Inspection on 26/07/05 for Willoughby House

This inspection was carried out on 26th July 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willoughby House 18/09/06

Willoughby House 03/01/06

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 Ken Hague Unannounced 26 July 2005 @ 8am 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 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 Stationary 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 C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 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 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 PC Care Home Only 8 Category(ies) of LD - Learning Disability - 8 registration, with number of places Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 7 March 2005 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 service users with a learning disability who are under the age of 65. The home is set just off the seafront in 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 service users to take part in day activities and there is a local day centre in Orby, which can be attended by service users, if they so wish. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took between 8am and 1pm. The main method of inspection used is called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. A tour of the premises was conducted and care records were inspected. One member of staff and three service users were interviewed. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4&5 There are satisfactory procedures for the introduction and assessment of people to the service, ensuring that care needs are met. The home provides potential service users with information which allows them to make an informed choice before choosing to stay at the care home. EVIDENCE: The home has a statement of purpose, which allows potential service users to identify the resources of the care home. This enables them to make an informed decision whether the resources and facilities can meet their needs. In addition, Boulevard Care have a ‘service user guide’, which is written in plain English and is given to new service users when they come to stay at the care home. Care records seen for individual service users all contain a full detailed initial assessment including a risk assessment. This information was then transferred onto care plans, which included any risk management for an individual service user. This provides staff with the essential information to provide safe care and to take into account the choices and wishes of individual service users. Staff were able to describe individual service users needs in formal interviews. The information they gave corresponded with that recorded on individual service users care plans. Staff stated all new service users are offered the opportunity to visit the home prior to making any decision to be admitted. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7&9 Care plans are written from the information attained at the initial assessment. They are written to a standard which exceeds the National Minimum Standards. Risk assessments are of a good quality. Staff ensure that the needs of individual service users are met while considering their choices and wishes regarding the manner in which personal care is provided. EVIDENCE: Each service user has an individual plan which contained detailed information relating to their care needs. This is presented in a format which is easy to follow by staff. The care records provided evidence in the form of signatures and comments that service users are directly involved in their reviews. Staff stated relatives of service users are actively involved in the writing of care plans and in reviews. Service users confirmed this statement to be correct. The care records contained very detailed recording in respect of the provision of health care services. There were details of appointments made for dental care, eye care and chiropody recorded on the individual service users files. The service users choices in relation to bathing was recorded which included whether a bath or a shower was preferred and if staff supervision was agreed with the service users. Another file contained the instruction “this service user requires a shower on a regular basis. He requires prompting to clean all areas of his body. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 9 His nails must be cleaned once a month he likes them tidy and short at all times. He prefers to use an electric razor and no supervision is required.” The individual choices of activities are recorded on personal care plans. One service users care plan states “likes to use computers, watch alien films. Enjoys music, animals, likes his food and has set himself a personal goal to walk to the shops without staff supervision”. A risk assessment has been carried out for the service user who wishes to shop without supervision. The management of that risk is that the service user will carry a two-way radio which keeps him in permanent touch with staff at the home. In addition, there is an agreed time period for that service user to be away from a home before staff should be concerned. A second service user who has very limited eyesight still wishes to go out into the community unsupervised. The risk assessment states this would be unsafe in respect of the risk from road traffic. The management of that risk is for staff to arrange transport to the place where he wishes to take part in activities and collect him at an agreed time. This allows him to visit local pubs and restaurants without supervision. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12,13,14,16,17. A wide range of activities are available for service users to participate in, ensuring that they have an enjoyable and stimulating lifestyle. Catering arrangements reflect service users preferences and choices. EVIDENCE: Staff stated that there are activities held at the care home which include barbecues, visits to local restaurants and outings to places of interest. Service users can attend local leisure centres and further education opportunities are offered through colleges and the Orby day centre. Service users interviewed confirmed this to be the case. Service users are encouraged to maintain their own individual skills by carrying out small domestic tasks and taking responsibility for their own individual bedrooms. There are TV and video equipment in the lounge of the care home. Some service users have their own TV, video, DVDs in their bedrooms. Service users stated that the food provided is good and enjoyable. A service user stated his likes and dislikes in relation to his diet. These details were recorded on his individual care file. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 The home consults with service users in agreeing the manner in which personal care and support is to be given to each individual. Service users physical, emotional and health needs are being met by the home by using community services, consultants and GPs. EVIDENCE: Care plans contained details of dental care, eye care and chiropody. A service users file contained details of hospital appointments this information was confirmed to be correct by the service user. The homes medication policy is being followed by staff. In discussions with staff they explained how medication was administered and confirmed that no service user in a home at present is self-medicating. They confirm that the home has a policy for self medication which includes a risk assessment. A file details the triggers and indicators for a service user who can become distressed while personal care is being provided. The management of this problem is detailed it includes a structure process of reducing his anxiety reassuring him to enable staff to complete the personal care task. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has robust procedures for handling complaints and allegations of abuse. Staff were clear on the action to take in the event of them having any suspicion of abuse taking place. EVIDENCE: The home has a complaints policy and a vulnerable abuse policy which meets the National Minimum Standards. A copy of the Lincolnshire County Council Vulnerable Abuse Policy is kept in the office. Staff confirmed that they have been provided with training in the recognition and prevention of abuse. A member of staff interviewed explained the company’s abuse policy and stated she would report any incident immediately to her line manager. The home has received no complaints since the last inspection. The home holds service users meetings. Staff stated that they speak to service users on a daily basis obtaining their views regarding the provision of services. These comments are referred back to the acting manager. A Service user stated “ I can talk to staff if I am unhappy or concerned”. A second with service user stated. “I feel very safe living in this home”. The staff were able to discuss the wishes and opinions of individual service users. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,30 The standard of the environment within this home is good, providing service users with a comfortable and homely place to stay. EVIDENCE: The home was clean and well decorated. All furnishings are of a domestic nature. There is a patio and large garden to the side of the property. Service users said that they liked the home and were happy with their bedrooms. Two bedrooms were inspected and found to contain personal items. Service users stated that they are encouraged to take responsibility for their own bedrooms with the support from members of staff. Service users were observed to take pride in the appearance of their own room. They stated they were very happy being able to personalise their own room. One service user showed the Inspector additional lighting which he had added to the use with his hi-fi system. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 &36 Service users feel that competent, caring and considerate and well trained staff are meeting their needs. The manager ensures that staff are recruited safely by following the recruitment policy of the home which meets the National Minimum Standards. EVIDENCE: Service users stated that staff are kind and helpful and are available when help is requested. A recruitment file for a new member of staff provided evidence that the recruitment policy of Boulevard Care is being followed. This policy meets the National Minimum Standards. The companies training plan provided evidence that staff are being provided with training to ensure they can meet the needs of service users who fall into the registration category of the home. There was one service user who became distressed and displayed difficult behaviour during the inspection. The staff were observed to follow the risk management identified in his care plan and the situation was calmed down quickly in a sensitive and professional manner. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42 An acting manager manages the home. Staff stated that he is supportive and approachable. Staff are receiving supervision and appraisals in accordance with the National Minimum Standards. The homes staff follow the health and safety policy of the company. EVIDENCE: There were no health and safety issues identified at this inspection. Staff confirmed that they are being provided with supervision and an annual appraisal. The inspection and supervision records provided evidence that the National Minimum Standards are being met. Staff stated that the acting manager is approachable and will discuss any concerns with any member of staff or service user. The home holds service users meeting. Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willoughby House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 17 yes 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 Regulation none Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard none Good Practice Recommendations Willoughby House C04 C53 S2479 Willoughby House V240001 26-705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 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. 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