Inspection on 06/03/06 for Willow Bay

This inspection was carried out on 6th March 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 found no outstanding requirements from the previous inspection report, but made 1 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 27/06/05

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 Announced Inspection 6th March 2006 11.00 Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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.V265514.R01.S.doc Version 5.0 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.V265514.R01.S.doc Version 5.0 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 Mrs Susan Christine Morford Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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. 27th June 2005 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 close to local shops, transport, seafront and includes one lounge, large garden, a small music/quite room, 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.V265514.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on the 06/3/2006. Records and documents were looked at, including the previous requirements and recommendations from the last inspection. As part of the inspection process questionnaires were sent out to relatives and visiting professionals prior to inspection. Five questionnaires were returned and details are included in the report. Time was spent in the lounge, kitchen and dining area chatting and taking note of residents daily routine in the home. The home accommodates five residents, four of which are unable to verbalise. The inspector spoke to three residents, one relative, five staff members, the acting manager, the director and registered provider of Kingswood Care services. Staff in particular the new acting manager was most helpful, and this was greatly appreciated. The inspector would like to thank Willow Bay residents, their relatives and staff for their time and cooperation during the visit. What the service does well: What has improved since the last inspection? The home has updated its statement of purpose with management and staff changes. A personalised quality review has been completed which includes relatives’ views and opinions. The new acting manager is training to NVQ level 4 and has worked hard to meet the needs of residents. Minutes evidence residents’ views and opinions and the home has improved the homes health and safety. Daily living skills for residents have improved and staff have more input into working hours and how they deliver care. Staff receive regular supervision and support. The home has purchased new equipment to assist less able residents. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 Page 6 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.V265514.R01.S.doc Version 5.0 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.V265514.R01.S.doc Version 5.0 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 The home service users guide is not in a suitable format for residents accommodated. EVIDENCE: The home is currently putting together a new guide for residents, which includes pictures and symbols. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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 Residents changing needs are assessed in individual care plans and residents and their relatives consulted on decisions made in the home. EVIDENCE: Examined care plans evidenced residents receive regular reviews every six months and appropriate professionals attend, including the resident and their family whose opinions are taken into account when making changes to care. Minute’s evidenced residents have a choice in activities and holidays. Staff discuss the type of activities with residents using pictures and symbols as reference and then observe their comments and actions when deciding a programme of activities for residents. One relative told the inspector staff have a good understanding of my daughter and know when she does not want to do something. They respect her wishes and always involve us in decisions regarding her care. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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 the following standard(s): 17 The home offers healthy meals but the low fat diets for residents could be improved. EVIDENCE: The food stock and menus evidenced residents receive fresh and varied nutritious meals but one resident who had gained weight since living in the home was having problems with her breathing and had been put on a low fat diet by staff, however the diet intake records confirmed the resident did not always eat low fat meals. Records evidenced in one week the residents ate chips twice, once with rice, steak and kidney pudding, puddings and chocolate spread on toast and chocolate snacks for supper. Weight records confirmed the resident weight continued to increase. Staff had purchased low fat chocolate snacks and crisps for the residents but these were not restricted. At inspection residents were seen to eat healthy food and help themselves to drinks when required. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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 the following standard(s): 20 Medication administration procedures in the home are appropriate and protect residents. EVIDENCE: Medication stocks examined confirmed residents receive medication, as prescribed and stock numbers were correct in date and stored appropriately. Records of staff signatures were seen with appropriate medication stock returns book kept however no signatures were seen to evidence the amount of stock returned to the pharmacy. The acting manager stated this was because the stock is taken to another Kingswood Home for collection. Files confirmed residents have regular medication reviews. The home has an appropriate policy and procedures for administration of medication. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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 the following standard(s): 23 Residents are protected from abuse neglect and self-harm. EVIDENCE: The home has received no complaints. Incidents and accident files were examined and confirmed residents are protected them from harm. The homes vehicle had recently been involved in a road traffic accident and action was taken by staff to ensure residents were examined and checked by medical professionals. The home completes regular regulation 37 notifications for all serious incidents in the home. Staff receive regular protection of vulnerable adults training and conversant with the signs and types of abuse and the procedures for reporting abuse. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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 the following standard(s): 24,29,30. The home is homely, comfortable, clean and hygienic and provides specialised equipment to maximise residents’ independence. EVIDENCE: The home is decorated to a high standard, personalised providing adequate space for residents. Residents are happy with their bedrooms and the amount of bathing facilities. The home has purchased a new portable hoist for residents, which is housed above the bath and does not take up space in the bathroom. Staff demonstrated how the hoist worked at inspection and stated how popular it was with residents. The house is homely and includes pictures of residents and staff with facilities for residents to choose meals using picture boards. The home has a notice board for residents, which includes details of who to speak to if they are sad or unhappy. The rear garden gate now has a combination lock for staff to use in the case of emergency evacuation. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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 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): 35 Appropriately trained staff meets residents’ needs. EVIDENCE: Residents’ benefit from living in a home that has a low staff turnover and staff appeared to be kind, caring understanding residents’ individual needs. It was observed the communication between staff and residents was mutually respectful. Comments from one relative and a health professional included “I have been to Willow Bay on several occasions. The staff are always very welcoming and helpful and work well to provide best outcomes for residents”. “The staff are brilliant and keep my daughter clean, nothing is too much trouble. Could not get better personal care anywhere else. They know how to approach my daughter and are guided by her.” Staff receive regular training and have their future training needs assessed by the acting manager. Staff undertake NVQ training and regular health and safety updates. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 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 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): 37,38,39 The home is run well by a suitable qualified manager. Resident rights are protected by the homes policies and procedures and selfmonitoring systems. EVIDENCE: The new acting manager is undertaking NVQ level 4 registered managers award and adapting well to her new role. Staff stated since the employment of the new acting manager the atmosphere in the home has improved and they are able to approach the acting manager in confidence. Staff stated they were able to voice their views and opinions although this was not evidenced in minutes. Staff receive regular supervision and training. The home has produced a quality assurance and monitoring system, which includes the views of relatives but not residents. The acting manager had not yet completed an action plan for future progress to the service. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 Page 16 The homes policies and procedures were examined and reviewed in April 05. Fire evacuation records evidenced the home completes regular fire checks, tests and evacuation with response times and action taken. Times included one nighttime evacuation. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 Page 17 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 X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willow Bay Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X X X DS0000018027.V265514.R01.S.doc Version 5.0 Page 18 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA17 Regulation 12 Requirement The health needs of residents who are overweight must be taken into account and services provided to reduce potential health risks. Timescale for action 01/04/06 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 Refer to Standard YA1 YA22 YA39 Good Practice Recommendations The service users guide should be in pictorial format. The home should appoint independent advocates for residents who require them. The homes quality assurance should include residents and placing social workers opinions with an action plan giving details of how the service is to progress and copy should be sent to the CSCI. A low fat diet should be maintained for residents who are overweight. Residents should be given incentives, which are not food based for achieving goals in relation to healthy diet intake to improve health outcomes. The home should seek the advice of a dietician for residents who are overweight. DS0000018027.V265514.R01.S.doc Version 5.0 Page 19 4 YA17 Willow Bay 5 6 YA35 YA20 Staff meetings should evidence staff views and opinions. Stock medication return records should include the signatures of staff to evidence the amount returned. Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 Page 20 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 © 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 Willow Bay DS0000018027.V265514.R01.S.doc Version 5.0 Page 21 - 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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