so that individual needs and preferences are taken into account. A revised activity rota is being implemented so that they can plan and choose what they will do each week with staff. People who use the service did not highlight any issues regarding food. The manager is in agreement that there needs to be more consultation with people who use the service to find out what foods they would like to be offered and appropriate menu plans then made. Improvements are needed to the storage of medication so that it is secure. The management of PRN medication needs to be more robust so that the home can account for all medication that it has in the home. Staff must attend accredited training in the safe handling of medicines so that people who use the service are better protected from medication errors. The homes medication policy and procedure needs to be updated so that current practices are accurately reflected. The manager will arrange to attend the Safeguarding (Adult Protection) course. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 8 The policy and procedure in the management of people who use the service monies is in process at Spectrum Headquarters that will ensure that future monies are kept safely and accounted for. The manager has undertaken a audit of the environment, from this plus a tour of the premises it is identified that improvements are needed to the homes environment as currently it does not provide a comfortable or homely venue for those who live or work at the home (i.e. sofas must be replaced, redecoration needed). In addition there are infection control concerns, which need to be addressed urgently (e.g. the fridge is located in the laundry area were soiled laundry is washed, this must be moved) Less than half of the staff has a formal qualification in care practice and the recommended minimum is 50 . The manager is aware that certain training such as infection control, moving and handling, and fire training are needing to be updated and is addressing this. On the 1st November 2007 Ms Jo Kitts was appointed as manager for The Willows and is in the process of completing her application for the registered manager post and must forward this to the CSCI when completed. Ms Kitts has twelve hours dedicated administration time. The amount of management time needs to be reviewed in light of her recent appointment as this inspection has identified many areas where improvements are needed to the service and needs time to be able to achieve this. Fire checks must be carried out regularly to ensure the safety of all at the home. The inspector would like to thank the People who use the service, staff and manager for their kind assistance during this inspection process. 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 DS0000009122.V343700.R01.S.doc Version 5.2 Page 9 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 DS0000009122.V343700.R01.S.doc Version 5.2 Page 10 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, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of purpose needs to be reviewed and updated so that it accurately reflects the service that The Willows provides for people who use the service and their representatives information People who use the service are assessed prior to their admission so that they can be confident it will meet their health, personal and social care needs. EVIDENCE: There have been no changes to the service user group since the previous inspection. From observations and talking with people who use the service it was evident that they are settled in the home, and that they get on well with each other and with the staff. The homes managing is currently updating the Statement Of Purpose and Service Users Guide to reflect accurately the services, facilities and staffing arrangements of the home. People who use the service and their representatives can then have accurate information on what The Willows provide. From documentation inspected it was evident that admissions are made following a full assessment and in consultation with the service user, their family or advocate, and relevant professionals. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans must be updated to address the person’s health, personal and social care needs, including needs relating to their individual and diverse backgrounds. They are able to take safely managed risks and make important decisions about their lives so that they develop their skills and independence. People who use the service individual risk assessments should fully reflect any necessary restrictions to protect them and/or other people, which should be minimal and only in their best interests EVIDENCE: People who use the service their family, advocate and relevant professionals are involved in the development of individual care plans and their subsequent reviews. The reviews record their views so that they are aware of the purpose of their placements in the home and are able to contribute to the ongoing care planning process. The care plan has specific headings to address the individual’s health, personal and social care needs, including their diverse needs. These need to accurately
The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 12 reflect the individuals care needs and direct, inform and guides staff as to what actions are needed to provide care to the person. The manager acknowledged this and stated that she is in the process of reviewing and updating all the care plans. The manager has introduced the updated format of Personal Care plans which provide service users with specific goals to work towards, and inform and direct staff in how to support the person to achieve this goal to encourage them to fully maximise their skills for independent living. Therefore this is in progress. People who use the service participate in making decisions about important aspects of their daily lives, according to their individual abilities and this was observed during the inspection. Staff were observed supporting people who required it, to make decisions about what to do during the day. People who use the service can choose the level of privacy they wish to enjoy in their private accommodation. Spectrum has undertaken an internal review of all its restrictive practises towards people who use the service to ensure that any restrictions placed on them are necessary and in their best interests. People who use the service are able to take managed risks, backed up with written risk assessments and risk management plans, particularly with regard to their engagement in higher risk activities. However there is an outdoor RSA area, which are used for when people who use the service need ‘time out’ must be reviewed urgently. This area is outside, exposed to the elements and pose health and safety hazard for the individual person, staff and those who witness the incident. This was discussed with the manager. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15, 16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to take part in a range of activities in and out of the home so that they develop their skills and confidence. They are supported to maintain valued social and family relationships so that they are not isolated or institutionalised. The menus and range of activities would benefit from review in consultation with People who use the service. EVIDENCE: At the time of the inspection, people who use the service were going out on a bus ride, as due to the weather they could not attend their planned horseriding lesson. The manager and staff acknowledge that the range of activities needs to be reviewed so that individual needs and preferences are taken into account. A revised activity rota is being implemented so that people who use the service have information, in pictorial formats about the different activities available to them so that they can plan and choose what they will do each week with staff.
The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 14 People who use the service have contact with their families, including regular visits to/from relatives. Needs in relation to their developing personal relationships are considered as part of the ongoing assessment and care planning process, including specific risks. People who use the service did not highlight any issues regarding food. The manager is in agreement that there needs to be more consultation with people who use the service to find out what foods they would like to be offered and appropriate menu plans then made. Currently it appears that this is reliant on in put from one person who use the service and hence others peoples views need to be sought. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service personal and healthcare needs are well met so that they are able to live full and active lives in and out of the home. Medication systems must be improved to ensure that medication errors are prevented. EVIDENCE: People who use the service appeared to be attractively and fashionably dressed and were well groomed so that they can comfortably take part in community life. The home has suitable bathroom facilities so that they can attend to their personal care in private. People who use the service healthcare needs are considered as part of the care planning process and regularly reviewed. Documentation showed that access to external healthcare providers, including specialists, occurs when needed. Medication is stored in a lockable filing cabinet. This is not suitable and a more robust storage facility, which is firmly affixed, to a wall/floor must be obtained. The home uses the Monitored Dose System and tablets counted tallied with MAR sheets. However there were some omissions of PRN medication recorded on the MAR sheets, which meant that additional medication was in the cabinet and the amount of medication was unable to be audited, as there were no
The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 16 records of its receipt or administration. It was difficult to undertake an audit of medicines (PRN) as the MAR sheets did not record the number of tablets it had received and therefore a tablet count of tablets, which were not in blister packs, was difficult to do. This therefore showed more medication was in the cabinet then was recorded on the MAR sheets. It is required that improvements in this area are made. The homes manager was aware of some of these issues and has changed the way medication is administered so that a single staff member is designated on shift for this role. The home’s training records indicate that whilst most staff have undertaken basic “in house” training on medication, none have undertaken full training in the safe handling of medicines and this needs to be arranged so that people who use the service have improved protection from medication errors. The homes medication policy and procedure needs to be updated so that current practices are accurately reflected i.e. the policy states that dispensing trays are used but this is not the current practice. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 17 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. This judgement has been made using available evidence including a visit to this service. People who use the service are listened to and respected so that their views, concerns and complaints are taken seriously and acted upon. There are formal and informal systems in place to ensure that they are able to feel safe in the home. The procedure in managing service users monies needs to be more robust. EVIDENCE: People who use the service were encouraged to speak to the inspector if they wished in private or with staff present so that they could make their views known or raise any concerns. No concerns were raised and the home or the Commission has received no complaints. People who use the service are provided with written copies of the home’s formal complaints procedure and have formal and informal opportunities to raise any concerns with staff before they become serious complaints. The home has written procedures to guide staff on what to do if they suspect a person is at risk of abuse. There are records to show that staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting and appropriate checks are made. Residents are not isolated in the home, but take part in a range of activities in the local community and have relationships with people from outside of the home that they can communicate serious concerns to. Spectrum has a whistle blowing policy. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 18 The manager will arrange to attend the Multi Disciplinary Adult Protection course. The home does have a copy of the Cornwall Multi agency adult protection procedure. Service users monies are audited at Spectrum Headquarters and the manager has recently highlighted a concern regarding this arrangement that is being investigated. The Commission is aware that Spectrum is reviewing the policy and procedure of the management of monies. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 19 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 27,28,30 Quality in this outcome area is poor. Improvements to the homes décor and furnishings must be made to allow a comfortable home for Service users to live in. More emphasis must be made to reduce the current infection control risks. EVIDENCE: People who use the service appeared to be happy in the home. It is well located so that there is good access to the local town. It is an ordinary, domestic building so that they live in a non-institutionalised environment in which they can develop their skills and become more independent. With the appointment of a new manager she has undertaken an audit of the environment. From this plus a tour of the premises it is identified that improvements are needed to the homes environment. For example: redecoration of communal spaces and some bedrooms, bathrooms need updating as there are current infection control issues present there, windows need replacing as the wooden frames are rotting, the staff shower does not work, a fan was installed in the laundry room but its not within reach to turn it on. In addition the furnishings in the home need replacing. It is urgent that the sofas are replaced as theses are very uncomfortable and are difficult to get up
The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 20 from once seated as the sofas springs are now near the surface. Bedroom and lounge windows do not have any coverings on them, which does not promote privacy. A water leak has occurred in the dining room leaving damp patches, which need to be repaired. The dining room furniture would benefit from being replaced, as it is not an attractive area to sit and enjoy your meals. The kitchen would also benefit from refurbishment, as cabinets are old and looking worn. In addition the kitchen fridge cannot be located in the laundry room as soiled laundry enters these premises and therefore infection control risks are high. The communal areas appeared in the main clean and tidy throughout at the time of the inspection, which was unannounced. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 21 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): 32,33,34,35,36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers at all times. Less than half of the staff team are qualified to the level recommended in the National Minimum Standards so that service users can have confidence that people working with them are competent to do so. Staff are recruited fairly, safely and effectively on the basis that they are suitable to work with vulnerable adults in a care setting. They have access to ongoing training. EVIDENCE: The minimum number of staff on shift at any time is two. However the staff rotas demonstrated that three care staff are on duty from 8am to 10pm, which allows people who use the service the opportunity to partake in their individual activities. One sleeping in staff member is on duty with on call for support if needed. Staff spoken with felt the daytime staffing levels were sufficient but queried the nighttime arrangements. As identified at the last inspection one person who uses the service has disturbed night’s sleep and this has in the past affected other residents. This was addressed in that this individual can no longer access their rooms and at one point additional waking night staff were on duty for a trail period, this has now stopped. However staff are concerned that the person who uses the service is at risk of falling down the stairs into
The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 22 the communal areas due to mobility difficulties The manager agreed to risk assess this and identify if any further actions need to be taken. The manager is aware that when looking at the individual people who use the service risks assessments there were insufficient staffing levels at times to take them out safely as the risk assessment identifies a higher level of staffing. The manager is in the process of risk assessing and reviewing staff levels on group activities so that sufficient staff are with people who use the service at all times which correspond to their risk assessments. According to the manager and records held in the home, less than the recommended 50 of care staff are qualified to NVQ level 2, although this situation should improve as more staff are due to complete it in the near future. Staff recruitment records inspected evidenced that staff have undergone the necessary clearances before they commenced employment at the home. An induction programme for new staff is implemented. Care staff have individual training records and those interviewed during the inspection confirmed that the training has been beneficial to their work. The manager is aware that certain training such as infection control, moving and handling, and fire training are needing to be updated and is addressing this. The manager has just started at the home and therefore is in the process of ensuring that all staff receives supervision approximately every 6 weeks. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 23 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): 37,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The homes manager must apply to the Commission to be registered manager so that the home is operating legally. The home is mainly well managed for the benefit of people who live there. There are systems in place to protect those who live, work or visit the home from avoidable harm and injury. EVIDENCE: On the 1st November 2007 Ms Jo Kitts was appointed as manager for The Willows. She has gained a NVQ level 3 and is in the process of starting her NVQ level 4. She has many years experience in working in this care sector. Ms Kitts is in the process of completing her application for the registered manager post and will forward this to the CSCI when completed. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 24 Staff spoke highly of Ms Kitts skills and felt that she was approachable and listened to their ideas or concerns. From observations people who use the service were comfortable in her presence. Ms Kitts has twelve hours dedicated administration time. The amount of management time needs to be reviewed in light of her recent appointment as this inspection has identified many areas where improvements are needed to the service and needs time to be able to achieve this. Due to her recent post as manager the quality assurance process has not commenced however views from residents, family and staff plus regulation 26 visits are in the process of being sought. Records are stored confidentially, staff need to be conscious of their recordings to ensure that it adheres to the data protection act i.e. communications book. The home’s environment in the main appeared safe and there is written individual and environmental risk assessments in place to minimise risks to people who use the service and staff working in the home. Maintenance of the home and its equipment are satisfactory. The fire risk assessment was in the process of being updated following a fires assessment on the morning of the inspection. Therefore this was not inspected further. The manager stated that she was aware that there must be more focus on fire issues in the home i.e. checks and she is addressing this. The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 2 26 3 27 2 28 2 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X X X X 2 X The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 (1) Timescale for action All people who use the 30/01/08 service must have an up to date detailed care plan. This will ensure that they receive person centred support that meets their needs. The RSA areas must be reviewed urgently and risk assessed to ensure that they do not pose a health and safety risk to People who use the service and staff. All medication in the home must be accounted for and accurately recorded. This will prevent the risk of medication errors. The facility to store medication must be secure to ensure that all medication kept at the home is safe at all times. (As specified in the Misuse of Drugs (safe custody) Regulations 1973. 29/02/08 Requirement 2 YA7 13(4)(7) 3 YA20 13 (2) 30/12/07 4 YA20 13 (2) 30/12/07 The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 27 5 YA23 16 (1)(l) 20 The policy and procedure in the management of people who use the service, monies must be reviewed and followed so that peoples monies are kept safe at all times. The manager must address all the issues highlighted in the homes internal environmental audit and this report to ensure action is taken so that the premises are kept reasonably decorated and all furnishings are in working order. 30/03/08 6 YA24 23 (2) (b) (c) 30/06/08 7 YA30 13(3) The manager must ensure 30/01/08 that the home promotes and actions infection control guidance so that people who live, work or visit the home are not placed at unnecessary risk. The homes manager application for the registered manager post must be sent to the Commission without delay. Fire checks must be carried out regularly to ensure the safety of all at the home. 30/01/08 8 YA37 8(1)(2) 9 YA42 23 (4)(d)(e) 30/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No.
The Willows Refer to Good Practice Recommendations
DS0000009122.V343700.R01.S.doc Version 5.2 Page 28 1. Standard YA1 The homes Statement Of Purpose and Service Users guide should be updated to accurately reflect the services that The Willows provides. This should be presented in an appropriate format for Service users use. Service users’ care plans should contain clear and specific goals. The range of activities should be reviewed so that people who use the service are consulted in what activities they would choose to participate in. The menus would benefit from review so that People who use the service are consulted and involved in the food provided. The medication policy and procedure should be reviewed to ensure that it accurately reflects current practice. The home’s manager should undertake Safe guarding (multi-agency training on the protection of vulnerable adults from abuse) training and cascade this to staff working at the home. Night staffing levels should be reviewed so that people who use the service needs are properly met at all times, with particular reference to their safety at night. At least 50 of the care staff team should have qualifications to NVQ level 2 or above. The homes manager administration time should be reviewed to allow her the opportunity to undertake the necessary management tasks to improve the quality of care and facilities that The Willows can provide. 2 3 4 5 6 YA6 YA14 YA17 YA20 YA23 7 8 9 YA33 YA32 YA37 The Willows DS0000009122.V343700.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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
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