Inspection on 31/01/06 for Willow Court

This inspection was carried out on 31st January 2006.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow Court 06/02/07

Willow Court 12/07/05

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 West Yorkshire WF14 9DQ Lead Inspector Cathy Howarth Unannounced Inspection 31st January 2006 10:00 Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow Court Address Far Common Road Roe Head Mirfield West Yorkshire WF14 9DQ 01924 491205 01924 483901 chris.g@hollybanktrust.com# 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) Holly Bank Trust Mr Christopher David Graefe Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 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 self-contained with dining, cooking and communal areas. There is a garden area within large grounds and adequate car parking facilities. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a five-hour period. The inspector met with service users, two visiting relatives, staff and the manager. Relevant documents were examined in relation to the standards being assessed. The inspector would like to thank service users and staff for their welcome on the day. What the service does well: What has improved since the last inspection? Complaints have been properly recorded. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 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 Court DS0000026336.V263372.R01.S.doc Version 5.1 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 Court DS0000026336.V263372.R01.S.doc Version 5.1 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): These standards were not assessed on this visit. EVIDENCE: Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 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 and 9 The service is good at identifying and meeting needs of service users in a way that reflects their preferences and maintains their independence as far as possible. EVIDENCE: Service users are consulted about their individual preferences wherever possible. Their agreement to the Individual Support Plan is indicated on each file. Relatives are also consulted about these plans but the staff are aware of the need to consider the needs and rights of individuals when consulting relatives. If service users do not have relatives, or there is conflict between the wishes of the service user and those of the relative, then advocates may be sought. Three individuals currently have advocates. Risk assessments are carried out for any activities which may present significant risk to the individual tenants. The individual support plans make clear links to these (by them being emphasised in red on the plans) to alert staff to these danger areas. Risk assessments were generally well-written and detailed but for some service users there needed to be more detail on these to make them useful to staff. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 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): 13 and 15 Service users have good opportunities for self-development and to adopt a lifestyle that suits them. They are active within the local and wider community. The service is good at supporting people to maintain meaningful relationships with family and friends. EVIDENCE: The service users at Willow Court are in the heart of a small community in Roberttown, where the Hollybank Trust campus is a major feature. Although service users live on this campus and are therefore not in close proximity to other people, one of the features of lives for service users is the emphasis on ensuring that people have ample opportunities to go out and about and establish friendships and networks within the community. This commitment is supported by the fact that the home has seventeen vehicles for eighteen service users. There are therefore few problems in ensuring that people can get out if they wish to do so. Each file contains a weekly timetable of activities for service users. For one service user this showed a wide variety of activities including horse riding, Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 11 college, tai chi class, drum circle and hydrotherapy. This is typical of the variety that each person can access with staff support and is a very positive aspect of the service which individuals appreciate, as do families. Contacts with families are encouraged via telephone, letters, visits and reports by staff both verbal and written where service users may be unable to let their families know themselves what they have been doing. One important aspect of maintaining these relationships is sending birthday and Christmas cards to friends and relatives. It was very positive to see extended lists for individuals of people who are significant to service users. Named workers play a key role in ensuring that cards and presents are bought in time to send these at the right times. One service user told the inspector that he has a number of family birthdays in February and he has already got cards and presents organised for these events. During the visit, the inspector met with two visiting relatives. Their relative had only recently moved into the home but they indicated that they were pleased with the service so far. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 21 Personal preferences of service users are respected. Health issues are addressed adequately. Some improvements are needed in stock control of drugs and the handling of controlled drugs. EVIDENCE: On this visit, it was clear that there is a lot of care taken within the service to ensure that the physical and emotional needs of service users are met. The inspector observed staff taking care to keep service users safe and comfortable where they are wheelchair users. The home has recently employed the services of a physiotherapist to ensure the physical needs of service users are met fully and that they have the correct equipment. Individual support plans identify areas of emotional support that may be required also. One service user has significant health needs and is predicted to have a limited life expectancy. This raises issues in terms of managing the process of supporting the individual and their family through this difficult time. There was evidence of significant planning taking place to prepare for this and support has been obtained from health professionals at the hospital and the local hospice. The manager is also seeking support for staff in dealing with this Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 13 issue, acknowledging that such events have a significant impact on staff as well as service users and families. Arrangements for medication handling and administration, and handling were found to be generally satisfactory. However, there is a need to implement a system to ensure overall stock balances can be checked regularly. As the stocks are now spread between the main store and the kitchens in each bungalow, this task is more complicated. A brought forward system is also needed to ensure that stock levels can be reconciled easily. This was discussed during this visit and is to be addressed without delay. Also the home has recently needed to take in a controlled drug. The storage for this is adequate but the recording of stock needs to be tightly controlled and a controlled drugs book for the administration of the drug needs to be purchased. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 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 the following standard(s): 22 Complaints are managed satisfactorily within the service. EVIDENCE: Since the last inspection there have been improvements in the recording of complaints, although there has only been one received in this time. As detailed in the previous report, the complaints system is robust and is accessible in picture format for service users to use. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 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 the following standard(s): 26 and 29 Service users have bedrooms that suit their personalities and needs. Appropriate equipment is provided to make sure service users are comfortable and able to maximise their skills. EVIDENCE: Each service user at Willow Court has their own spacious bedroom with ensuite facilities. Not all bedrooms were seen on this visit but those that were were found to be decorated according to the choices of individuals or, if they are unable to express this clearly, families are consulted. Bedrooms and ensuites were found to contain appropriate equipment to maximise the independence of service users. For example, one service user has environmental controls for his bedroom. Others have appropriate seating, sleeping and bathing equipment to ensure their needs can be met safely and comfortably. In other areas, equipment is used to promote independence. One service user has a “Neater-eater” to enable them to feed themselves. Also there are height-adjustable units in the kitchen to allow wheelchair users to help in the kitchen with the preparation of meals. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 16 At the last inspection two recommendations were made in respect of the environment. From this, it has been agreed that the kitchens will be refurbished in the next financial year which is positive. The carpet in bungalow 1, however, still needs to be re-stretched and refitted. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 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): These standards were not assessed on this visit. EVIDENCE: Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 18 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 and 39 The home is well run and quality assurance systems are in place to ensure the service continues to develop for the benefit of service users. EVIDENCE: The manager of this service is well qualified and competent in achieving the aims of the service. The service has a mid to long-term development plan which runs alongside those of the wider adult services provided by the Hollybank Trust. The service carries out surveys of service users and relatives from time to time. The last one was eighteen months ago and a new one has just been sent out. Responses from the last survey indicated a high level of satisfaction with the service provided. The home’s development plan identifies targets for improvements ranging from developing the complaints procedure in audio-visual format in the short term, Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 19 to the development of the new rebound and hydrotherapy suite. Progress has been made in respect of the plans and this is positive. There are internal monitoring systems to assure the quality of service, such as monthly visits by the line manager, and supervision systems. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 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 X 2 X 3 X 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 X ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 X 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 1 X 3 X 3 X X X X Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 21 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 YA20 Regulation 13(2) Requirement Stock balances of medication should be checked frequently and the systems must be in place to enable this to be done accurately. The storage, handling and administration of controlled drugs should be carried out in accordance with the guidance from the Royal Pharmaceutical Society. Timescale for action 07/02/06 2 YA20 13(2) 14/02/06 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. Refer to Standard YA24 Good Practice Recommendations The carpet that is rucked should be re-stretched or replaced to prevent it becoming a trip hazard. Willow Court DS0000026336.V263372.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Brighouse Area Office 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 DS0000026336.V263372.R01.S.doc Version 5.1 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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