Inspection on 06/02/07 for Willow Court

This inspection was carried out on 6th February 2007.

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 Court 31/01/06

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 Bronwynn Bennett Key Unannounced Inspection 6th February 2007 9:20 Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 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.V319676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 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. The home is within the large grounds of Holly Bank School which provides residential care and education for children with learning and physical disability. The accommodation is purpose built on a single level with three wings. Each wing has its own kitchen, dining and lounge areas. Every bedroom has its own toilet, washing facilities and a shower. There is an office and meeting room at the front of the home. There is a garden area within large grounds and adequate car parking facilities. There is disabled access to the home and there is fixed equipment provided such as hoists. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by one inspector. The visit began at 9.20 am and finished at 5.20 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager. The inspector read records of people’s care, staff records, looked at how medicines are given and looked at the accommodation available in the home. There were eighteen service users living at the home on the day of this visit. Prior to this visit the Commission for Social Care Inspection sent out questionnaires. Ten questionnaires were sent to service users living at Willow Court. Ten completed questionnaires were returned. Surveys were sent to ten service users’ relatives and six responses were received. Surveys were also sent to eight social workers and a health care professional. We received three responses. One GP responded to the survey. Other information used as part of this inspection includes notifications from the home about illnesses, accidents and incidents. Before we visited, the manager completed a pre inspection questionnaire. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The service provides a level of care that service users, their relatives and other professionals are satisfied with. There are sufficient numbers of staff to ensure service users are supported to develop skills and interests and maintain links with the local community. The staff work hard to ensure service users maintain relationships with family and friends. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 6 The home ensures that staff receive the training required to meet the needs of service users. Specialist equipment is provided to help service users reach their full potential. 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. The summary of this inspection report can be made available in other formats on request. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their individual needs assessed prior to admission into the care home. EVIDENCE: The individual needs of service users are assessed prior to admission into the care home. The manager discussed how staff spend time with potential service users, their parents and relatives, to ensure Willow Court is the right place for them. Visits to the home are encouraged. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users assessed and personal care needs and goals are recorded in their plan of care. The support required by service users to make decisions, and the risks taken as part of an individual’s lifestyle, are appropriately recorded in care records. EVIDENCE: The relatives spoken with during this visit were very satisfied with the care and support provided at Willow Court. The information received from all the surveys indicates that the service users are always treated well by staff. Alternative methods of communication were seen being used during this visit, such as body language and signs. Some methods of communication are Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 10 displayed in the home. Discussions with staff showed they had a good understanding of individual service users’ needs. Whenever possible, service users are consulted about their individual preferences. The care records for three individuals were looked at and their agreement to an individual plan of care was recorded. The care records were person centred with specialist interventions and individual personal care needs recorded. Risk assessments are carried out for any identified risks for each individual. The link between care records and risk assessments is good and directs staff to the relevant information. The staff were seen interacting well with service users and respecting their right to make decisions. The information recorded was clear, easy to follow and outlines the level of risk and the measures in place to minimise the risk and any associated hazards. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported to be part of the local community and take part in appropriate activities. Service users are supported to maintain relationships with family and friends. The service users’ rights and responsibilities are respected. Service users are offered a choice of food that meets dietary and cultural needs. EVIDENCE: During this visit the service users were seen being supported by staff to go out and take part in their chosen activity. Others were being supported to take part in domestic activities such as washing and drying own laundry and the planning and preparation of meals. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 12 A relative said there is always staff to support them to take their relative out to visit places of interest. The information received from the service user survey indicates that service users are supported to make decisions about what they do each day. Individuals were seen being supported to make decisions during this visit. Service users are supported to take part in educational activity and, during this visit, some individuals were supported to go out to college. The manager and staff work hard to ensure service users access a variety of activities. Service users are supported to be part of the local community. Individual files contain a timetable of activity. Activities accessed include horse riding, drum circle, hydrotherapy, trampoline, college and community clubs and classes. In addition, domestic skills are encouraged in the home such as helping staff plan and cook meals and personal laundry. Individual relationships with family and friends are supported. A relative spoken with during this visit said that staff ensure birthday cards and Christmas cards are sent to those who are important to the service user. There was good interaction and relationships noted between service users and staff. The staff were observed treating individuals in a respectful and dignified manner throughout this visit. Where appropriate, some individuals are supported by staff to clean their own rooms and launder their own clothing. There is flexible serving of meals in the home. During this visit, meal times were noted to be relaxed and staff were giving people the right sort of help to eat their meals. The preparation of food respects the service users’ cultural and religious needs and dietary requirements. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users receive personal support in their preferred way and the individuals’ health care needs are met. Greater care is required to ensure the home’s medication policy and procedure protects the service users. EVIDENCE: Service users have the equipment they need in order to maximise their independence. The service users’ preferred times for bathing, meals and choice of clothing were seen recorded in the individual records kept and the movement and support required for each individual is also recorded. There was information available to show that service users have a health care plan. Individuals are supported to access NHS healthcare facilities and access visits to their GP. Willow Court also has access to physiotherapy and an Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 14 occupational therapist to meet service users’ healthcare care needs. All service users have an annual health care check. The medication for three service users was checked and two of the records were correct. One pain relief medication had not been carried forward onto the current MAR (Medication Administration Record) sheet. This was discussed with the manager who agreed to take immediate action to rectify the matter. The home has a “homely remedies” policy. Where such remedies are to be given, prior consent should be sought from the individual’s GP and recorded in their records. Since the last visit by the CSCI, the home has addressed the matter of safekeeping of controlled medication. A controlled drugs book has now been purchased. There was a missing signature noted which was discussed with the manager who agreed to address the matter urgently. A system is in place for stock medication; this is now recorded and checked regularly. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, service users feel that their views are listened to and acted upon and they are protected from abuse. EVIDENCE: The home has a complaints policy and procedure that is also available in suitable formats for service users. One relative who responded to the survey said they felt they were always listened to and taken seriously should any issues arise. Five of the 6 relative surveys received said they were aware of the home’s complaints procedure. A record is kept of all issues raised including complaints. There have been no complaints made to the home since the last visit by the CSCI. All staff have received adult protection training and the staff spoken to were able to demonstrate a good understanding of the required actions that must be taken should there be any allegations of abuse. The personal money for three service users was checked and correct. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, service users live in a comfortable and safe environment. The home is clean and hygienic. EVIDENCE: As part of this visit, a tour of the premises was carried out and the home was noted to be clean and odour free. The lounge areas offer a comfortable and homely environment for the service users to enjoy. All surveys received by the CSCI commented that the home is always fresh and clean. The bedrooms seen during this visit had been decorated and personalised through choices made by the service users. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 17 Service users have access to the equipment they require to maximise their independence. For example, there is appropriate sleeping, seating and bathing equipment to ensure individual care needs can be met. The kitchens are due to be refurbished in the next few months and this will include a height adjustable kitchen to allow wheelchair users to help in the preparation of meals. The laundry facilities were seen and were clean and well organised. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff work hard to support the service users. Appropriately trained staff meet the needs of service users. The home’s recruitment policy and procedure is sufficiently robust to protect the service users. EVIDENCE: During this visit, service users and staff were seen interacting well and there were sufficient staff on duty to meet the needs of service users and support them in their chosen activities. Some service users require support in communication and there is communication systems displayed in the home. The service user surveys received said the staff treated them well and acted on and listened to what they had to say. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 19 The relatives spoken with were very complimentary about the staff working at the home. One relative was very satisfied with the care and kindness shown by the staff. The health care professionals and a GP who responded to the surveys said they were satisfied with the overall care provided by the home. The relative surveys received showed some positive comments. One commented about the “outstanding care” provided in the home, and another said their relative receives “excellent care”. One relative felt that there were occasions when the home had not communicated very well. This was discussed with the manager at the time of this visit. All staff have received induction training and the required mandatory training. Staff also receive training specific to the health and care needs of the service users living at the home. Forty two staff have achieved NVQ level 2 training and this training is continuing for all staff. The records for three staff working in the home were audited and held the required information. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current management arrangements ensure service users benefit from a well run home. Generally, the home is run in the best interests of the service users. The health, safety and welfare of the service users and staff is generally promoted and protected. EVIDENCE: The manager of the home is Christopher Graefe. He has good experience of caring for the service user group and is a qualified social worker with NVQ level 4 and 5 and holds a management degree. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 21 The staff spoken to during this visit was very complimentary about the manager and said he was approachable and supportive. There is some quality monitoring carried out within the home and monthly visits carried out by a representative of the organisation and there is regular supervision of staff. There are plans to develop the use of service user and relative satisfaction questionnaire. In addition, the service has a development plan. A previous area of development was the rebound and hydrotherapy suite that is now complete and fully functional. The fire records were checked and the home’s fire system and emergency lighting is tested weekly with the appropriate records being kept. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 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. Standard YA20 Regulation 13(2) Timescale for action The registered person shall make 06/02/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The medication records must be kept up to date. All medication carried forward from the previous month must be transferred onto the current MAR sheet. Requirement 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 YA20 Good Practice Recommendations Where homely remedies are to be given, prior consent should be sought from the individual’s GP and recorded in the individual records. Willow Court DS0000026336.V319676.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V319676.R01.S.doc Version 5.2 Page 25 - 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. 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