Inspection on 09/09/08 for The Willows

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 18/09/07

The Willows 24/05/06

The Willows 01/11/05

The Willows 18/05/05

The Willows 20/01/05

The Willows 22/07/04

The Willows 18/11/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Willows, The 1 Park Road Hockley Birmingham B18 5JH Lead Inspector Donna Ahern Key Unannounced Inspection 9th September 2008 09:00 Willows, The DS0000033630.V372020.R02.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 DS0000033630.V372020.R02.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 DS0000033630.V372020.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows, The Address 1 Park Road Hockley Birmingham B18 5JH 0121 554 1427 0121 523 6073 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) Thelma Floresca@ Birmingham.gov.uk www.birmingham.gov.uk Social Care and Health Ms Thelma Gurion Floresca Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Currently residing people who are over 65 may continue to be accommodated provided their needs can be met appropriately. The minimum staffing level on weekends when daycare is off site are: 7.00am - 9.00am 4 care assistants, 1 of whom is designated shift leader 9.00am - 4.00pm 3 care assistants, 1 of whom is designated shift leader 4.00pm - 10.00pm 4 care assistants, 1 of whom is designated shift leader 10.00pm - 7.00am 2 care assistants both awake At weekends and periods without off-site daycare 09.00am - 10.00pm 4 care assistants, 1 of whom is designated shift leader 10.00pm - 07.00am 2 care assistants, both awake 07.00am - 09.00am 4 care assistants Reprovision plans to progess at a pace which is acceptable to CSCI to allow continuation of registration. The regional registration team are in the process of reviewing the Homes conditions of registration. Date of last inspection 18th September 2007 3. Brief Description of the Service: The Willows is a large two- storey purpose built home providing care and accommodation for up to 14 adults with learning disabilities. The range of needs of individuals living at the home is diverse and some of the people have complex additional needs. The home is owned and staffed by Birmingham Social Care and Health. The home is situated on the corner of a busy street in the middle of Hockley. The Willows is central to a selection of bus routes and other amenities such as shops, pubs, leisure facilities and various places of worship. To the front of the building there is a large area used for off street parking and minibus drop offs. Disabled access to the building is variable. The home has a shaft lift and adapted toilet and bathing facilities. All bedrooms are single. The home has a lounge, dining room and a room identified for people to use who choose to smoke. The fee level for the home as stated in the service users guide is £50.83£525.00. Per week. The Fee information applied at the time of the inspection; Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 5 persons may wish to obtain more up to date information from the service. The CSCI inspection report is available in the home. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out over one day; the home did not know we were going to visit. This was the homes key inspection for the inspection year 2008 to 2009. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and an Annual Quality Assurance Assessment (AQAA) completed by the manager. Three people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Some of the people who live at the home were not able to tell us their views because of their communication needs. Time was spent observing care practices, interaction and support from staff. The manager and three staff on duty were spoken to. A partial tour of the premises took place. A sample of care, staff and health and safety records were looked at. Surveys were received from four service users and three staff and their comments are included in this report. What the service does well: The home has a core team of staff who have worked at the home for a long time and know people’s individual needs well. Service users made positive comments regarding the support they get from staff. People living in the home said that they have made very good friends with some of the other people that live at the Willows. They said that their friends and relatives are made welcome to the home. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 7 Interactions between people living in the home and staff were friendly and respectful and indicated that people felt comfortable with the staff. Regular meetings take place with the people who live in the home to ask their views about menu planning, trips out and activities. What has improved since the last inspection? What they could do better: Risk assessments must be accurate so people are supported to be safe. Peoples health appointment records must be kept up to date so that staff can monitor people and make sure they get the support they need to stay healthy. Arrangement need to be made so that staff are aware of and implement speech and language therapy guidelines so they are clear about how to support people safely. Moving and lifting risk assessments should be in place for all people living in the home so that staff know how to support people safely. Some people’s bedrooms need painting so they are clean and comfortable for people to live in. The use of free standing lamps in peoples bedrooms and socket adaptors with trailing wires should be risk assessed so that there is no risk of injury to people living in the home. The manager must make sure that there is enough staff on duty at all times to meet peoples assessed needs. Some staff need to have some of their training updated so they have up to date knowledge to meet peoples assessed needs. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 8 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. Willows, The DS0000033630.V372020.R02.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 Willows, The DS0000033630.V372020.R02.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 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have most of the information they need to make a choice of whether or not they want to live there. EVIDENCE: Birmingham Council had previously indicated to us that their future plans for this home is to eventually reprovide the service. Registration numbers for the home has gradually decreased as and when people have left the home. There are currently fourteen people who live at The Willows on a permanent basis many of the people have lived at the home for a number of years. There had been no new admissions to the home for several years. However in August 2008 the Home had someone placed there as an emergency placement due to the closure of another home. Birmingham City Council made a late application to the Commission to vary their registration numbers so that the person could be accommodated. At the time of completing this report we are still processing this application. Due to the nature of the placement the Home was not able to carry out a full assessment of the persons needs prior to admission. However the persons Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 11 needs did fall within the category of registration. A care plan assessment had been completed by the Social Worker and made available to the Home upon admission. The manager had completed their own care plan assessment and risk assessments following admission. The service user guide and statement of purpose were looked at and were in the process of being updated so prospective service users would have the information they need to make a choice as to whether or not they want to live there. The statement of purpose must accurately reflect the registered numbers and any plans to take future emergency placements. These documents were being produced using some pictures making it easier for people to understand. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 12 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff do not have all the information they need to support individuals to meet their needs and keep them safe, which could impact on their well being. EVIDENCE: The care provided to three people was tracked; this included looking at their care records. Each person had an individual care plan that stated how staff are to support the individual with their daily routine, sleeping, personal care, the things they like and dislike including activities and leisure interests. Care plans were generally satisfactory and had been reviewed and updated to reflect changing needs. Care plans cross-referenced to other documents where appropriate such as behaviour management strategies so that it was clear to staff how to support the person in all areas of their life. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 13 Annual review takes place with other relevant people such as family members, advocate and staff at the day centre. This should ensure that support people receive is consistent. Risk assessments were looked at. These detail the support people need to be kept safe while still being enabled to be independent. These included assessments about bathing, showering, fire safety and support during the night. Although reviewed there were some instances where care practice had changed, moved on, but the risk assessment was in conflict with the current practice. An example of this was a risk assessment in place stating some restrictions in contact between two service users. However progress had been made and the risks identified were no longer present but the risk assessment had been reviewed and dated as still relevant. Risk assessments must be up to date and accurate so that people get the right support from staff. During the visit staff were observed giving people choices about what they wanted to drink, how they wanted to spend their time, what activities they wanted to do. Regular service user meetings are held and the minutes of these were looked at. They include discussions about day trips, peoples birthdays and future plans like where people would like to live. It would be positive if the minute’s included some follow up information, showing that matters raised by service users have been followed through in practice. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 14 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, 15, 16 and 17 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People are supported to take part in age appropriate activities at home and in the community that they enjoy so that they are offered a meaningful and fulfilling lifestyle. Opportunities are limited for people to develop and enhance their independent living skills, which limits the opportunity for personal development. People are offered a healthy diet that meets their dietary needs. EVIDENCE: Many of the people attend local day centres Monday to Friday. Some people have been supported to reduce the time they spend at day centres or leave altogether if they feel the day centre no longer meets their needs. It is important that people are supported to do this especially when people become Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 15 more elderly and want to arrange their time in a more relaxed way. This should enable people to have more individualised care. Previous reports have highlighted the limitations of the homes environment, which limits people’s opportunities to develop their independent living skills. The kitchen and laundry areas are industrial in lay out and design and people are not allowed to access the kitchen and therefore have no opportunity to shop, cook and only limited opportunities to prepare their own food. An area is available in the dining room so that people can make their own drinks during the day. A small kitchen is utilised on the first floor so that service users can make snacks. People spoken with said “We sometimes make a snack like beans on toast or we might make a cake, depending if there is staff available”. Some people said they are supported to do their own laundry. Its important that people continue to get the support and opportunity to maintain and develop new skills and promote their independence. People were seen to move freely around the home and had full access to their own bedroom, lounge and dining areas. The activity room on the ground floor has been made into a bedroom and the spare room on the first floor is currently being used for storage. Service users said they would like somewhere to play darts or games. This was also raised by staff who said there is now only one lounge area for all service users to use. In the evenings people seem to go out a lot together. On the evening of the visit many of the service users went out to the gateway club. Service users spoken with said they do go out to the cinema, meals out, shopping and to the local pub. People have been supported to develop and maintain personal relationships within the home. Service users are also encouraged to maintain family and friend contact. One service user had just returned from a holiday with their family, another said they had regular visits from their sister; some people rang family and friends at the time of the visit. Another person spoke about their advocate and said “I like seeing them and going to the pub”. People said they liked the food. “The food is okay you get a choice” “yes I like the food most of the time” Staff did not sit with people at meal times but were present to support when required. Menus seen indicated that choices are offered at mealtime. Guidelines were in place to support one of the people with their eating and drinking needs. Service users said they can have a drink and a snack when they want to. One person was seen having a late breakfast and people were seen having drinks at different times throughout the day. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff support people well with their personal care but arrangements do not always ensure that the health care needs of individuals are fully met, which could impact on their well being and safety. EVIDENCE: Many of the people have lived at the home for a long time. As they become older some of the people have experienced an increase in health problems and changes in their needs and mobility. Staff spoken to demonstrated a good understanding of the potential impact of changes in peoples needs and the need to keep peoples needs under review and liaise with other professionals to ensure health care needs are met. People had been supported to dress appropriately to their age, gender, the weather and the activities they were doing this indicates that people receive good support from staff. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 17 Guidelines and risk assessments are in place regarding the support people require from staff during the night so they are supported in a way that they prefer. A moving and handling risk assessment required implementing for one person so they are supported safely, other files looked at contained this information. Records sampled included an individual health action plan. This is a personal plan about what support the individual needs to meet their health needs and what healthcare services they need to access. One of the health action plans looked at did not accurately detail the recent outcome of hospital appointments and the reduction in the person’s medication. There must be clear information recorded on people’s health care records so that there is a full and accurate account of any health care issues or changes so that staff can give people the support they need and accurately monitor any changes in their well being. Service users spoken with said staff are very good when they are not well and that they are supported to go to the doctors if they need to. One person said, “I was not very well and have been in hospital the staff were very good and very supportive”. Eating and drinking guidelines written by the speech and language therapist to reduce any risk must be signed by care staff, as requested by speech and language therapy as this provides evidence that staff have read the guidelines and are clear about what to do and understand how to support the person safely. Arrangements need to be made so that staff are aware of the choking policy so staff know what to do in the event of this happening. Discussion with staff on duty at the time of the visit indicated that they did know how to support this person. The systems for medicine management were satisfactory. All audits undertaken were correct indicating that the medicines had been administered as prescribed. The medication cabinet is metal and secured to the wall in the office. There were protocols in place for medication taken on an as required basis so people receive their medication safely. None of the people living in the home were self administering their medication. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The systems in place for dealing with complaints if followed would ensure that people are listened to. Arrangements are in place to protect people from the risk of harm and the arrangements for managing peoples finances are robust. EVIDENCE: The home has not received any complaints since the last inspection. No complaints have been made to us concerning the service provided at this home. People spoken with said they could talk to the staff or manager if they are not happy about something. Service users said, “I can talk to staff” “I would talk to Thelma (manager) if I was not happy about something”. Two service users did raise some concerns with the inspector and they agreed for this information to be passed onto the manager for further investigation. The manager confirmed that staff had dealt with one matter appropriately and the other matter would be logged as a complaint and followed through. As reported in the previous inspection report the manager had implemented a system for recording minor concerns that people raise and this is seen as good practice and evidence that people are listened to and should continue to be used. The complaint procedure is now available in a format suitable for people living in the home. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 19 The policy on abuse and whistle blowing policy was available in the office for staff to refer to and staff spoken with confirmed that they knew what to do if a concern was raised. Systems are well established for the reporting of incidents to CSCI via a regulation 37 reporting form. This ensures that outside agencies receive notification of incidents effecting peoples well being. The arrangements in place to support people with managing their personal allowances were sampled. Individual financial record sheets with details of transactions were recorded and signed and are audited. Birmingham City council has a financial procedure, which is available in the home. Systems in place should ensure people’s finances are safeguarded. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home does not provide people with an environment, which encourages their independence. Some improvements have been made so that the home is more comfortable for people to live in. EVIDENCE: The owner plans to reprovide the service provide by The Willows. However, at the time of the visit there was no proposed timescale for this to happen. Previous reports have highlighted that the design and lay out of the building does not provide opportunities for service users to develop their independedent living skills. The kitchen is industrial in design and layout and service users are not allowed access. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 21 All parts of the home were seen to be clean and satisfactorily maintained. Since the last inspection the smoke room had been painted and decorated and new flooring fitted this makes the room more pleasant for service users to spend time in. New fire doors have been fitted throughout the home and in one location there is a push pad door entry, which allows people with limited mobility to move safely and independently to their bedroom. Each person has his or her own bedroom. Rooms seen were personalised. Two people have moved to a bigger bedrooms which had been redecorated and they said, “ I really love this room and happy that I moved” it is more spacious and the person who has some limited mobility has more space to move safely. Some of the bedrooms seen are in need of painting and decorating so that they are clean and comfortable for people to live in. It would be good if the lounge located on the first floor currently used for storage, is developed into an activity room for service users use so there is space for people to take part in games and activities of their choosing. This facility was previously available but was lost when bedroom moves took place. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 22 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 and 36 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The arrangements for staff support and development ensure that they can meet the needs of the people living there. The recruitment practices ensure that the people living there are safeguarded from abuse. EVIDENCE: Support to people who live at the home is given in a friendly manner, and staff were polite, considerate and patient. Staff spoken with had a good understanding of the needs of people in their care. Over 50 of staff have achieved an NVQ in care so they have the skills and knowledge to meet the needs of the people living there. The staff rota’s were sampled for three weeks and these show that usually there are four staff on duty during the day and two staff on duty throughout the night. This level of staff would usually be adequate to meet people’s needs. However since a new person has recently been admitted to the home there is Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 23 more pressure on staffing, as the person requires two staff for personal care. Discussion with staff during the visit confirmed that this has had an impact on staffing levels. The manager said during the visit that there is some capacity for some extra care hours and the best way these care hours can be used would be looked at so peoples individual needs continue to be met. There has been no new staff employed since the last inspection so it was not possible to fully assess the homes recruitment procedures. The manager said that she was in the process of updating staffs Criminal Records Bureau (CRB) check to ensure that ‘suitable’ people are employed to work with the people living there. One staff member had transferred from another Birmingham Council home and a full induction had been completed so that they had the required information to do their job in a new setting. Staff training records sampled showed that staff had received training in adult protection, food hygiene, epilepsy, moving and handling, first aid and fire safety. Some staff requires refreshers in mandatory areas so they continue to have the skills and knowledge to meet the needs of the people living there. Staff files seen indicated that regular supervision takes place with either the manager or the deputy manager. Records seen indicated that well above the six sessions per year take place. Daily handovers of information at the point of a staff change over take place and regular staff meetings are held to ensure that staff receive the information they need to support people consistently and to raise any concerns they may have about meeting peoples needs. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):37. 39 and 43 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The current management arrangements are ensuring that the people living at the Home benefit from an improving service. Some health and well being matters must be improved so people are safe. EVIDENCE: The manager has a number of years experience and has NVQ level 4 and the registered managers award. The manager facilitated the inspection process and was open and welcoming to the inspection process and informed the inspector of relevant information. She interacted well with people living in the home and staff on duty. People living Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 25 in the home said “the manager is fine I can talk to her” “I go to Thelma (manager) if I need to talk she is very nice”. Good progress had been made on previous requirements indicating compliance with the regulations and a commitment to improve the Home for the benefit of the people who live there. However the report has identified some areas that do require attention by the manager so that assessed needs are met and people are supported safely. These include the need to review staffing levels due to a new admission, attention to some of peoples health care recording and monitoring and the need to sign guidelines implemented by the Speech and language therapists. Some of the homes maintenance and service records were looked at and dates of testing were provided by the manager at the time of the visit and indicate that gas, electrical and fire equipment is serviced and maintained so that the building is safe for people to live in. Some service users like to leave their door propped open by choice. The manager said that she has arranged for a health and safety officer from the council to visit later in the week to assess some bedroom doors that require automatic door closures fitted. The fitting of this mechanism should ensure the door closes in the event of the fire alarm sounding and therefore safeguarding service users. One of the bedrooms seen had an open style lamp fitting leaning against the curtains, which could be a fire risk. Some bedrooms had lots of trailing wires from extension leads that could be trip hazards. The manager’s said she receives good support from the line management structure. Regular monthly visits are made by the team manager to assess that the homeowners, Birmingham City Council are fulfilling their responsibility to oversee the overall management of the home. The health and safety department carries out health and safety audits and financial audits take place. Regular meetings are held with the people who live in the home to seek their views on day-to-day matters such as menu planning, organising trips out. The manager said she had not yet developed surveys to seek the views of people living in the home, their relatives and other stakeholders but as stated in the last inspection report she hopes to do this. This should enhance the homes quality assurance system. Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 26 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 2 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 3 X X 2 X Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 27 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 YA18 Regulation 12 (1) a,b Requirement Staff must ensure that people’s health care needs are properly documented and monitored to ensure their health and wellbeing. Timescale for action 10/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA1 YA9 YA8 Good Practice Recommendations The statement of purpose and service user guide requires some minor updating so they accurately reflect the service provided at the Home. Risk assessment must be updated, as peoples need change so that staff have up to date and accurate information available to support service users safely. The follow up and action taken following discussions made in service users meeting should be recorded as evidence that people have been listened to, acted upon so their views are considered in the day to day running of the Home. Consideration is given to clearing an area currently used for storage to create additional communal space so people living there have a choice of areas where they can choose DS0000033630.V372020.R02.S.doc Version 5.2 Page 28 4 YA12 Willows, The 5 6 7 8 9 YA18 YA18 YA24 YA33 YA39 to spend their time. Arrangements need to be made so that staff are aware of and know the guidelines and protocols implemented by other professionals. A moving and handling assessment must be completed so people are moved safely and in a way that meets assessed needs. Some of the bedrooms need painting so they are comfortable and clean for people to live in. Staffing levels must be reviewed so there is adequate staff on duty to meet peoples assessed needs. Quality assurance systems require further development so that the views of the people who live in the Home underpin any development. The use of stand lamps and plug adaptors with trailing leads in peoples bedrooms must be risk assessed and appropriate action made to make safe. 10 YA42 Willows, The DS0000033630.V372020.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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