Inspection on 18/09/06 for Willoughby House

This inspection was carried out on 18th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Willoughby House 03/01/06

Willoughby House 26/07/05

Willoughby House 07/03/05

Willoughby House 20/09/04

Willoughby House 12/01/04

Willoughby House 23/07/03

Willoughby House 14/01/03

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

CARE HOME ADULTS 18-65 Willoughby House Willoughby Road Sutton-on-sea Lincs LN12 2NF Lead Inspector Mr Ken Hague Unannounced Inspection 18th September 2006 08:00 Willoughby House DS0000002479.V311856.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 Willoughby House DS0000002479.V311856.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. Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willoughby House Address Willoughby Road Sutton-on-sea Lincs LN12 2NF 01507 442555 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) Boulevard Care Arthur Trude Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: Willoughby House is owned by Boulevard Care, which has a number of care homes within the Skegness area. It provides residential care for 8 residents with a learning disability who are under the age of 65. The home is set just off the seafront of Sutton-on-Sea in Lincolnshire. It is a single storey building surrounded by its own grounds and is within walking distance of all the local amenities and shops. It is very accessible by public transport and there is a large car park at the front of the care home. The home provides minibus transport to enable residents to take part in day activities and there is a local day centre in Orby, which can be attended by residents, if they so wish. There are other activities organised by the home at alternative venues including colleges. Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place between 08.00 am & 12.30am. A site visit was made as part of the inspection. Care records were inspected, staff and the registered manager was interviewed The main method of inspection used is called ‘case-tracking’; this involved ; reading the individual care records for residents being case tracked and discussions with staff and the registered manager. Observations are made of the manner in which care and help is provided throughout the inspection. Discussions were held with the residents being case tracked to ensure that their care plans were being followed and their choices and wishes were considered in the day-to-day management of the care home. The home has supplied the Commission for Social Care Inspection with 5 copies of the “have your say document”. This document ask questions to the residents and invites them to pass comments which reflect their views on the resources been offered by the care home. All 5 documents were studied, and the comments and opinions are reflected within this report. What the service does well: What has improved since the last inspection? What they could do better: The Inspector looked at the files of two residents who had recently come to stay at the care home did not contain a current assessment and care plan written at the time they were admitted. Staff were able to describe the Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 6 individual needs of these residents. The information had been passed on verbally rather through recording in care records. 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. Willoughby House DS0000002479.V311856.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 Willoughby House DS0000002479.V311856.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 adequate. This judgement has been made using the available evidence including a visit to this service. The care home has made an assessment of the needs of residents who live in the care home. They are able to meet the needs of residents by using the resources of the care home. However in the case of two residents their assessment has not been written into their care records. EVIDENCE: The inspector looked at the individual care records for two residents. One resident had been admitted from another care home owned by Boulevard care had no current assessment on their individual file. The home was using a previous care plan completed at the last care home, which has not been updated to reflect the resident’s current needs. A second resident had no assessment on their personal file and there was confusion whether a risk assessment on their care records was accurate. Discussions with the registered manager, a member of staff and a senior manager confirmed that the resident’s needs had been identified and were being met. The residents stated that they felt their needs were being met. Care records however did not reflect the current identified needs of both residents. Willoughby House DS0000002479.V311856.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 adequate. This judgement has been made using the available evidence including a visit to this service. Resident’s needs are identified, individual goals are generally reflected within care plans. However the home has failed to consistently ensured that up-todate care plans are written and maintained for all residents. This could result in residence needs not being fully met. Individual residents are supported and enabled to make decisions about their everyday life. Any identified risk is balanced against the choices and wishes of the residents. EVIDENCE: The staff and managers of the care home were able to describe the individual needs of two residents being case tracked. This included their choices and wishes in terms of their everyday activities and contact with their family. They were able to describe in detail the concerns relating to one resident, whose behaviour had deteriorated recently. This included the progress made since he came to stay at the care home and his aims for the future. The care plan of this resident had not been updated since his last placement, at another care home within the company. It was clear from the description of his needs on Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 10 the day of the site visit that there had been considerable changes, which were not reflected within the care plan transferred from his last placement. The evidence gathered from observations, discussions with the resident and senior management of the company was that his needs were being met. The resident stated his satisfaction with the care services being provided by the care home. Willoughby House DS0000002479.V311856.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 the available evidence including a visit to this service. Residents are encouraged to keep in contact with their family and friends. All visitors are made welcome by staff at the care home. Catering arrangements for the home reflects the residents choices, preferences and personal dietary needs. Residents with a special diet are provided with a menu, which takes their personal needs into account. EVIDENCE: The home has a visiting policy known to residents and staff. Residents stated at the site visit that their family and friends are encouraged to visit. The registered manager outlined in formal discussions, individual residents family contact. But the inspection questionnaire sets out the range of activities offered to residents. Residents were seen to be going out to college on the day of the site visit. Discussions with residents stated that they were happy with the activities been offered. The have your say documents provided further evidence that residents are satisfied with activities and their social lifestyle. Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 12 All residents are encouraged to go out into the community either for day or social activities. On special occasions such as birthdays residents go out to a restaurant for a party. One resident confirmed that a party was being planned for this week as it was her birthday at the weekend. The have your say documents provided evidence that in the opinion of the residents that care staff respects their dignity and privacy. There was evidence found in reviews and care records that resident’s wishes and choices are consider at each review of their individual care plan. Willoughby House DS0000002479.V311856.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 the available evidence including a visit to this service. Care plans contain information, which identify the care needs and personal preferences of the residents. Risk assessments provided management strategies that enable residents to be as independent as possible EVIDENCE: The care records contain information regarding the resident’s choice in relation to the manner in which personal care should be provided. Residents stated that they felt all staff respected their privacy and dignity. The registered manager stated that the home liaise with community health services. The care records demonstrated that eye care, foot care and dental care are being provided for all residents. The details of visits and appointments for hospitals, dentist, opticians and visits from chiropodist were recorded on the individual resident’s files. The registered manager stated that all staff are following the medication procedure for the home which meets the National Minimum Standards. Staff confirmed appropriate training has been provided in the administration of medication. The risk had been identified for residents, this is recorded on the individual care records. There was one risk assessment that a residents care records, which contained the wrong Christian name. The registered manager Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 14 stated he did not think this risk was still current and should not be on the residents care records. Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 15 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 Excellent. This judgement has been made using the available evidence including a visit to this service. There are policy and procedures in place to ensure that all residents are protected from any possible abuse situation. Residents are confident that they are able to raise any issues with the management team. Staff have been provided with training in the recognition and prevention of abuse. EVIDENCE: There is a complaints procedure and adult abuse procedure in the home’s policy and procedure manual. The home has a copy of the Lincolnshire County Council vulnerable abuse procedures. The Staff were able to discuss in detail the Prime Life Ltd abuse policy and explained how any suspicion of abuse should be reported. A resident stated that they would feel able to raise any concerns with any member of staff at the home. The registered manager said that all staff have received training in the recognition and management of abuse. The inspection of training records confirmed this statement to be correct. The home has had no adult protection inquiries in the last five years. There have been no complaints raised by residents or members of the public in the last five years. Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to this service. The home provides a welcoming, comfortable, clean and homely environment and has an on going maintenance programme. There were no a health and safety issues identified at the care home. All areas of the home smelt fresh. EVIDENCE: A tour was made of the care home. The home was cleaned to a high standard throughout and was odour free. Bedrooms furnished in accordance with the National Minimum Standards and contained the personal possessions of individual residents. Residents spoken to confirmed their satisfaction with their own individual bedroom. The home has a planned maintenance programme. There were no health and safety issues identified at this site visit Willoughby House DS0000002479.V311856.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 the available evidence including a visit to this service. The home ensures that appropriate staff are recruited and employed by the home. There are always sufficient numbers and skill mix of staff on duty. The staff training provided does not cover all essential core training. EVIDENCE: The managers of the care home stated at the site visit that staff continuity to be recruited in accordance with the homes recruitment procedure. The recruitment standard was met at the last inspection and there have been no staff recruited since the last inspection. The Pre-inspection questionnaire, discussion with staff and the inspection of the staff training record provided evidence that staff are being provided the training both and core training and specialised training needs. Staff stated that they felt confident in being able to meet the needs of all residents in the care home. The “have your say” documents completed by residents provided further confirmation that residents feel there are sufficient staff on duty who can meet their needs while respecting their dignity and privacy. Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 18 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 the available evidence including a visit to this service. The care home has an experienced and supportive registered manager who has worked in the provision of residential care for many years. Staff are provided with appraisals and supervision as required by the National Minimum Standards. All service users financial interests are safeguarded by the policies and procedures of the care home. The home is a safe home in which to live and a safe working environment. EVIDENCE: The home has an experienced registered manager in post. Inspection reports from the last three inspections provide further evidence that the home is being run in accordance with the National Minimum Standards. Staff Stated that they find the register manager and the Company very supportive. All discussions with staff and management confirmed that residents views are always sought when changes are being made to the care home. The “have your say” Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 19 documents provided evidence that residents feel the home is being run in their best interest. There were no health and safety issues identified at this inspection. The company has introduced a review of it’s financial procedures to ensure that residents money is safeguarded. A copy of this policy is on the care homes file. Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 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 4 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 3 35 3 36 X 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 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 Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14-1 Requirement Timescale for action 01/10/06 2 YA6 15-1 The registered manager must complete an assessment, prior to a resident being admitted to the care home The registered manager must 01/10/06 complete a care plan which sets out the identified needs of residents of the how these are to be met by the resource to the care home. 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 Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Willoughby House DS0000002479.V311856.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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