Inspection on 07/03/06 for Willow End

This inspection was carried out on 7th March 2006.

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

The inspector found 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 3 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 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 Unannounced Inspection 7th March 2006 10:00 Willow End DS0000040671.V286280.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.V286280.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.V286280.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.V286280.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 14th December 2005 Date of last inspection Brief Description of the Service: Willow End offers care to 7 individuals with learning disabilities. 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.V286280.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken to ensure that all of the National Minimum Standards that apply to the service had been inspected during the period 1st April 2005 to 31st March 2006. The majority of standards were assessed during an inspection undertaken on 14th December 2005, less than 3 months prior to this current inspection, so the aim was to revisit those standards not achieving minimum requirements and to inspect those standards not previously assessed. This inspection concluded that the service provides a good standard of practice, overall, notwithstanding the shortfalls noted. Two of the shortfalls noted at the previous inspection have been carried forward as not having been resolved. The time scale agreed for these standards having now expired. It was disappointing to note that these matters had not achieved the minimum requirements. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 6 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.V286280.R01.S.doc Version 5.1 Page 7 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): 3, 4 & 5 • Services users are not yet fully assured that their needs and aspirations will be met. EVIDENCE: The service provided meets with a high proportion of National Minimum Standards, although some key practice requirements remain in need of development to meet minimum requirements. On this basis the service, whilst working toward full compliance, is unable to demonstrate full capacity to meet service users needs. The service has an admissions policy and practices procedure to assist the transition arrangement for enabling a person to move into the home. This specifies the underpinning rights and responsibilities of the service user and of the service. However, one anomaly was noticed in that the trial period was stated to be either 6 or 3 months, according to either the policy or the terms and conditions document. This needs to be harmonised. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 8 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): 10 • Service users do not fully benefit from the service policies and procedures regarding confidentiality. EVIDENCE: Overall, the approach to confidentiality was satisfactory, with information being maintained in a way that prevents sensitive information becoming available to those who should not have access. The home has an office separate from service users and visitors and there are lockable cupboards and filing cabinets. The policy regarding matters associated with the disclosure of abuse requires review to ensure that service users are protected appropriately. For example, where the service becomes aware of an abuse disclosure the service user confidentiality must be maintained, subject to the potential risk to other service users, whereby disclosed data and material may not be subject to confidentiality. These matters need to be set out within the home’s guidance and procedures for staff. See National Minimum Standard 23. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 9 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): 17 • Service users benefit from a balanced diet, at times suitable for individual lifestyles. EVIDENCE: The service recently submitted a pre-inspection self-assessment, which included a range of supporting data. Included was a sample menu for service users that reflected a suitable planned week of various meals. The menus are produced on a weekly basis, although service users are said to be offered an alternative if a planned meal is unwanted. On the day of inspection the menu planned for the week was of equal variety and food stocks reflected the planned meals. The person in charge advised the Inspector that none of the service users accommodated require special diets. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 10 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): 21 • Service users benefit from a well planned and sensitive approach to illness and end of life issues. EVIDENCE: The practice associated with serious illness and end of life issues are a challenge, at times, for carers working with adults who have learning disabilities. Based upon a sample taken, the home had carefully and comprehensively worked with the loss and bereavement issues, associated with the end of life, of a service user’s relative and this was seen as an example of good practice. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 11 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): 23 • Service users do not yet fully benefit from a comprehensive approach to managing Protection of Vulnerable Adult (POVA) issues. EVIDENCE: The POVA arrangements were reviewed and found to be, in the main, satisfactory, although the link between the procedure and practice was not made in relation to determining how the service would respond to a disclosure, in particular to the lead body (Essex Social Services) in appropriately carrying forward any matter for investigation. The POVA procedure needs to ensure that the practice, throughout the disclosure and action phase, is clear, including who should be contacted and when. Other issues need to be made clearer, such as preservation of potential evidence in matters that may be investigated as a criminal matter. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 12 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 • Service users benefit from a homely and comfortable environment. EVIDENCE: All of the standards associated with the environment were examined at the December 2005 inspection and were found to meet with requirements. At this inspection a tour of the premises was undertaken and, whilst there was no specific review of the home undertaken, the Inspector noted that each of the visited rooms were comfortable, pleasant and well furnished. None of the rooms visited had any unpleasant odours and there were no obvious health and safety hazards noted. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 13 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): • None of the standards within this group were assessed on this occasion. EVIDENCE: All of the National Minimum Standards associated with staffing matters were reviewed during the December 2005 inspection and were found to comply with requirements. There were no obvious staff related issues raised during this inspection that would indicate further examination of the individual standards. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 14 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): 39 • Service users do not fully benefit from a quality assurance and quality monitoring approach. EVIDENCE: The quality assurance system requires further development to meet National Minimum Standards. Whilst the system could not be fully examined, in the absence of the Registered Manager, the data indicated that no analysis of the information gathering had been undertaken to draw any conclusions or outcomes to form a quality related action plan. Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 X X 2 X X X X Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 16 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 YA3 Regulation 22, 14(1d) 22(7) Timescale for action The Registered Person must 30/05/06 ensure that the home has the capacity to meet service users’ needs. The Registered Person must 30/05/06 ensure the home’s POVA procedure is revised to ensure continuity of reporting and safe action. This is a repeat requirement. The Registered Person must 30/05/06 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. This is a repeat requirement. Requirement 3. YA23 4. 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. Refer to Standard Good Practice Recommendations Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 17 Willow End DS0000040671.V286280.R01.S.doc Version 5.1 Page 18 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.V286280.R01.S.doc Version 5.1 Page 19 - 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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