Inspection on 12/07/05 for Willow Court

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Willow Court 06/02/07

Willow Court 31/01/06

Willow Court 01/03/05

Willow Court 02/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Willow Court Far Common Road Roe Head Mirfield WF14 9DQ Lead Inspector Cathy Howarth Announced 12 July 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 Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willow Court Address Far Common Road Roe Head Mirfield WF14 9DQ 01924 490833 01924 483901 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) Holly Bank Trust Mr Christopher David Graefe Learning Disability for Adults 18 Category(ies) of 18 places for people with a Learning Disability registration, with number aged 18-65 of places Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 March 2005 Brief Description of the Service: Willow Court is a care home providing personal care and accommodation for 18 younger adults with moderate to profound learning disabilities with associated physical disabilities. It is sited on the periphery of a large administrative and residential complex providing a range of services for younger people and children with learning disabilities. The accommodation is within large grounds and is some distance from the local village facilities. The accommodation is purpose built on a single level with three wings surrounding some administrative facilities. All the wings have single en-suite rooms and are selfcontained with dining cooking and communal areas. There is a garden area within large grounds and adequate car parking facilities. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over a ten-hour period from the morning until the evening. The inspector observed interactions within each of the separate bungalows, spoke with individual tenants and staff. Two care plans were examined and other records including complaints, health and safety records, staff rotas and staff and tenants meeting records were examined. The manager’s self-assessment was also used to inform this inspection. Questionnaires were sent to tenants and their relatives before this visit. Two tenants and thirteen relatives responded. One relative spoke to the inspector by telephone on the day of inspection. It was positive to note that the overwhelming majority of these responses were very positive about the quality of the service provided. Relatives who responded spoke highly of staff. The comment “The dedication and commitment of the staff towards the residents and their families is exemplary.” is typical of the type of comments received. Other comments from tenants and relatives have been included in this report where relevant. The inspector would like to take this opportunity to thank all the tenants and staff at Willow Court for their welcome and hospitality throughout this visit. What the service does well: The tenants who live at Willow Court are actively encouraged to make choices, take risks and to lead active and fulfilling lives. People’s individual needs and preferences are carefully listened to, documented and followed by staff on a daily basis. Staff try to find out tenants’ views about the service by talking individually, tenants’ meetings and by asking relatives or advocates. Staff use a variety of communication methods to find out what tenants views are. High staffing levels and having transport available makes it easier to make sure that people can do the activities they want to, and so the tenants at Willow Court can enjoy a wide range of activities and leisure pursuits. The accommodation is clean and tidy and home-like in as far as it can be, given the range of needs that have to be catered for within the home. There are good opportunities for training for staff to ensure that they have the skills they need to support the tenants that live there. Health and safety issues are managed well. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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) 2 Prospective tenants at Willow Court have personal goals identified and actively encouraged to ensure they continue to grow and develop while living at the home. EVIDENCE: An important part of assessing the appropriateness of the placement at Willow Court is to check whether the tenants’ personal aspirations can be met at the home. The manager is clear as to the limits of what can be offered but the ethos of the service is to offer life-enhancing opportunities for every individual, so that they can develop their own interests and personalities within a safe and caring environment. Each tenant has personal goals, which are written into their Individual Support Plans. These are monitored six monthly either through the annual review or the Person Centred Plan review. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 and 9 Tenants can make individual choices within their daily lives, and are assisted to develop and grow through exercising choice and taking appropriate risks. EVIDENCE: Tenants at Willow Court have Individual Support Plans and documents detailing their specific strengths as well as needs. This is positive and emphasises the philosophy of encouraging people to do what they are able to do and to continue to develop. Identifying strengths also encourages staff to limit their interventions when the task may be something that the tenant may wish to do themselves with minimal assistance. These plans indicate whether and how the tenants have been consulted. Where possible they sign the form but otherwise their agreement may be sought through non-verbal means or through an advocate or relative. This is good practice. Risk assessments are carried out for any activities, which may present significant risk to the individual tenants. The individual support plans make Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 10 clear links to these (by them being emphasised in red on the plans) to alert staff to these danger areas. There is a clear philosophy that taking risks is part of enjoying life and trying new things for people living at Willow Court. Therefore there is a commitment to making it possible for people to participate in activities they want to do while minimising the risks. One parent explained that they were happy that despite their son’s difficulties the staff ‘Constantly amaze with their inventiveness’ finding solutions to the problems their son encounters. This parent explained that they had searched the country looking for somewhere that could offer as ordinary a life as possible said they feel ‘Willlow Court provides my son with outstanding care.’ Tenants’ meetings are held approximately three monthly. These have some value but are limited as to who can be fully involved; as is shown through the minutes of these meetings. However there are other mechanisms within the service that are more suitable for eliciting views of tenants on a variety of topics, such as a pictorial complaints procedure and pictorial questionnaires, which are used from time to time to find out what tenants think of such things as food. These need to be done on an individual basis and are time consuming but worthwhile. These audits feed into the internal quality assurance processes within the service. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 and 17 Tenants at Willow Court are positively encouraged and assisted to lead fulfilling lives. EVIDENCE: A very important part of the philosophy of the service is that service users have the right to make individual choices, to follow their interests and to live fulfilled lives in terms of their relationships with others both in their families and in the wider community. During this inspection it was evident that staff have a commitment to helping tenants to make the most of their opportunities. An important aspect of this is having sufficient staff to enable individual interests to be followed. The home is well staffed which means that most tenants can have the opportunity to go out every day if they wish. This commitment is also translated into availability of transport. There are thirteen vehicles, which are adapted for wheelchair use, that can be used to transport tenants. These vehicles are mainly adapted ordinary people carriers rather than minibuses. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 12 Most of the tenants attend college courses at various local colleges and do a range of classes according to their particular interests, such as IT, yoga and art to name but a few. Because of the availability of transport tenants can use local facilities easily. On this visit the inspector observed and heard about people doing numerous activities within the locality such as attending an ‘Abba’ night, going to local pubs, going to rugby and football matches and some tenants have recently started sailing. Within Willow Court the inspector observed staff using their knowledge of the particular likes and dislikes of tenants to offer activities and pastimes to suit. Some tenants had hand and foot massages; enjoyed music while others went out for a walk or used a paddling pool. The inspector observed several people enjoying their meals assisted by staff, as well as some tenants who helped to prepare meals alongside staff. Meals are planned according to the preferences of the people living in each bungalow and choices are offered where individuals may not like the main meal. One observation from this is that it would appear more natural and dignified for staff to ensure they sit with tenants as far as possible to assist them, rather than standing over people to help them eat. Some tenants have a gastrostomy and need regular tube feeds. These were seen to be managed well, on time and recorded accurately by staff in terms of amount of food taken. Relatives who responded to the questionnaire indicated their satisfaction with the service, for example one relative said they “Strive to offer highest quality care- on an individualised basis. They are open and receptive at all times”. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 People living at Willow Court can choose how they are supported with personal care and to live their lives as they wish. EVIDENCE: Each tenant living at Willow Court has an individual support plan, which details how he or she need or prefer to be supported in his or her daily lives. This is very important in a large staff team to ensure that each person is following the agreed approaches. These plans cover areas of physical need such as bathing and using the toilet, as well as covering areas such as activities and interests. Issues such as preferences for particular gender staff to assist tenants with personal care are clearly identified as part of this plan. In addition individual goals are identified for each individual. This ensures that areas where individuals wish to develop, are emphasised. It was not clear exactly how these goals were being monitored on the files examined, it may be useful to consider more frequent monitoring than through the current review system as this is not frequent enough, for example where someone has expressed a desire to pursue a particular college course. The daily recording should also reflect goals in order to make this easier for the staff to monitor. One tenant who spoke with the inspector said they were happy that staff support them how they wish to be supported, and that they value this. They also said they value the equipment that has been provided to help them be as independent as possible. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 14 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 and 23 There is a robust complaints and adult protection procedure, but recording needs to be tightened up. EVIDENCE: There is a robust complaints procedure at the home. Relatives and tenants are informed of how to raise concerns and these appear to be taken seriously when they are raised. The complaints procedure is also available in pictorial form to enable tenants who can’t read to understand how to raise concerns. One tenant who spoke with the inspector said that they knew what to do if they wanted to complain but that they had had no reason to do this. Four complaints have been logged in 2005 so far. Three had been fully recorded and satisfactorily resolved. One however did not have details of the investigation and the outcome on file at the time of inspection. This was provided subsequently, but the manager should ensure that all complaints are fully recorded in the log for monitoring purposes. The home has a policy for the protection of vulnerable adults. At the last inspection there were some queries raised about staff awareness relating to this issue. At this inspection staff were able to give a clear idea of what they would do if the situation arose, including one staff member who is new to the service. Staff meeting minutes showed that this is an issue that has been raised at meetings to ensure that staff are fully aware of their responsibilities. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 15 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 and 30 The environment at Willow Court meets the needs of tenants and is generally in good condition. EVIDENCE: Willow Court is a fairly new purpose built home, which provides accommodation in three individual bungalows for 18 tenants. The accommodation is homely in communal areas, with furniture and fittings, which are domestic rather than institutional. Some adaptations have been made to accommodate the specific needs of tenants, such as adjustable work surfaces in the kitchens and a ‘neater eater’ for one person to help them eat independently. Of necessity, because so many of the occupants use wheelchairs, corridors are wide and doors need to be left open for easy access. This does detract a little from the homely atmosphere but the cheerful décor and artwork on the walls does improve this. Individual bedrooms were clearly decorated and personalised to the taste of the occupants. All areas of the home were found to be clean and tidy with no offensive odours noted. The kitchen surfaces were found to be starting to deteriorate and could present a hygiene problem in the near future. The manager confirmed that Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 16 there are plans to upgrade these in the future. It is recommended that this is within the next twelve months. One carpet appeared to be rucked in places, possibly due to wheelchair traffic. This could be a trip hazard in time so it is recommended that the carpet is restretched to prevent this. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 36 There is a good system of induction and training and support for staff working at Willow Court. EVIDENCE: There is an extensive programme of training for staff that work at Willow Court. The training is co-ordinated by a designated person within the Hollybank trust, who ensures that all staff receive the required training and refreshers at appropriate intervals. Staff who spoke with the inspector gave extensive examples of training opportunities that they are offered and expected to attend. One person said they particularly valued the disability awareness training where they had spent a day using a wheelchair to experience first hand how that feels. The inspector spoke with one staff who had only been working at the home for seven weeks. This staff member could outline a good induction, with adequate support to help develop skills. All staff are registered for NVQ training once they have completed their probation. With alternative equivalent qualifications the home has achieved the required level of 50 NVQ2 qualified staff. The service offers supervision to staff every two months and there is a mentoring scheme in place, which offers staff the chance to talk through practice or personal issues at other times. There are regular team meetings Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 18 held, although because of the staffing levels not all staff can attend every one. However staff reported that team meeting minutes are attached to wage slips each month to make sure that every member of staff has the opportunity to see these. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 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) 42 Health and Safety issues are given a high priority at Willow Court. EVIDENCE: The home has good arrangements in place to monitor health and safety matters. There are two staff who are responsible for this, monitoring risk assessments, conducting safety checks and preparing such things as COSHH assessments. There arrangements with external contractors to monitor such things as water temperatures and to ensure that the water supply is free from legionella. Fire tests are carried out weekly, in fact one was done during this visit. Risk assessments for individual tenants were found to be good and up to date on the files examined. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 1 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 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 x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willow Court Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 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 22 Regulation 17 Requirement A full record of all complaints must be kept, including a record of action taken and the outcome of the complaint. Timescale for action 31.7.05 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. Refer to Standard 24 24 Good Practice Recommendations The kitchen worksurfaces should be replaced within the forthcoming year. The carpet that is rucked should be re-stretched or replaced to prevent it becoming a trip hazard. Willow Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 22 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse. HD6 4AB 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 Court J51J01_s26336_Willow Court_v229561_110705.doc Version 1.30 Page 23 - 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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