Inspection on 14/12/05 for Willow End

This inspection was carried out on 14th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow End 25/09/07

Willow End 21/11/06

Willow End 07/03/06

Willow End 18/03/05

Willow End 20/07/04

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Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

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

CARE HOME ADULTS 18-65 Willow End 82a The Willows Mersea Road Colchester Essex CO2 8PX Lead Inspector Neal Wolton-Harragan Unannounced Inspection 14th December 2005 11:35 Willow End DS0000040671.V276863.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 End DS0000040671.V276863.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 End DS0000040671.V276863.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow End Address 82a The Willows Mersea Road Colchester Essex CO2 8PX 01206 769713 N/A 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) Willow Health Limited Mr Keith Walters Care Home 7 Category(ies) of Learning disability (7), Physical disability (5) registration, with number of places Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 7 persons) Five people with a learning disability who also have a physical disability whose names were provided to the National Care Standards Commission in September 2002 The total number of service users accommodated must not exceed 7 persons 28th July 2005 3. Date of last inspection Brief Description of the Service: Willow End offers care for 7 individuals who have a learning disability. There were 3 service users being cared for who had additional physical disabilities. Willow End is owned by Willow Health Ltd, a private company that is described within the Statement of Purpose as a ‘small family run company’. The home is a detached, purpose built bungalow, situated in an established residential area. There is a range of local shops within easy walking distance. Public transport was available close by. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection at Willow End, the first inspection of the home for the 2005-2006 inspection year. Mr Keith Walters, the home’s Registered Manager, was at Willow End on the day of inspection and contributed fully to the inspection process. During this inspection, 38 of the 43 applicable standards were looked at; 36 were met, one was nearly met and one was unmet. During the day of inspection, six members of staff were spoken with, as well as four service users. The staff and service users spoke well of the home and of its management. Service users appeared at ease with the care staff and were happy to talk to the Inspector. Interactions between staff and service users observed during this inspection were positive. This inspection included discussions with service users, staff and the home’s Manager, as well as the opportunity to look at records of how people living at Willow End were supported and how the staff were recruited and trained. What the service does well: What has improved since the last inspection? The team at Willow End has made good progress since the last inspection, with all but one of the previous requirements being met. The home has revised its Statement of Purpose and Service User Guide, improved record-keeping, developed a complaints procedure and ensured that all staff are appropriately trained and experienced to undertake their roles. Willow End DS0000040671.V276863.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 End DS0000040671.V276863.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 End DS0000040671.V276863.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): 1, 2 & 5 Prospective service users had the information they needed to make an informed choice about where to live. The needs and individual aspirations of prospective service users were assessed prior to admission. Service users did not have individual written contracts or statements of terms and conditions with the home. EVIDENCE: The home’s Statement of Purpose and Service User Guide had been revised to include all the information required by Regulation 4, Schedule 1 of the Care Homes Regulations 2001. These documents were made available to existing and prospective service users, as well as for families and supporters. Care records for two service users were examined and it was found that a comprehensive needs assessment was conducted prior to service users entering the home. These assessments formed the basis of the service users’ initial care plan and contributed to the on-going process of assessment within the home. Service user records did not show evidence of each service user having an individual written contract or statement of terms and conditions with the home. Willow End DS0000040671.V276863.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, 7, 8 & 9 Service users’ assessed and changing needs were reflected in their individual plans and service users were involved in the decision-making process in all aspects of their lives. Service users were supported to take risks as part of an independent lifestyle. EVIDENCE: The service user records sampled during the inspection showed that individual needs were assessed and were reflected within individual service user plans. These plans were subject to regular monitoring and review and changes in needs were identified and acted upon. The examination of records, and discussions with individual service users and staff, gave evidence that service users were central to the decision-making processes within Willow End as well as playing a pivotal role within care reviews. Individual service user records showed that thorough risk assessments had been undertaken and risks were managed and reviewed appropriately. Willow End DS0000040671.V276863.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): 11, 12, 13, 14, 15 & 16 Service users had opportunities for personal development and were able to take part in age, peer and culturally appropriate activities. Service users were active members of the local community, engaged in appropriate leisure activities and had appropriate personal, family and sexual relationships. Service users’ rights were respected and responsibilities recognised in their daily lives. EVIDENCE: The examined service user records gave evidence that each person living at the home had a detailed weekly programme that included work, education and leisure type activities. Service users spoken with on the day of inspection stated that they used community facilities as part of their daily lives and enjoyed the activities on offer. Discussion with service users and staff, as well as the examination of records, showed that service users’ rights were respected and appropriate personal relationships supported. All service users had regular and positive contact with their families and all were due to spend time away from Willow End with their families over the Christmas period. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 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): 18, 19 & 20 Service users received personal support in the way they preferred and required and physical and emotional health needs were met. No service users retained, administered or controlled their own medication at the time of this inspection. Service users were protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Service users spoken with were happy with the way they were supported and this was reflected within the care plans examined. Service user plans identified individual needs, as well as the choices made by individuals as to how these needs were to be met. Care plans were well detailed, regularly monitored and formally reviewed at intervals depending on individual need. There was an ongoing process of assessment to take account of the changing needs of individuals and the services of healthcare professionals, such as community nurses, speech and language therapists or psychologists, were accessed as necessary. None of the service users retained, administered or controlled their own medications at the time of this inspection. This decision was taken on an individual basis, for each service user, following a comprehensive process of need and risk assessment and was recorded within individual service user records. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 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): 22 & 23. Arrangements were in place to help protect service users from abuse, neglect and self-harm. Service users felt their views were listened to and acted upon. EVIDENCE: The home had a robust complaints procedure that had been the subject of review since the last inspection. However, there was a need to further amend this document to show the contact details of the Commission for Social Care Inspection. The adult protection policies and procedures were adequate to protect service users from abuse and where service users presented with behaviours likely to cause self-harm, these behaviours were identified within their care plans and management strategies devised. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 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, 25, 26, 27, 28, 29 & 30 Service users lived in a homely, comfortable and safe environment and had bedrooms that suited their needs and lifestyles and promoted independence. Service users toilets and bathrooms provided sufficient privacy and met individual needs and shared spaces complemented and supplemented service users individual rooms. The home was clean and hygienic. EVIDENCE: An environmental tour of the home gave evidence that service users lived in a homely, comfortable and safe environment and that individual bedrooms suited service users needs and lifestyles, were decorated to the colours of the service users’ choice and promoted independence. Bathing facilities at Willow End were adequate and four bedrooms benefited from en-suite facilities. There were sufficient shared spaces throughout the home, and within its grounds, to complement and supplement service users’ individual rooms. Service users spoken with on the day of inspection were happy with the environment at Willow End. There was remodelling in progress for the home whereby the larger lounge/kitchen area was to be converted to a dedicated activity area with a training kitchen. This area also contained a communication board that was Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 14 part of the home’s move towards creating a total communication environment for those living at Willow End. All areas of the home were clean and hygienic and there were no odours noticed. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 15 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): 31, 32, 33, 34, 35 & 36 Service users benefited from clear staff roles and staff were appropriately trained to meet the individual and joint needs of service users. Service users were supported by competent and qualified staff and protected by the homes recruitment policies and practices. Staff were adequately supported and supervised. EVIDENCE: Examination of staff records, as well as discussions with the Registered Manager and staff, gave evidence that care staff had a good understanding of their roles and responsibilities and that staff were qualified and competent. Staff were employed in sufficient numbers to meet the needs of the service users, creating an effective staff team. Staff spoken with on the day of inspection stated that training was regularly made available and the home’s Manager fully supported staff in meeting their training needs. The examination of staff files showed that all staff received regular full support and supervision. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 16 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, 40, 41 & 42 The home was well run and service users benefited from the ethos, leadership and management approach of the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures and record keeping at the home was good. The health, safety and welfare of service users are promoted and protected. The home has yet to implement a process of quality monitoring. EVIDENCE: Examination of records, discussions with staff and discussions with service users gave evidence that the home was well managed. Mr Keith Walters, the Registered Manager, has appropriate skills and experience and has NVQ level 4 in care. Mr Walters is working towards completing the required NVQ management units and fully supports the development of skills within the team members, with all carers now having completed or commenced NVQ awards at level 2 or above. Records examined showed that risk assessments for activities undertaken by staff and service users had been completed. Policies, procedures and records Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 17 showed the health, safety and welfare of service users, staff and visitors was promoted and protected. Record keeping at the home was of a good standard. Discussions with the Registered Manager confirmed that although some progress had been made in the development of a quality monitoring system this had yet to be implemented. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 18 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 3 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 3 3 3 3 Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 YA23 Regulation 22(7) Timescale for action The Registered Person must 01/03/06 ensure the home’s complaints procedure is revised to show contact details of the Commission for Social Care Inspection. The Registered Person must 01/03/06 ensure that the home has a quality assurance and quality monitoring system in accordance with regulatory requirements. The previous timescale of 30th June 2005 was not met. Requirement 2 YA39 24 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 YA5 Good Practice Recommendations It is recommended that copies of terms and conditions of residence issued to service users be retained in individual service user records for future reference. Willow End DS0000040671.V276863.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 End DS0000040671.V276863.R01.S.doc Version 5.1 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. 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