Inspection on 31/01/06 for The Willows

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 16/10/06

The Willows 25/08/05

The Willows 15/12/04

The Willows 16/06/04

The Willows 28/01/04

The Willows 03/09/03

The Willows 23/10/02

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

CARE HOME ADULTS 18-65 The Willows No 1 The Willows Bungalows Gas House Lane Morpeth Northumberland NE61 1SW Lead Inspector Bill Middlemist Unannounced Inspection 31 January 2006 11:00 st The Willows DS0000000647.V276235.R01.S.doc Version 5.1 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 DS0000000647.V276235.R01.S.doc Version 5.1 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 DS0000000647.V276235.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Willows Address No 1 The Willows Bungalows Gas House Lane Morpeth Northumberland NE61 1SW 01670 395850 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) pauline.carr@nmht.nhs.uk Newcastle, North Tyneside & Northumberland Mental Health NHS Trust Mrs Pauline Carr Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2005 Brief Description of the Service: The Willows is small home in Morpeth that provides care and support for a mix of younger adults and older people who have mental health problems. There are three separate bungalows within the attractive and well-maintained grounds. This home is placed close to a number of good local amenities, and is close to local transport services. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that lasted for 4 hours. The people who live at The Willows gave their views about what it is like to live there. Care and support plans for 3 people were inspected, and the general care needs of all residents were discussed. The Manager discussed how the service would be developed in the future. 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 Willows DS0000000647.V276235.R01.S.doc Version 5.1 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 The Willows DS0000000647.V276235.R01.S.doc Version 5.1 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): Standard 2 was assessed and met at the previous inspection. EVIDENCE: The Willows DS0000000647.V276235.R01.S.doc Version 5.1 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, 9 Each person knows that their assessed and changing needs are recorded in an individual plan. Each person is able to take risks as part of their everyday life. EVIDENCE: If anything, care and support plans are getting stronger at giving as much control to people as their level of needs dictate: each plan relates a deep understanding of each person’s needs. There are good contingency plans for people should their health deteriorate. The Manager explained that a strategic and risk based approach is being used to develop care and support plans further. People are supported by the home’s risk assessment and risk management strategies, including health relapse factors. The home recognises that taking risks is an essential part of people’s lives, and takes proper steps to ensure that new experiences and learning are combined with safety. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 17 Each person is able to take part in activities that suit them. Each person is able to have relationships that are important to them. Everyone is offered a healthy diet. EVIDENCE: Each person is able to take place in activities that they have identified as enjoying: some people attend a day service that offers a range of things to do, and some are involved in work placements. Some people choose not to be involved in services or activities outside of the home, and they confirmed that this was their personal preference. Staff support people to keep in touch with the others, such as relatives and friends, who are important to them. Relatives are consulted about what happens in people’s lives, with permission gained. People have opportunities to mix with people who do not have disabilities, through the use of what the local community has to offer. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 10 Meals at The Willows are very good: menus are varied and well planned, and there is always a good range of choices. The Housekeepers are fully aware of any specialist diet requirements. Each person spoken with said that they really enjoyed their meals. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 11 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): 19 Standards 18 and 19 were commended at the previous inspection. Each person is supported by the home’s medication policies and procedures. EVIDENCE: Some people have control over their own medication and this is monitored by care staff and agreed in the service user plan. Other people are reliant on care to staff to administer medication in line with the home’s medication policy and procedure. Records were examined and a spot check made on a limited number medications: all those inspected were in order. There was evidence that staff have received the right training in order to deal with medication, and are assessed as being managerially competent to deal with medicines. All medication was stored in line with pharmacy guidelines. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 12 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 Each person’s views are listened to and acted on. Each person is protected from abuse and neglect. EVIDENCE: The home has an effective complaints procedure that details action to be taken in the event of a complaint being made, including timescales, and ensures that people will not be victimised for making a complaint. The home has procedures for the protection of vulnerable adults which includes whistle blowing; the home has provided evidence that procedures has been followed in the past and that prompt action was taken to protect residents. There are good guidelines available for staff to meet the needs of people whose behaviour may challenge the service. The home has an effective system for recording transactions made on resident’s behalf. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 13 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): The Willows provides a comfortable and safe place for people to live in. Everywhere inspected was clean and hygienic. EVIDENCE: Each of the three bungalows is well presented and accessible for the people who live there. Each bungalow has a programme of ongoing repairs, decoration and replacement of worn items. There are good arrangements to maintain high standards of cleanliness and hygiene. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Each person is supported by a competent and qualified staff team. EVIDENCE: Again, the people who live here strongly reinforced how much they thought of the staff. One person said that they “work really hard to keep you well” and another said that the staff are “smashing”. Throughout the inspection, staff were observed working directly with people in a way that they found reassuring, and most of the staff were working in a way that demonstrated their values and attitudes. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 15 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 Each person benefits from a well run home. EVIDENCE: The Manager is good at her job: she manages this service in a way that combines practical approaches with academic and evidence based practice. The Manager was observed working with both the people who live at The Willows, and the staff who work there, and provided evidence that she has the range of skills and experience necessary to maintain standards and improve them where improvements are needed. The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 4 X X X X X X The Willows DS0000000647.V276235.R01.S.doc Version 5.1 Page 17 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 DS0000000647.V276235.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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