Inspection on 03/01/06 for Willoughby House

This inspection was carried out on 3rd January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willoughby House 18/09/06

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 3rd January 2006 09:30 Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 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 Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 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 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. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place between the hours of 13:40 and 17:00. A tour of the building took place and care records were inspected. The main method of inspection used is called ‘case-tracking’; this involved selecting two residents and tracking the care they received through the checking of their records, discussion with the residents, care staff and observation of practices. A sample of care records, policies and procedures were examined. The Acting Manager was present throughout the inspection. 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 DS0000002479.V275974.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 &5 Prospective residents are assessed and assured that their needs can be met before they are admitted. EVIDENCE: There is a statement of purpose and service user guide, which is used in all Boulevard Care homes. These two documents both meet the National Minimum Standards. The acting manager stated that these documents have been reviewed and are to be re-issued in early 2006. A copy of the statement of purpose was seen to be displayed in the office. The acting manager stated that the service users guide is given to all residents at the time they are admitted to the care home. A copy of the terms and conditions for resident stays at the care home were found on individual resident’s files. The acting manager stated that all new residents receive a full assessment and are invited to visit the care home prior to be admitted. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Care plans contain sufficient information to ensure that the care needs of Residents are met during their stay they included evidence of the involvement of residents or their representatives. Risk assessments are of a good quality, there was evidence of risk assessments being reviewed and amended as resident’s needs changed. EVIDENCE: The files of the three residents being case tracked all contained the personal aspirations and goals of the residents. In one case a resident’s wishes and goals were recorded but it was acknowledged by the resident and staff that some of these goals may not be achievable. There was evidence that care plans and risk assessments are being reviewed at the frequency set out in the National Minimum Standards. A resident’s care records stated that his physical condition had deteriorated his risk assessment had been adjusted to ensure a new risk have been reduced or removed. One resident had taken part in a formal review and the records demonstrated that his wishes in respect of social activities have been considered in detail. The resident had requested to be allowed to go into the community unsupported by staff. The risk assessment demonstrated that this was unsafe due to a health problem. An agreement was reached at the end of this review which satisfied the resident and the care home. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 A wide range of activities is available for residents to participate in, ensuring that they have an enjoyable and stimulating stay. EVIDENCE: The acting manager stated that activities are organised in the home, in the community and at the Orby Day Centre. A weekly activity programme which rotates over a two-week period was seen for the residents being case-tracked. Residents confirmed that the information on activity programme was correct. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &20 Resident’s health, personal and social care needs are set out in their individual care plan. Health care needs are fully met. Residents are protected by the home’s policies and procedures for the storage and administration of medication. EVIDENCE: The home has a medication policy, which meets the National Minimum Standards. Staff confirmed that they have received training in the administration and management of medication. A resident being case tracked is a diabetic. He manages his own insulin with the supervision of care staff. The individual residents files seen during this inspection all contained details of the input from community health services to the individual residents. These services included hospital consultants, GPs and district nurses, chiropodist, dentist and opticians. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 11 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 Residents and their relatives can be confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: The company has an abuse procedure, which meets the National Minimum Standards. A copy of the Lincolnshire County Council’s Vulnerable Abuse procedure was seen to be in place at the care home. No complaints have been received by the home or the Commission for Social Care Inspection since the last inspection in July 2005. Residents stated that they were aware of the complaints procedure and were confident in being able to make a complaint. Staff stated in their formal interviews that residents meetings are held at the home. Residents confirmed this statement to be correct. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 12 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 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 of the care home was made and all areas were found to be clean and smelt fresh. There was evidence of ongoing maintenance being carried out to the building, a new fire door had been fitted the fire escape had been checked steps repaired and repainted. A walkway at the side of the home has been resurfaced. The driveway has been extended and covered with new stones. A number of resident’s bedrooms were seen, they were all found to be furnished in accordance with the National Minimum Standards. Residents stated their satisfaction with their own individual bedroom. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 13 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 The acting manager is following the recruitment policy of Boulevard Care Ltd, which meets the National Minimum Standards. All staff have received supervision and appraisals. EVIDENCE: The recruitment files of three new members of staff were inspected. They all contained the appropriate information required by the Care Home Regulations before a member of staff is offered employment. It was recommended to the acting manager that he reviews the manner in which information is filed. It would be beneficial to have a single recruitment file with information stored in a consistent manner. The acting manager stated that all staff receives supervision and appraisals in accordance with the National Minimum Standards. The inspection of staff files and discussions held with staff confirmed that this statement was accurate. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 14 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 The home is run in the best interest of residents. All staff are following the health and safety policy of the care home. There are policies and procedures in place to ensure that all residents are protected from any potential harmful situation. EVIDENCE: Staffing rotas provided demonstrated that the home was meeting the minimum staffing levels with an adequate mix of qualified and care staff on duty 24 hours a day. The member of staff interviewed confirmed that the staff in rota is always followed. He stated appropriate notice is given to all staff in respect of future shifts. In his opinion the home is a safe environment in which to work and there are always sufficient staff on duty to provide safe care. The inspection of the homes policy and procedure manual provided evidence that there are policies and procedures in place to ensure that residents are protected from any harmful situation. The acting manager confirmed that training had been provided in the identification and management of the abuse. A member of staff described the action he would take if he was suspicious of abuse taking place within the care home. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 15 This action conformed with the instructions set out in the homes procedure manual. Staff stated the acting manager is very supportive to all staff. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 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 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x 3 x 3 x x 3 x Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations It is recommended that the home reviews it’s recruitment records to ensure that all information required for inspections is kept in a structured manner and is available. Willoughby House DS0000002479.V275974.R01.S.doc Version 5.1 Page 18 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.V275974.R01.S.doc Version 5.1 Page 19 - 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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