Inspection on 21/11/06 for Willow End

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 4 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 07/03/06

Willow End 14/12/05

Willow End 18/03/05

Willow End 20/07/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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 Tim Thornton-Jones Key Unannounced Inspection 21 November 2006 09:00 Willow End DS0000040671.V317889.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 End DS0000040671.V317889.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 End DS0000040671.V317889.R01.S.doc Version 5.2 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.V317889.R01.S.doc Version 5.2 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 7th March 2006 3. Date of last inspection Brief Description of the Service: Willow End offers care to 7 individuals with learning disabilities all of whom are accommodated in single bedrooms. There were 5 service users being cared for that 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.V317889.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The range of fees charged by the home per week at the time of inspection was from £754.60 to £1227.59. Overall the home was well maintained and decorated, providing individual and personalised bedroom accommodation. There is ample communal space for dining, sitting room and activities. Care management arrangements were well organised and appropriate to meet the needs of service users incorporating good arrangements for healthcare. Service users access the community and participate in activities and social outings, although this would be better organised with increased opportunity if assessed hours were being fully met. Recruitment procedures were well organised although some development is required to ensure that frequency of supervision meets with National Minimum Standards. Staff training is developing. What the service does well: What has improved since the last inspection? What they could do better: • • • • Some carpets require improvement. The quality assurance system needs to be completed. An application to register a manager needs to be made. Improve documents such as the Service Users Guide. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 6 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 End DS0000040671.V317889.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 End DS0000040671.V317889.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): Standards 1, 2 & 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • Service users benefit from information available within the Statement of Purpose in terms of advising representatives although the format of the service users guide needs to improve to increase accessibility. Service users admitted to the home benefited from the overall approach taken with appropriate assessment. Contract terms and conditions sampled indicated that the documents were not individual. EVIDENCE: The service Statement of Purpose was available for inspection and met with requirements. This is available upon request. The Service Users Guide was also available for inspection but the sample seen had not been produced in a format that would be considered suitable for service users to fully understand without considerable assistance. The service was not able to demonstrate the extent and type of assistance that would be required. The acting manager was advised that the document be produced in a more ‘easy read’ format and use a variety of media to ensure that service users can access the information more Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 9 readily. The document had, however, been personalised for each person and a version was seen that was available for a particular service user. The document did include all of the necessary information, although parts of the document relating to the role of CSCI will need to be amended in relation to referral of complaints and frequency of inspections for example. This was discussed with the acting Manager. Service users contractual arrangements were reviewed. A sample viewed indicated that for one service user the contract terms and conditions were not individualised, for example the service user was not mentioned by name and is unsigned and undated. No service users have been admitted since the previous inspection and therefore the homes practice in supporting people during the transitionary period was not reviewed, however, based upon samples of previous admissions, all demonstrated that appropriate assessment information was available. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 6, 7 & 9. • • • Service users mainly benefit from care planning arrangements and the homes approach to risk assessment and recording. Service users benefit from the support that carers provide to encourage decision making and choices although this could be better reflected within the plan of care as part of a person centred approach. Service users benefit from the risk management approach of the service. EVIDENCE: Care plans were examined as a sample to ascertain both compliance with requirements and reflection of good professional practice. The first care file sampled indicated that a pre-admission assessment had been undertaken by the supporting agency. The care plan had been previously reviewed, the most recent being January 2006. At this review the outcome concluded that a further review was required within six months (July 2006) although at the time Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 11 of this visit the review had not taken place and was 4 months overdue. The acting Manager advised the inspector that the review was to take place very shortly. The care plan structure is well designed and decisions were clear with achievable and realistic objectives. A number of objective outcomes had been set. The Inspector discussed this with the acting manager in the context that for the purpose of achieving priority objectives, the number of outcomes identified may be more that can be reasonably monitored. The Inspector advised that in terms of good practice, the number of objectives could be reviewed and placed in priority of short, medium and ongoing objectives. All key persons involved in the support of the service user are included in the plan with contact details. Typically these included relatives and supporting professionals. The plan indicated that arrangements had been made for the service user to attend a day centre twice weekly. The assessment activity was generally sound and highlighted clear areas of need and covered a wide range of risk areas. The plan has ‘implementation guidelines’ for 12 areas of need. These were well written and include clear guidance for staff to achieve outcomes. An example seen was a helpful step-by-step guide to assisting the service user with personal hygiene. This was very detailed and written in an informative way using plain English. Anyone reading it would be in no doubt as to how the service user was to be encouraged and assisted. This approach supports outcome continuity. It was not possible to check with the service user how helpful this approach had been. A health action plan is also incorporated within the plan. This focused upon specific healthcare issues, for example care and support with Epilepsy. This provided carers with a clear plan of action in the event the person has a seizure. Further supporting information was also available in relation to primary healthcare support, which was considerable within the sample file seen. The intervention and support by both GP and community nurse was recorded comprehensively and showed a sound control plan. The home maintains good recording practice for visits to professionals detailing all of the essential information required. healthcare Supplementary recording sheets were evident and these included, for example, monitoring for weight, which on the sample taken was an identified care related issue. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 12 A record of activities were evident including attendance at Colchester Institute on a life skills programme for a session one day per week (music related). A standardised approach was being used (ABC charts) for unwanted aggressive behaviour. The record indicated that the onset of these episodes had become less frequent as a result of medicine changes and, as stated by the Manager, a more consistent and measured approach to the persons support, however, for part of the inspection the service user was observed to display difficult and challenging behaviours, of which the carers supported and responded to in an appropriate manner. Each service user has a ‘health information file’ supplied by Essex County Council which enables a comprehensive recording format to be ‘portable’ and taken to healthcare appointments. Each service user has a daily narrative written which comprises of both a ‘code’ section relating to matters such as time of getting up, whether the person had a bath, cleaned their teeth, what they had for breakfast etc. There is also a free text section giving the carer opportunity to describe what the person did during the part of the day being reported upon. There is a section for morning and afternoon. Medicine records were well maintained and details of medicines were held within the care file. Risk assessments were in place identifying the risk associated with selfmedicating. A second sample of a care file was viewed and this showed a similar layout and structure. The care plan objectives were last reviewed April 06 and in a similar way the previous file had intended to be reviewed in 6 months (Oct 06), so this example was also overdue. This care plan indicated that the overall structure was flexible, in that the objectives were demonstrably different than that of the previous sample. In reviewing some supporting documents it was noted that some helpful symbol based signs were in place for service users use and an increasing number of documents are being converted into ‘easy read’ and symbol format. This approach if further developed within the care plan would be beneficial to service users. Overall, the care plans and supporting documents sampled lacked adequate evidence that service users had been fully consulted about decisions. Service users right to make decisions and choices was evidenced by the way in which carers supported service users within their daily contact. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 13 The arrangements the home makes with service users to support them with finances and accounting systems for those whose cash is being held in safe custody on their behalf were not examined on this occasion. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 15, 16 & 17. • • • • Service users benefit from community awareness. Service users benefit from family and friends. Service users benefit from service users. Service users benefit from activities associated with social, leisure and the arrangements to maintain links with the manner in which carers interact with the homes catering arrangements. EVIDENCE: Resulting from records kept and discussion with care staff, service users were demonstrably enjoying access to community facilities. Service users expressed interest in swimming sessions, going to the cinema and shopping. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 15 Some service users are encouraged to undertake simple gardening, where this involves use of power equipment such as a lawnmower, this needs to be subject to a suitable risk assessment and adequate training. It is recommended that both processes be regularly repeated to ensure those involved are safe and adequately supported. Service users attend further education classes within the community on a session basis and attend two day centres. No service users undertake employment or are involved in a work substitute scheme. Based upon the information available and discussion with carers and service users, integration within the community is satisfactory although service users mainly access services designed for people who are disabled. The home facilitates and supports positive links with family and friends. The visitor’s book was being maintained and showed frequent visits by family. One person explained that they were going to visit relatives over the weekend. The care plans sampled did not include matters associated with personal and intimate relationships or address these matters as part of long term planning. Carers where observed to provide sensitive and considered support to service users, at times under challenging circumstances, with appropriate tone, verbal and body language and volume. The overall quality of interaction was considered good. The way in which carers went about their tasks and interacted with service users suggested that ‘rules’ within the house were kept to a minimum and that a flexible and informal atmosphere existed. This was demonstrated at mealtimes, for example. The mealtime was well planned and appropriately recorded to fulfil requirements, although at the time presented as relaxed and service users were observed to enjoy their meal in pleasant and comfortable surroundings. (See environment). Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 & 20. • • • Service users benefit from the way in which carers provide personal support. Service users benefit from having their physical and emotional health needs met. Service users benefit from the homes practice in administration of prescribed medicines. EVIDENCE: Based upon observation and discussion with service users and carers, the quality of communication and support was good. Cares sought service users preferences and where service users required support with the outcomes of their behaviour, which at times was challenging, this was managed in a calm, supportive and appropriate manner. The ‘rules’ within the home are flexible in that, for some service users who require more structure to their day, the care plan sets out the way in which Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 17 choices are presented. planning objectives. The approach is varied in accordance with care Of the bedrooms visited, all were individualised and this was further example of how the service strives to ensure that each service user is supported as uniquely as possible. The service also has various equipment for mobility and this includes wheelchairs specifically adjusted for the needs of the user to moving and handling equipment. Some service users needs require a multidisciplinary approach including the involvement of a Physiotherapist. The service operates a key-worker style arrangement, which further contributes to the move toward an individual approach to the care outcomes for each person. Based upon records and discussion with carers the service is aiming to ensure that the support provided to service users is as user-focussed as possible. The healthcare records demonstrated that all required primary healthcare services such as Optician and Dentist were regularly accessed. The home have consulted with service users about consent regarding medicines and have included a consent form within the care plan, the sample seen was signed and dated. The medicines being held in safe custody and administered by the home is a monitored dosage type. The procedure for care staff to assist service users to take their prescribed medicines was not observed on this occasion, although the administration record was accurately maintained. All carers who undertake assistance with medicines have received training by the medicines supplier. The medicines were securely held. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Standards 22 & 23. • • Service users mainly benefit from the homes arrangements in managing complaints. Service users are protected by the homes arrangements for safeguarding adults. EVIDENCE: This inspection was undertaken over two days and for the most part, the acting manager was in attendance. The first day of inspection continued into the early evening and following the departure of the acting manager a senior carer was delegated the responsibility for the home. During the early evening the care staff were asked for a copy of the complaint procedure that were unable to locate it, although did produce a complaint logging form used internally when a complaint has been received. On the second day of inspection the acting manager, when asked, produced the procedure and it was noted that a copy produced in ‘widget’ symbols and plain English was on the notice board in the hallway for the use of service users. In addition the service user format included the photographs of three key carers to indicate whom service users could complain to. The acting manager will need to ensure that all senior carers who take charge of the home in the absence of the management are familiar with the location of key documents, policies and procedures. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 19 The acting manager advised the Inspector that the home had not investigated any complaints or made any safeguarding adult referral during the period since the last inspection. CSCI have received no complaints about this service and are unaware of any safeguarding adults referrals made during the same period. The home was in possession of the ‘Safeguarding Adults’ pack provided by the local authority and in addition, the home has a comprehensive guidance document for staff. Whistle blowing arrangements were well developed and staff interviewed demonstrated a sound understanding of the principles involved. All carers are following a distance learning pack provided by Essex County Council covering safeguarding adults. Two cares interviewed during this inspection were both very positive about the home and giving examples of good practice in safeguarded adults. They described the home as being very informal and being focussed upon the care and needs of service users and promoting choice making. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 24 and 30. • Service users mainly benefit from the homely, clean and well furnished accommodation. EVIDENCE: As previously stated the inspection covered two periods of the day over two dates. In addition to a tour of the building on the first day the Inspector spent time in both the communal areas. Overall the building is well decorated and furnished although carpets in the dining room and lower activity room remain in need of either deep cleaning or replacement. The acting manager discussed with the Inspector the possible alternatives to carpet in areas where heavy soiling was a difficulty. Options are available although the environment will need to remain reflective of a homely and comfortable setting. Those persons who require the use of wheelchairs for mobility were observed to be able to move around the home without undue restrictions. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 21 The home does not operate respite and short stay services. The premises are a bungalow located within a residential development and is in keeping with the style and design of properties nearby. The home has good gardens accessible by service users. The front of the property has a large area for vehicular parking. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All standards in this group were checked. • • • • • • Service users benefit from the clarity of staff roles and responsibilities. Service users do not fully benefit from being supported by competend and qualified staff. Service users do not fully benefit from support provided by an effective staff team. Service users benefit from the homes recruitment practices and policies. Service users benefit from the homes approach to the organisation of care staff training and development. Service users do not fully benefit from the arrangements for staff supervision. EVIDENCE: As part of the inspection process, a sample of staff records were examined and carers interviewed and practice observed. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 23 Since the previous inspection of this service several staff have been recruited. Recruitment practices were reviewed by discussion with the acting manager and by examining the actual practice of recruitment. One carer commenced employment in April 2006. The senior support worker provided two references and other required information to meet regulatory requirements, including a Criminal Record Bureau (CRB) and ‘POVA first’ check. This employee does not have a National Vocational Qualification at level 2 (NVQ2) but does have a Nursing qualification awarded overseas. The person was given a period of induction following recruitment although the only supervisory session recorded as having been provided was dated October 2006. The frequency stated within National Minimum Standards is six per year and therefore the frequency for this employee was not adequate. A supervisory contract was on file. The carer had attended a number of in-house training sessions including the administration of prescribed medicines, moving and handling and care planning. A copy of the job description was on file. A further carer file was examined for an employee who commenced in August 2006. All of the recruitment procedures were found to be satisfactory, including a CRB and ‘POVA first’ check. The carer undertook an in-house induction. A supervision agreement was in place. A third example was reviewed of a carer who stated employment May 2006. All recruitment checks CRB and POVA 1st checks had been carried out. An induction had taken place and a job description was available. Whilst a supervision contract was in place and a supervisory session was due in July 2006, no evidence was found of the scheduled session or any thereafter. Training had been provided on stress management, Safeguarding Adults, Moving and Handling and the Mental Health Act. This employee had attained an NVQ2 qualification in care. A final example was taken for a carer who had been employed by the home for a longer period April 2004). Recruitment practice was satisfactory, including CRB. A supervisory contract was in place although the file indicated that at total of Seven sessions had been undertaken since recruitment, which is below the frequency set out in National Minimum Standards. All of the files sampled presented as well organised. Of all the staff currently employed, 27 have achieved an NVQ2 qualification. A further 27 are in the final stage of completion and the remaining 46 are scheduled to commence training toward this qualification in January 2007. National Minimum Standards require that at least 50 of carers should be qualified to NVQ2 in care and therefore, at present, this standard is not yet achieved. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 24 The files show that some training has been undertaken in addition to NVQ2 and a staff training plan is maintained. This incorporates a yearly training planner to ensure that some training is revisited to top up skills. At the time of inspection a trainer was visiting the home to deliver equal opportunities training to carers. During this training there were adequate additional carers to support service users, however, the acting manager will need to continue to review the appropriateness of using service user accommodation for this staff activity and to carefully demonstrate the consultation and agreement methods with service users in this regard. The staff to service user ratio is calculated using a method recommended by the Department of Health. This method assesses the required care hours to be 385.96 hours per week. The rota sampled indicated that 360.50 hours are being deployed. This does not include an allowance for care staff to undertake non-care related tasks such as cooking cleaning and laundry/housekeeping tasks, although it is accepted that a small proportion of these tasks are undertaken with service users and are therefore included within the care hours. Overall the assessment and deployment figures suggest that an increase in care hours are required. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 37, 39 & 42. • • • Service users do not yet fully benefit from the service being managed by a person registered by the Commission. Service users do not benefit from the service quality assurance and monitoring system. Service users benefit from the homes approach to health and safety. EVIDENCE: Whilst the acting manager is experienced and has obtained a suitable qualification (Registered Managers Award), no application to register with the CSCI has been received to ensure that the day-to-day management of the home is being undertaken by a person judged by the Commission to be ‘fit’ under the meaning of the Care Standards Act 2000. The acting manager has Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 26 been in day-to-day control of the home since approximately April 2006, and therefore an application to register is considerably overdue. The acting manager gave an explaination to the Inspector for the delay. Based upon the findings of this inspection and various other information received about the service, there is no presenting concern about the overall way in which the home is, or has been, managed, however the regulatory requirement has not been met. The Acting Manager showed the Inspector the developing Quality Assurance and quality monitoring system. This appeared to be a comprehensive and detailed approach covering all aspects of the home. The approach includes a questionnaire that is currently being developed for service users in an ‘easy read’ and symbol format. At the time of this inspection this was not ready to be used and no recent stakeholder information has been collected to inform how the home is performing in terms of quality outcomes. The Registered Person will need to ensure that the home has a quality monitoring system, based upon the consultation of service users and their representatives, which has been subject to analysis to show how the home is addressing quality issues and to drive improvement. A report on the outcome of this should be sent to the Commission and made available to service users and their representatives. On this bases, the regulatory requirement in relation to quality assurance was not being met. This has been a requirement carried forward from the previous inspection, although it was evident that the overall approach to quality and monitoring will be more comprehensive that the system proposed by the home at the time of the previous inspection. CSCI forwarded questionnaires to the home for distribution prior to the inspection. Based upon the forms returned, all expressed satisfaction with the service, however the forms returned at the time of the inspection were relatively few. Various checks were made on the safety equipment in operation at the home. These included the fire alarms and equipment, emergency lighting, gas safety and portable electrical equipment. All were found to have been checked, where appropriate, by a competent person. The home also maintains a Care of Substances Hazardous to Health register, which contained hazard data sheets of substances used within the home, mainly for cleaning. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 27 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 2 2 3 3 X 4 X 5 2 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 3 32 2 33 2 34 3 35 3 36 2 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 3 X 2 X 2 X X 3 X Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 28 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 YA1 YA5 2. YA32 Regulation 5(1 to 4) and 6. 18(1)(a) 18(2)(a) 18(5)(b) Requirement The Registered Person must ensure that the Service Users Guide meets with the regulatory requirement. The Registered Person must ensure that staff employed at the care home are trained and supervised to standards as set out in regulation and described within National Minimum Standards. The Registered Person must 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. This is a repeat requirement. Timescale for action 31/01/07 31/03/07 2. YA39 24 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 29 1 2 YA30 YA37 The Registered Person is recommended to attend to the carpets located within the home that require either deep cleaning or replacement. The Registered Person is recommended to apply for a manager to be registered with the Commission. Willow End DS0000040671.V317889.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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