CARE HOME ADULTS 18-65
Willow Bay 11 Marine Approach Canvey Island Essex SS8 0AL Lead Inspector
Patricia Stanton Key Inspection 24th July 2006 09:30 Willow Bay DS0000018027.V300436.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 Willow Bay DS0000018027.V300436.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. Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Willow Bay Address 11 Marine Approach Canvey Island Essex SS8 0AL 01268 694759 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) Kingswood Care Services Limited Manager post vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Personal care and accommodation may be provided for up to 5 service users of either sex who are aged from 18 - 65 years. Personal care and accommodation may be provided for up to 5 service users who have a learning disability. 6th March 2006 Date of last inspection Brief Description of the Service: Willow Bay provides residential accommodation and care for five female adults with learning disabilities. The home is situated in Canvey Island, close to local shops, transport, seafront and includes two lounges, large garden, dining room, kitchen, five single bedrooms, three with en-suites and one communal bathroom. There is off street parking to the front of the home, with room for two vehicles. The home provides transport for residents. Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The routine key unannounced inspection took place on the 24/07/2006. The home accommodates five residents, two who were spoken to plus three staff members and the new acting manager. Records and documents were looked at including requirements from the last inspection. Time was spent in the lounge and hall with residents taking note of their daily lives. The inspector would like to take this opportunity to thank the residents’, staff and acting manager for their cooperation during the inspection. What the service does well: What has improved since the last inspection?
The acting manager has progressed the home empowering staff to utilise their individual skills and enhance their awareness of residents needs. The home has an excellent key working system. The home has sought advice regarding food in the home and introduced healthy eating plans for residents who require them resulting in a better outcome for residents’ health. Care plans have improved and are reviewed regularly to include residents changing needs. An independent advocate is available for residents who require the service. Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 6 Residents’ benefit from incentives for healthy eating, which is not food based and staff meetings now include staff views and opinions. Medication records evidenced the amount of stock returned to pharmacy. Staff supervision has started to help identify training needs. The home now has a homes assistant manager and key workers have introduced photo diaries for residents, which reflect residents’ progress in relation to social and emotional progress. The home has received three compliments since the last inspection regarding good quality care. New staff employed in the home have good induction training with appropriate support. The home has improved communal space for residents and made administration files more accessible to staff. The home has fitted an appropriate lock for easy access in the event of a fire in the garden. 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. Willow Bay DS0000018027.V300436.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 Willow Bay DS0000018027.V300436.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): 1,2,3, Relatives have the relevant information to make a choice about the home prior to admission to help them identify individual needs in relation to residents but the homes service users guide has not been updated in a suitable format for residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. EVIDENCE: The home has started to produce a pictorial format service users guide for residents, which includes photos of staff/residents, how to complain to the CSCI but this was not complete at inspection. Residents appear to enjoy fulfilling lives with the support of staff that encourage them to participate in recreational activities and personal interest. Many residents attend educational schools/colleges and enjoy days out, annual holidays and time in the community. Residents have individual activity plans. Willow Bay DS0000018027.V300436.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): 6,7,8,9,10. Care plans reflect the needs of residents’ who are consulted and supported on all aspects of care including reviews, however, consultation could be improved with regard to quality assurance. Care plans and risk assessments are regularly audited to ensure they meet residents changing needs. Recreational activities offered at the home are individualised and varied. Personal files are currently not stored securely. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this home. EVIDENCE: Residents are consulted on a one to one basis in reviews, meetings and in the home key working system. One key worker has produced with the help of the residents a picture story file of notable events in her life. Files seen included annual holidays, steps in choosing, buying and decorating her bedroom and a picture file evidencing the residents recreational and education achievements. Files were stored in the residents’ room so that these could be seen at any time by the resident who liked to share them with friends and family.
Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 10 The acting manager stated the files were to be introduced for all residents following its popularity. Care plans examined were detailed and included all aspects of residents needs including social, emotional, self help, communication and behavioural patterns’ with information regarding residents’ needs to help staff identify and deliver appropriate care as deemed appropriate by the placing authority. Reviews were completed regularly and included residents and families. One independent advocate had also been invited to a review and plans included residents’ goals with information regarding their daily life and personal interests. Files confirmed residents attend local colleges, schools to continue education and enjoy going out with staff in the community. Residents enjoy various annual holidays. This year residents were going to Norfolk for one week. The home provides transport to take residents out and staffing is arranged according to risk assessment. Evidence was seen in minutes of residents meetings that a sensory garden was requested by one resident and during inspection this was seem by the inspector. Minutes also confirmed residents were asked their opinion regarding the changing of the office location in the home. The staff meetings are recorded in a suitable pictorial format using symbols and signs. Willow Bay DS0000018027.V300436.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): 11,12,13,14,15,16. Residents have good access to the community and leisure activities plus appropriate social contact with family and friends. Residents are able to develop personal skills and interest in the home and have their needs respected in relation to daily life skills. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. EVIDENCE: Each resident has an individual activity plan that is varied and age appropriate. Residents’ activities reflected their personal interest such as keep fit, swimming, bowling, daily living skills, shopping, cooking, evening walk, top cat club, parachute games and social club. One placing social worker stated “My client is happy and contented in the home and has bonded with staff benefiting from the high staffing levels, social events and community placed activities offered”. Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 12 Residents have use of a variety of activities in the home and garden. At inspection residents watched TV listened to music and had access to a large garden with trampoline and paddling pool. One resident enjoyed listening to her favourite boy band in the lounge. The home accommodates residents in wheelchairs and although the garden has a wheel chair ramp it does not have a path to take residents around the garden. The acting manager stated the home had requested completion of a path by 2007. Residents participate in daily living skills within their capabilities and are offered services related to their religion if required. Residents have good access to family and friends who are encouraged by staff to maintain contact with residents. Evidence was seen in files of residents having family and friends over to the home to visit. Residents now have the opportunity to entertain relatives or friends in private in the small lounge area. Willow Bay DS0000018027.V300436.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. Residents receive personal support and appropriate health care and administration procedures for medication have improved. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this home. EVIDENCE: At inspection all residents looked happy and healthy. Care plans confirmed residents receive appropriate health care from medical professionals and one file examined confirmed the resident received care from medical professionals, optician, doctor, dentist, chiropodist, psychiatrist and occupational therapist. Staff receive training to ensure they are able to care for residents with medical conditions such as epilepsy and at inspection one staff member was observant in noticing trigger signs for one young lady who was developing a seizure. Staff reassured the resident and kept her calm during the seizure observing and timing the seizure to ensure she recovered. It was noted staff made appropriate recordings. Residents receive personal support from staff and at inspection communication between staff and residents were mutually respectful ad caring. The home operates a key working system and evidence was seen in one file of excellent key working work with residents.
Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 14 Medication was not inspected on this occasion but the acting manager stated staff now sign for medication returned to the pharmacy. The home has rearranged the homes office and small lounge to make the administration procedures more accessible but had yet to change the location of the medicine cabinet and key cabinet. This should be given urgent attention as the cabinet, although secure, is stored in a communal lounge. Willow Bay DS0000018027.V300436.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. Residents are consulted but this could be extended to quality assurance monitoring. Residents are protected from abuse and neglect. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. EVIDENCE: Staff are trained in Protection of Vulnerable Adults. One new staff member was aware of the signs of abuse and the procedures for reporting abuse, able to respond appropriately to a scenario given by the inspector. The staff member stated she had received training in whistle blowing and would report any concerns to the CSCI. Staff also accommodate residents with challenging behaviour and receive appropriate training to help them take appropriate action. The home has received no complaints since the last inspection but had received three compliments from grateful relatives. The home does not keep regular details of all visitors to the home, which may jeopardise residents’ protection. Willow Bay DS0000018027.V300436.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): 24,27,28,30. Residents live in a clean homely environment, which is safe and decorated to a high standard. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this home. EVIDENCE: The home was very clean, welcoming, bright and comfortable decorated to a high standard with resident bedrooms personalised and decorated to their individual taste. The lounge is bright but the suite was worn and stained and in need of attention. However, the rest of the home was in a very good condition. Residents’ rooms were personalised containing good quality furniture and fittings. Willow Bay DS0000018027.V300436.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): 31,32,33,35. Staff are competent, dedicated and appropriately trained to meet residents needs. Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this home. EVIDENCE: Staff working in the home work hard to meet the needs of residents accommodated and the current core staff team work well together along with the acting manager who appears popular with the staff and residents. A resident appeared happy with staff and communication although limited was mutually positive and respectful. The home currently has only one full time vacancy and agency workers are seldom employed. The home is registered to accommodate only 5 residents. The number of staff on duty appeared sufficient to meet residents’ needs and the staff rota matched the numbers of staff on duty. Minutes of staff meetings evidenced staff are able to voice their views and opinions. Minutes are read and signed by all staff to evidence inclusion. Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 18 One new staff member confirmed the acting manager is always available and stated she had received two weeks pre employment training plus worked supernumerary for the first two weeks when in the home. The staff member had also had one formal supervision session from the acting manager since employment in April 06. Staff receive regular training in all health and safety aspects and are encouraged to attend all meetings and training. Some staff are currently undertaking NVQ training. Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42,43 The acting manager who runs the home ensures residents’ needs are met and has progressed the home since the last inspection. The acting manager has the appropriate experience to manage the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. EVIDENCE: The acting manager has made improvements in the home to improve outcomes for residents, which is run in their best interests. The acting manager is currently undergoing NVQ level care management training and is scheduled to complete this in 2007. All staff were very happy with the homes management who appeared capable and efficient. The registered provider has not completed any regulation 26 visits to the home and the quality assurance survey completed by Kingswood services does not include the views and opinions of residents. Various ways of seeking residents’ views was discussed with the acting manager during inspection.
Willow Bay DS0000018027.V300436.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 3 2 3 3 3 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 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 4 34 X 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 X X 3 X 3 3 X 3 3 Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 21 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 YA10 Regulation 17 1 (a) Requirement Files must be stored in line with the data protection act 1989. Timescale for action 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 3 4 5 Refer to Standard YA39 YA1 YA30 YA24 YA29 YA42 Good Practice Recommendations The homes quality assurance should include residents’ opinions. The service users guide should be in a suitable format. The homes medication cabinet should be installed away from residents and their relatives. The home could renew the homes worn suite in the lounge. The home could create a path for wheelchair access for the garden. All visitors should sign in and out of the home. Willow Bay DS0000018027.V300436.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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