Inspection on 27/06/05 for Willow Bay

This inspection was carried out on 27th June 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow Bay 19/06/07

Willow Bay 24/07/06

Willow Bay 06/03/06

Willow Bay 02/11/04

Willow Bay 18/06/04

Willow Bay 01/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Willow Bay 11 Marine Approach Canvey Island Essex SS8 0AL Lead Inspector Patricia Stanton Unannounced 27th June 2005 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. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 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 Mrs Susan Christine Paisley CRH 5 Category(ies) of Learning Disability (LD) 5 registration, with number of places Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 27/6/05 Brief Description of the Service: Willow Bay provides residential accommodation and personal care for five adults with learning disabilities all of whom are female. The home is situated close to local shops, facilities and the seafront. The home is owned by Kingswood Care Services Limited. The home’s facilities include one large lounge, with a view of and access to a well kept garden, a dining area, kitchen, five single bedrooms, three with ensuites 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 the shared use of residents. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The routine unannounced inspection too place on the 27/6/2005. During the inspection thirty-eight out of forty two standards were inspected. One staff member gave the inspector a tour of the premises and records and documents were looked at, including the previous requirements and recommendations from the last inspection. Time was spent in the lounge, kitchen and dining area chatting and taking notes from young adults daily routine in the home. The staff and in particular the senior carer in charge on duty, were most helpful, and this was greatly appreciated. The home accommodated five residents four of which are unable to verbalise conversation. The inspector spoke to two of the residents, one relative, three staff members including an agency carer, deputy manager and the senior carer. The inspector would like to thank Willow Bay residents, their relatives and the homes staff for their time and cooperation during the visit. What the service does well: The service works well in ensuring that residents live in a good quality home, which is decorated to a high standard. The home provides leisure pursuits including transportation for residents. The homes statement of purpose is detailed and includes a service users guide in a suitable format to suit residents. The home seeks speedy professional medical support and monitors residents’ welfare. Residents are able to participate in daily living skills within their capabilities. Stable core staff understand the needs and wishes of residents. Visitors are able to visit at any time of the day and are kept informed of changes within the home. The residents participate in hobbies and leisure activities outside the home. Recruitment practices ensure residents are kept safe. Staff have good regular training in health and safety. Food provided to residents is fresh, varied and nutritious. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 6 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. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4. Residents and relatives have all the information they need to make an informed choice regarding the home and know their individual needs will be met prior to admission. The homes staff carry out full assessments prior to admission taking into account suitability and other residents needs. Residents are able to visit and stay over night prior to moving into the home. EVIDENCE: Care plans and relatives confirmed residents are able to visit the home prior to admission and stay overnight if required on a number of occasions to determine suitability, before moving into the home. The pre assessments plans seen in sampled resident’s files were thorough and comprehensive containing assessments for residents, social, behavioural, self-help, leisure, educational, communication, contact and health needs. This is good practice. The home has a detailed statement of purpose with clear details of the service with a suitable service users guide for residents in a suitable format including pictures and details of how to complain. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 standard(s) 6,7,8,9,10. Residents know they’re changing needs including personal goals will be reflected in individual care plans giving residents the opportunity to make decisions about their own lives within their own capabilities with support of their relatives and the homes staff. Residents are sometimes consulted and participate in aspects of life in the home to make decisions and take risks as part of their independence. Information about residents is handled within guidelines of the data protection act 1998. EVIDENCE: The care plans sampled were detailed evidencing residents’ participation in care planning process. In addition the plans were supplemented by clear management guidelines and full risk assessments enabling residents to participate in daily living skills and activities to achieve personal goals and achievements. The risk assessments on file were clear giving staff guidance on actions to be followed to minimise the likelihood of identified risk. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 10 Staff at inspection appeared to have a good understanding of care plans and risks to residents. Residents participate in meeting to seek their views and opinions and minutes were recorded in pictures but only one meeting had taken place this year. The senior carer stated relatives have input into the residents’ lives enabling them to make decisions. No resident currently has an independent advocate. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 standard(s) 11,12,13,14,15,16,17. Residents have opportunities for personal development and are supported to take part in peer and culturally appropriate activities in the community. Residents take part in a variety of activities to suit their needs and have good personal inks with family and friends. Residents right are respected. The home offers residents a healthy diet, which they enjoy. EVIDENCE: One resident loved to go horse riding each week, another residents liked to visit the sports and participate in educational courses at college. Activities residents attended included local clubs, pubs, swimming, shopping and bowling. Residents have a choice regarding participation in activities and one relative and care plans confirmed residents are given the opportunity and allowed freedom in respect of engaging in activities and times they go to bed and get up in the morning. Residents had been on annual holidays to Euro Disney and Norfolk and have access to a beach hut at Southend. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 12 One relative stated the staff understand not to pressurise my daughter into participating in activities if she is not in the mood, because she will retaliate and become distressed. Care plans evidenced staff awareness of the resident’s behaviour and relevant trigger factors. This is good practice. Another carer stated one resident had a petit mal seizure during inspection, which could be a trigger another. It was noted however during inspection the television was on with the radio at the same time in the lounge. Residents did not appear interested in the programme on TV and radio. Staff should ensure non-verbal residents have priority choice in the home. Residents have good family links but do not have independent advocates to help them make decisions for themselves. The menus examined at inspection were varied and nutritious offering choice and alternatives. Food stocks examined confirmed fresh food was readily available and residents were able to help themselves to drinks and snacks as required. Fresh fruit and vegetables were in good supply in the home. One resident stated the food was good and a relative stated, “the homes food was lovely, and the home offered her dinners when she visited”. One resident who arrived home from a sport centre at inspection was encouraged to make herself a cup of tea with support from staff and was allowed access to snacks because she was particularly hungry. Staff understood the individual’s increased appetite following her morning’s exercise. This is good practice. Residents diet intake is recorded and residents are weighted monthly. One parent whose daughter was unable to be weighted due to her skeletal posture confirmed her daughters weight appeared consistent. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 standard(s) 18,19, Residents receive personal support as they prefer and require and have their physical and emotional needs met. EVIDENCE: Staff were supportive to residents at inspection and communication was positive and mutually respectful. One relative stated, “Staff are brilliant and do their utmost to meet my daughters needs working around her. I feel they know her and her moods and understand when she does not wish to be handled. They read her brilliantly”. Staff assist residents to participate in physical activities i.e. swimming, bowling, personal care and support them emotionally along with relatives and other health professionals. At inspection one resident was preparing to visit a specialised hospital with her mother for a scan. The home had made all appropriate arrangements including refreshments for the journey with transportation. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 14 One resident had access to a psychotherapist and another to alternative therapy i.e. aromatherapy to assist in relaxation techniques. The home also has a relaxation rooms for residents to sit in away from the communal lounge, which includes sensory equipment, music and a fish tank. Staff were observed to be very caring and kind to residents at inspection and daily care notes evidenced residents are supported. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 standard(s) 22,23. Residents are listened to but this could be improved. Residents are protected from abuse by good recruitment practices and the home has an appropriate policy regarding adult abuse. EVIDENCE: Staff individually listen to residents and their relatives but this could be improved with the increase in resident meeting and ongoing reviewing including questionnaires for residents and relatives. The home could also introduce independent advocates to ensure resident’s rights are protected. Minute’s evidence residents wished to make pancakes and choose a holiday but no details of action taken was recorded. However residents do participate in cooking and have access to regular annual holidays. Staff spoken to including agency staff, were conversant with the signs of abuse and the procedures for reposting abuse in the home. The home has received no complaints since the last inspection. Records for accidents and incidents were examined at inspection and no anomalies found. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 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 standard(s) 24,25,26,27,28,29,30. The home is decorated to a high standard, comfortable and safe with bedrooms to suit individuals’ needs. The home has good quality furniture, shared space and sufficient bathrooms and toilets to provide privacy. The home provides specialised equipment for less able residents. The home is clean and hygienic. Fire access from the garden needs to allow easy access in case of emergency exit. EVIDENCE: The home was clean bright and decorated in a modern style to suit the age group of the home’s residents. Residents have good-sized bedrooms and quality furniture to suit their needs. Rooms appeared to be personalised and residents can choose colours décor to suit their individual taste. Rooms appeared bright colourful and individualised decorated to a high standard. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 17 The home provides specialist equipment for residents including wheel chairs and hoists, which were seen to be in good working order at inspection. Some bedrooms have soft foam mattresses placed on the floor to help cushion the floor for residents around their bed. The home now has a stair lift and walk in shower for wheel chair users with a ramp for wheelchair access at the front and rear of the premises. The homes rear garden was large and contained garden furniture and chairs for residents use. The home has two sheds to store equipment. The home has a paddling pool for residents but this needs to be repaired. The side gate in the garden is locked and not all staff has a key to the gate. This may hinder fire evacuation. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 18 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) 32,33,34,35,36. Residents are supported by competent staff that work effectively together to meet residents joint needs. Staff receive regular supervision by the homes management and staff recruitment is robust to protect resident’s welfare EVIDENCE: Staff at inspection appeared competent and able to meet the need of the residents. At inspection the senior carer assisted in the inspection process effectively and had a good knowledge of residents individual needs. One agency staff working in the home had appropriate checks and training completed and felt supported by the homes staff. The support worker stated staff were friendly and showed her around the home when she started and stated she had completed with her agency appropriate TOPPS induction, programme which included all health and safety plus training in epilepsy and protection of vulnerable adults. The support worker was able to identify types of abuse and procedures for reporting abuse clearly. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 19 The staff rota was examined and reflected the numbers of staff on duty at inspection. The rota contained some errors using white correction paint. The home employs seven staff members with NVQ level 2. Five staff members work in the morning; plus four in the afternoon and the homes employs two night waking staff. Staff files confirmed staff have checks and appropriate identification and references along with records of completed training in health and safety, first aid epilepsy, visual sensory awareness, medication, autism, rectal diazepam administration, challenging behaviour, conflict management, mobility awareness, incontinence, basic skills, learning disability, communication, fire, food hygiene, a key working to ensure staff are trained to meet all residents needs. Staff files confirmed staff receive regular formal supervision. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 20 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) 37,39,40,41,42. The home is run well but residents and their significant others views and opinions are not regularly evidenced. The home safeguards residents’ best interest with appropriate policies and procedures in place, which need to be individualised and reviewed regularly. The home competent management team protects residents’ health, safety and welfare. EVIDENCE: The homes’ manager was not available at inspection but staff stated the registered manager is supportive and approachable. The home needs to try to seek non-verbal residents views and opinions with evidence of this with actions taken to meet their needs. The home has a quality assurance system, could be extended to include views of residents, their relatives and other health professionals including placing social workers. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 21 The manager ensures all staff have appropriate training to ensure the health and safety of residents. Staff appeared competent and conversant with the homes policies and procedures but these were not recently updated or individualised for non-verbal residents at Willow Bay. The registered manager is currently undertaking NVQ level 4 in care management and has appropriate deputy managers to cover in her absence to enable continuity of care. The home appeared to be managed well to benefit residents at inspection. Willow Bay I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 22 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 3 4 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willow Bay Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 3 2 3 3 x I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 23 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. 2. Standard YA22 YA40 Regulation 12 (2) 24 20 (3) Requirement The home must evidence non verabl residents views and opinions. The homes policies and procedures must be updated regualry and individualised to the home. White correction fluid should not be used on staff rotas. The homes garden gate should be open to all staff in the event of emergency fire evacuation. Timescale for action 1/8/05 1/10/05 3. 4. YA31 YA42 23 4 (b)13 4 (a)(c) 1/8/05 1/7/05 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. 4. Refer to Standard YA22 YA22 YA24 YA39 Good Practice Recommendations the home should appoint advocates for residents accomodated. The home should hold regular meetings with residents to seek their views and opinions with action evidenced. The home paddling pool should be repaired for residents use. The homes quality assurance should include residents and placing social workers opinions. I56-I06 S18027 Willow Bay V236214 200605 Stage 4.doc Version 1.40 Page 24 Willow Bay Commission for Social Care Inspection 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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