Inspection on 04/07/06 for The Willows

This inspection was carried out on 4th July 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 27/09/05

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 Unannounced Inspection 4th July 2006 10:00 Willows (The) DS0000013832.V302201.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 Willows (The) DS0000013832.V302201.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. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 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) rajesh.doorga@sabp.nhs.uk Surrey Oaklands NHS Trust Rajeshwarsingh Doorga Care Home 14 Category(ies) of Learning disability (14), Physical disability (5) registration, with number of places Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 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 disabilities (LD) accommodated, 5 (five) will have an additional physical disability (PD). Two named individuals up to the age of 75 years may also be accommodated. 27th September 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.V302201.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced site visit to be undertaken by the Commission for Social Care Inspection year April 2006 to March 2007. Mr Kenneth Dunn Regulation Inspector carried out the site visit. Mr Rajeshwarsingh Doorga the registered manager for the home was present. The site visit was undertaken over 5 hours. There are currently ten residents living in the home, and the majority have lived in the home for some considerable time. A number of staff was spoken to and one commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. The inspector received positive comments from the staff team and all commented on the open management style feeling well supported by management. Observation made was that residents and staff have a good rapport; residents were relaxed and comfortable with staff on duty. The inspector would like to thank the residents, registered manager and staff members for their time, assistance and hospitality during the site visit. What the service does well: What has improved since the last inspection? What they could do better: The home to ensure any requirements made must be addressed within the timescales given. If for any reason these are not achievable to contact the Commission for Social Care Inspection, Regulation Inspector for the Willows to advise the reason for non-compliance. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willows (The) DS0000013832.V302201.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 Willows (The) DS0000013832.V302201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed and informative statement of purpose and service users’ guide. These documents, together with the home’s procedure of carrying out detailed assessments and offering visits prior to admission, enable prospective service users and/or their representatives to make an informed choice about the home. EVIDENCE: The statement of purpose and service user guide is designed to be clear, concise and generally delivers sufficient information about the home that is fully reflective of the services it provides. All potential service users must have a full assessment of needs prior to entry into the home. The service has not had any new service users since the last inspection. Since the last inspection one service user had been reassessed by a multi agency team including the manager of the home, as a result it was decided that her needs would be better met in another environment. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual plans were clear and comprehensive they included details of needs and goals of the individuals. The care plans also incorporate known or indicated preferences and choices, and include in depth risk assessments. EVIDENCE: Staff stated that the service users are supported to make decisions affecting their lives in a number of ways. The service users are each allocated a key worker, who is trained to offer one to one support and who is charged with developing a working relationship with the service user in order to develop a clear picture of the persons needs. The service users at the Willows have profound needs and rely heavily upon the assistance of regular care workers to meet even there most basic of needs. At the time of the inspection the inspector was unable to obtain direct feed back from the service users because of their complex disabilities and inability to communicate verbally. The inspector was however able to gather evidence by direct observation which Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 10 indicated that staff understood the needs of the individuals and were able to support them effectively. Information is provided in makaton, pictorial or visual formats and staff also give information verbally, as appropriate. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that residents’ rights are respected EVIDENCE: The service users are independent within the home, they demonstrate this by walking away or indicating to staff that they want to be somewhere else. The home has increased its activities within the community they have been enjoying outings to the seaside as a groups. The manager informed the inspector that staff have individually gone with the service users to the local pub to watch the World Cup and to have a meal. The inspector was able to review the records of individual activities chart, which are updated daily by the key workers or the manager. The records audited demonstrated the different and varying activities accessed by the service users these included Horse riding, Swimming, Trampolining, Bowling, Sensory Stimulus, Barbeque. The Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 12 inspector was informed that the home held two 2 held barbeques the weekend prior to this inspection. All relationships have to be fully supported by the staff due the nature of the service users disabilities, the staff find this a useful way of keeping the communication process open with their families and friends. The rights of the service users are respected and the staff understand fully their role with upholding their rights. The home employees a full time cook whose role is to provide homely and wholesome meals for the service users. A review of the menus indicated that the service users could enjoy a verity of meals from many areas of the world. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies and practices are in place for the administration and management of medication. EVIDENCE: Support with personal hygiene is well documented and the service users were observed to be clean and appropriately dressed. Healthcare needs of the individual service users were well documented and assessments from health professionals, and details of health-related appointments and health checks, were noted when examining resident’s files. Medication was well organised medication administration records were filled in correctly, properly dated and signed. The staff are trained in the administration of medication. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: The service has a complaints policy, which is contained within the Service User guide and the employee’s handbook. All staff has attended the safeguarding of vulnerable adults training and when spoken to by the inspector it was clear that staff are aware of the whistle blowing policy. The service users are well protected by the trusts employment practices. There have been no complaints made directly to the CSCI and a review of the complaints log would indicate that there have been no complaints made to the agency since the previous inspection. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 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, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and generally well maintained. The home was found to meet the service users individual and collective needs in a comfortable and homely way. EVIDENCE: The premises were found to be clean and hygienic, all staff to be congratulated on the cleanliness of the homes. The service users bedrooms had been made personalised with pictures and posters, televisions, music and radio facilities and individual bedding and soft furnishings. Bedrooms were seen to be of a good size. The communal areas of the home consist of a lounge, separate dining room and kitchen. There is also another small sitting/relaxation room also used as a quite area. However the general repair of the home is tatty and although the staff have made considerable efforts to improve the environment it still requires to be redecorated. The main décor and furniture in the communal rooms requires to be updated or replaced. The furniture was previously in a care home Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 16 belonging to the same NHS trust, which was closed in 2005. The Willows received the furniture as an interim measure to replace their existing items. However the style of furniture and the fabric used to upholster the items are not suitable for this service user group. It was discussed with the manager during this inspection that the furniture used in the communal areas was inappropriate view of the service users physical needs in addition the upholstery fabric is not easily cleaned and hygiene standards and infection control could be affected. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 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): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interactions observed between staff and service users evidenced a high degree of respect and skill in working with the individual at the home. Staffing is kept under review and provided to meet the needs of the individual and group needs of the service users at all times. EVIDENCE: Staff recruitment files are up dated and contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. The number of staff on duty and the mix of trained and care staff was seen to be satisfactory to the assessed care needs of service users in the home. Staff were observed sitting and interacting with service users in communal areas, checking on service users in their bedrooms and assisting service user where required. Staff supervision was seen to be undertaken on a regular basis, and staff are provided with a copy. A number of training courses have been undertaken and all new staff undertake a full an induction programme, which is covered over several weeks. Any specialist training required by staff is considered by trust HQ. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 18 Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. 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. Policies and procedures were in place to ensure the health and safety of the service users and staff. There was clear evidence that these were being followed at the time of the inspection. The homes Abuse policy is in line with the local authority Safeguarding Adults Multi agency policy. EVIDENCE: Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 20 The registered manager has been in post since 2005 and demonstrates a full commitment to the home and its Service Users. The frequency of staff meetings, formal and informal supervision was indicative of an open and supportive atmosphere. Regulation 26 (Monthly visits by the proprietor) are undertaken and evidence was seen of their occurrence. Relevant policies and procedures for the safety and welfare of the service users were in place. The manager has introduced systems to demonstrate these had been communicated to staff evidence of staff signing that they have received the policies. In addition any additional information of relevance to service users had been shared with them. Records examined included; care plans, medication procedures, staff meeting minutes, risk assessment policies and service user activity programmes. They were seen to be in good order. There were policies and procedures in place for the health, safety and welfare of service users and staff. Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 21 Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 22 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 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Willows (The) DS0000013832.V302201.R01.S.doc Version 5.2 Page 23 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 YA24 YA30 Regulation 13, 16 & 23, Requirement The manager must ensure that the communal rooms are appropriately and effectively furnished, they should be designed to meet the specific needs of the service users. Timescale for action 30/09/06 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.V302201.R01.S.doc Version 5.2 Page 24 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.V302201.R01.S.doc Version 5.2 Page 25 - 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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