Inspection on 16/02/09 for 116 Ashurst Road

This inspection was carried out on 16th February 2009.

CSCI found this care home to be providing an Excellent service.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

116 Ashurst Road 02/05/06

116 Ashurst Road 30/08/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Willow Holdings (UK) Ltd Trading As Willow Care Homes 116 Ashurst Road North Finchley London N12 9AB     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Julie Schofield     Date: 1 6 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: Willow Holdings (UK) Ltd Trading As Willow Care Homes 116 Ashurst Road North Finchley London N12 9AB 02084920363 02084920363 willowcarehomes@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Willow Care Homes Ltd care home 6 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: Date of last inspection Brief description of the care home 6 116 Ashurst Road is an extended detached home registered for six adults aged 18 - 65 with learning difficulties, who may have some additional health needs. The home is situated close to shopping areas of North Finchley and Friern Barnet with easy access to buses and tubes and links to central London. The home was opened in May 2005 and is owned and operated by Willow Care Homes Limited. The home consists of six bedrooms, each with their own en-suite facilities. There is a bathroom on the ground floor. Each bedroom is decorated to the individual taste of the resident. There is a staff room on the first floor, with an en-suite toilet. There is a well equipped laundry room. The office is to the ground floor. There is a communal lounge, dining room, laundry room and large kitchen. To the front exterior of the home, there is off street parking for several vehicles. To the rear of the home is a large well kept garden. The Statement of Purpose states that the aim is to provide a service for adults with learning difficulties who may have some additional health or behaviour needs and Care Homes for Adults (18-65 years) Page 4 of 33 Brief description of the care home may have relatively high levels of dependency. Information about the fees charged for the service may be obtained, on request, from the home. Care Homes for Adults (18-65 years) Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The inspection took place on a Monday in February. It began at 8.25am and finished at 5.35pm. During the time that we were in the care home we met each of the residents and had the opportunity to speak privately with most of them. With the permission of the residents we carried out a tour of the premises which included looking at the residents rooms. Lunch was served during the inspection. We spoke with the manager and with the responsible individual and discussed the running of the home. We looked at records, policies and procedures and case tracked the care of a number of residents. We reviewed the information supplied in the Annual Quality Assurance Assessments that had been returned to the Commission for Social Care Inspection and the information they supplied as part of the Annual Service Reviews. We also spoke with members of staff. At the time of writing the report we have received 3 completed staff Care Homes for Adults (18-65 years) Page 6 of 33 survey forms. We would like to thank everyone for their assistance during the inspection and for their comments. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get Care Homes for Adults (18-65 years) Page 8 of 33 printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. An assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. The prospective resident or their representative is assured that each of the needs of the resident is identified and addressed during the assessment process by involvement in the process. Evidence: All the residents living in the home at the time of the inspection were also present during the previous key inspection of the home in 2006. At the previous inspection the service demonstrated a process prior to the admission of the resident that included an assessment of the needs of the resident by the funding authority and an assessment carried out by the manager of the home. This enabled the manager to confirm that the service provided by the home could meet the needs of the prospective resident. Previously a statutory requirement had been made to address the lack of involvement in the homes assessment process by the prospective resident or by their representative. Although the home has not had the opportunity to demonstrate that Care Homes for Adults (18-65 years) Page 11 of 33 Evidence: this involvement now forms part of their pre admission procedure the manager confirmed that the procedure had been amended to comply with the requirement. Care Homes for Adults (18-65 years) Page 12 of 33 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Reviewing care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed. Residents are assured that their financial interests are protected by accurate record keeping. Responsible risk taking contributes towards the resident leading an independent lifestyle. Evidence: Each case file contained client support guidelines, which were in essence the plan of care. The guidelines were comprehensive and covered all aspects of the residents life. The document was signed by the resident. Areas covered included medication, communication, diet, leisure needs, personal care, religion and finances. The support guidelines had been recently reviewed. Copies of care plan review reports were on file. Files also contained records of skills development and these included areas such as making a snack or managing money. The manager said that the funding authority had reviewed the placement of each of the residents in November 2008, although the minutes of the meetings had not yet been forwarded to the care home. Care Homes for Adults (18-65 years) Page 13 of 33 Evidence: When members of staff were asked on the survey form whether they were given up to date information about the needs of the people they supported they ticked always. One member of staff added that the needs of clients are discussed at meetings, hand overs and during supervision. A resident attends a self advocacy group and showed us the invite that they had received for the next meeting. We looked at the financial records of the residents that were selected for case tracking. We saw that balance sheets were kept, which were up to date. The sheets contained details of the running total after each transaction and balances were checked on a weekly basis. Items of expenditure were supported by numbered receipts and details of savings were available. The financial records were satisfactory. Case files contained risk assessments that are reviewed on a six monthly basis. They are tailored to the individual needs of the residents. Areas covered included cooking, using the stairs, walking to the shops and going on holiday. The assessments included risk management strategies. They were signed by residents. Care Homes for Adults (18-65 years) Page 14 of 33 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents attending day care services are provided with an opportunity to develop their social skills. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. A varied and wholesome diet is offered to residents so that their nutritional needs are met. A more detailed menu would demonstrate that choices are always available to residents. Evidence: A discussion about day care provision took place with the manager and with the residents. The manager said that each resident had a programme that included a day centre and/or college placement. This involved between 3 and 5 days per week outside Care Homes for Adults (18-65 years) Page 15 of 33 Evidence: the care home. One of the residents said that they went to a day centre and to a college. While at college they took part in cookery sessions. Another resident said that they were using a computer at college. On the day of the inspection 4 of the 6 residents were based at home as it was half term. Residents make good use of community facilities and resources including restaurants, shops, pubs, parks, leisure centres, the cinema, bowling alley and library. Residents said that they use public transport and a resident said that she had a bus pass. The home has their own transport and a member of staff does most of the driving, taking residents to and from day centres. However, when this member of staff is off work the manager covers the duties. Residents said that they had been on a boat trip and the manager said that other outings that had taken place in 2008 included trips to a museum, Madame Tussuads, the Dr Who exhibition and Whipsnade. There was a selection of games in the home for residents to use and in the corner of the lounge there was a table, which is used for arts and crafts work. During the inspection one of the residents came to sit at the table to do some painting. One of the residents said that they go to America to visit relatives. Residents have the opportunity of taking part in an annual holiday arranged by the company and a member of staff said that there had been a house meeting where residents had chosen the venue for this years holiday. They had chosen Centre Parcs. Annual holidays have previously taken place to Somerset and to the Isle of Wight. A resident showed us a photograph taken while he was on holiday in the Isle of Wight. Some residents attend clubs that take place in the evening. Residents confirmed that they received visits from members of their family and that the members of staff on duty made visitors feel welcome when they call. They said that they sometimes talked with their visitors while sitting in the lounge or sometimes talked while sitting in their bedroom. Some of the residents enjoy outings with their relatives. One of the residents visits their relative, with a member of staff provided as an escort because the health of the relative prevents them visiting the care home. Residents are encouraged to take part in the daily routines of the home so that they develop independent living skills. A resident said that he helps around the house. We saw that as residents finished a meal they were encouraged to clear their plates from the table and place these in the dishwasher. Residents are able to exercise choice and this includes deciding whether they want to socialise with other residents, what activities they wish to see offered, whether they want to take part in activities, what items they want to see on the menu and what clothes they want to wear each day. Their right to privacy is respected and they can spend time in their rooms, without unnecessary interruptions, if they wish. Care Homes for Adults (18-65 years) Page 16 of 33 Evidence: Residents said that they enjoyed the meals served in the home and a resident said that their favourite meal was sausages and chips. We were told that residents are able to help with the preparation of main meals and that one of the residents likes to peel vegetables. We looked at the menu on display for week commencing the 16th February and then for weeks previous to this. Not every menu included details for Saturday lunchtime and although the menu was varied the type of vegetables served was not always specified. Alternatives to the main dish were not always shown on the menu. There is a good selection of fruits in the kitchen from which residents help themselves. We saw that most residents made themselves a breakfast and drink and that one resident made the sandwiches for his packed lunch. He said that he liked the sandwich filling. The manager said that when the meal was roast pork all the residents ate this including 2 residents that are Jewish. She said that this is the choice of the residents and that their families are aware of this. This was not clear from reading information provided by the funding authority. During the inspection residents had lunch and they had a choice of either a sandwich or a pasta dish. The dining area has 2 small tables so that residents are able to choose who they want to sit with at meal times. The home has achieved 3 stars in the Score on the Door scheme operated by the Environmental Health department. Care Homes for Adults (18-65 years) Page 17 of 33 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive assistance with personal care in a manner, which respects their privacy. Arrangements are in place to ensure that residents healthcare needs are met. The general well being of residents is promoted by assistance and support from staff in taking medication, as prescribed. Evidence: Residents are encouraged to take a pride in their appearance and we spoke to a resident that was wearing a shirt and tie and who looked clean and smart. Residents have their hair styled at local hairdressers. All residents need some assistance with personal care although the level of support varies from prompting to direct assistance. The staff team consists of male carers and female carers and the manager confirmed that female residents receive assistance with personal care from a member of staff of the same gender. Morning personal care routines were recorded on case files. Residents confirmed that they had access to health care facilities in the community. A resident told us that when she goes to the doctor she visits the surgery. We looked at three residents case files and these demonstrated that regular appointments with the Care Homes for Adults (18-65 years) Page 18 of 33 Evidence: dentist, optician and chiropodist took place. Residents had the chance to have a flu jab. Their medication was reviewed on a regular basis. There was also evidence of support to attend out patient clinics at the hospital, including a memory clinic and an epilepsy clinic. One case file included guidelines for the management of epilepsy and for administering rectal diazepan. Regular appointments with the psychiatrist were recorded. We noted that case files contained weight records but we queried one of the weights with the manager who agreed that either the scales were inaccurate or a mistake had been made by the member of staff in the reading of or the recording of the weight. We spoke with the member of staff that was responsible for administering medication to residents at breakfast time. None of the residents self medicates and we saw on the residents case files that there were individual consent to assistance with medication forms that the resident signed. We watched how medication was administered and noted that it was on an individual basis and that tablets were offered with sufficient water to enable comfortable swallowing. The home uses the blister pack system of administration and the member of staff was able to explain why some items were unsuitable for including in the blisters and how these were given. They confirmed that they had received medication training from an accredited trainer. We looked at the records. They were up to date and complete. The medication file also contained a copy of the homes medication policy and its policy in respect of homely remedies. Records are kept of medication returned to the pharmacist. We looked at the monitored dosage system used. The blisters had been opened in accordance with the time of day and the day of the week that the inspection was carried out. Any medication that was not stored in the blister packs was stored safely within the medication cupboard. Care Homes for Adults (18-65 years) Page 19 of 33 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A complaints procedure is in place to protect the rights of the residents. To assure residents that it is easy to use a more appropriate format is needed. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. Evidence: Although the home has a copy of the complaints procedure in the policies and procedures manual a copy is not on display in the home. We looked at the copy in the manual and confirm that it contained timescales for each stage of the process and that it informed complainants of their right to contact the Commission for Social Care Inspection. Complainants are advised that complaints will be investigated and that they will be notified of the outcome and receive a copy of the investigation report. Since the last annual service review 1 complaint has been received and after looking at the records it was noted that the complaint was partially substantiated. Residents said that they could talk to a member of staff if there was something that they were not happy with. The manager said that residents could make a complaint verbally rather than in writing. She agreed that the format of the procedure was not user friendly for all of the current residents. When members of staff were asked on the survey form whether they knew what to do if a resident or relative or advocate had concerns about the home they all ticked yes. A member of staff added that there was a procedure and that forms were available. Care Homes for Adults (18-65 years) Page 20 of 33 Evidence: Members of staff on duty confirmed that they had received training in the protection of vulnerable adults and when we spoke with them they were able to outline their responsibilities in the event of an incident of abuse occurring or in the event of a disclosure being made. The manager said that during staff meetings there are updates and reminders about protection of vulnerable adults procedures. A copy of the homes procedure was available and we noted that it included a link to whistle blowing. The home was also able to show me a copy of the Multi Agency Adult Protection Policy and Procedure from the local authority. The manager said that no allegations or incidents of abuse have been recorded since the last key inspection. Residents said that they could talk to a member of staff if there was something that they were not happy with. Care Homes for Adults (18-65 years) Page 21 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home, which is comfortably furnished and provides a pleasing environment in which they can relax and enjoy themselves. Cleaning or replacing the carpet on the stairs and in the lounge would assure residents that standards are maintained. Good standards of cleanliness provide residents with hygienic surroundings. Infection control training for all members of staff would assure residents that the risk of cross infection is minimised. Evidence: During the inspection we carried out a site visit. We saw that the furnishings and decoration were of a good quality and that there was a homely environment for residents. However, the carpet in the lounge and on the stairs was stained. Communal areas are of a good size and there are toilet and bathing facilities on each floor. Residents showed us their bedrooms. We saw that one of the bedrooms on the first floor had an en suite facility that was 3 steps down from the floor level in the bedroom. One resident said that they had a very nice room that was on the ground floor. The room had a toilet. The home has a no smoking policy inside the house and residents go outside if they wish to smoke. There is a beautiful garden at the rear of the property and there is Care Homes for Adults (18-65 years) Page 22 of 33 Evidence: access to this from the dining room and from the kitchen. There are steps down from a strip of decking to the patio and lawn areas. The garden contains mature shrubs and trees. The current residents are able to use the steps. We saw when we were walking around the home that all areas were clean and tidy and the home was free from offensive odours. Laundry facilities are situated on the ground floor. Access to these does not involve walking through any area where food is stored, prepared or consumed. The facilities consist of domestic appliances. The manager confirmed that none of the current residents have continence problems and so facilities with a sluicing cycle are not required. Only a few members of staff have completed infection control training. Care Homes for Adults (18-65 years) Page 23 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A programme of NVQ training for members of staff assures residents that care practices are based on an understanding of the residents needs. Staffing levels in the home assure residents that there are sufficient members of staff on duty each day to support the residents and to meet their needs. Recruitment practices promote the welfare of residents and reviewing the validity of documents that need to be kept on file would assure residents that the process is thorough. Residents benefit from support given by members of staff that are skilled and trained. Evidence: A member of staff confirmed that they were currently undertaking NVQ level 3 training. Another member of staff said that they were in the middle of an NVQ level 2 course of training. The third member of staff had been studying for an NVQ level 2 qualification with their previous employer and hoped to begin training again soon but at the next level. We discussed NVQ training with the manager and reviewed all of the members of staff listed on the rota. The home has passed the target of 50 per cent of carers achieving an NVQ level 2 or 3 qualification, when members of staff are included that have completed their portfolio but are waiting for their work to be assessed. We discussed staffing levels with the person in control and we looked at the rota for Care Homes for Adults (18-65 years) Page 24 of 33 Evidence: week commencing the 15th of February. Usually 3 people are on duty on the early shift and 3 people on duty on the late shift. At night 1 member of staff is on duty on a waking night basis. The manager may be one of the 3 members of staff on duty on certain days. Her duties can include working at the weekend. However, when she works a 10am to 6pm shift this is supernumerary to the rota and allows her time to carry out her managerial duties. When residents were asked about the members of staff that supported them a resident said that the staff were nice and that he had a key worker that was helpful. Another resident described the members of staff as kind and said that residents have fun with them. When members of staff were asked on the survey forms whether there were enough staff to meet the individual needs of all the residents, 2 members of staff ticked always and 1 member of staff ticked usually. We examined the personnel files belonging to 3 members of staff. We saw that each file contained an application form that included a declaration by the applicant regarding whether they had been cautioned or conviction of any crime. Each file contained evidence of 2 satisfactory references, declaration of health, proof of identity and an enhanced CRB disclosure. One file contained a copy of a residence permit with limited leave to remain that had expired in 2005. We spoke with members of staff about the training they have received. One member of staff said that although they had previously worked in a residential care setting prior to joining the Willow Care Home they had still received a full programme of induction training that had lasted for longer than a week. They said that induction training was important as it helped members of staff to carry out their job well. They confirmed that they had received training in mental health, epilepsy, protection of vulnerable adults, first aid and fire safety. When members of staff were asked on the survey form whether their induction covered everything they needed to know to do the job when they started, 2 members of staff ticked very well and 1 member of staff ticked mostly. When asked whether the training that they have been given since starting to work in the home is relevant to their role, helps them to understand and meet the individual needs of the residents and keeps them up to date with new ways of working they all agreed that it did. The training checklist matrix was available for us to look at and a new training programme starts in March 2009 for the next 6 month period. Training is to include medication, protection of vulnerable adults procedures and safe working practice topics. Care Homes for Adults (18-65 years) Page 25 of 33 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager demonstrates her competence and commitment to a quality service by continuing to develop her understanding, skills and knowledge through further training and staff praise her support. An excellent system is in place to gather feedback on the quality of the service provided to enable the service to develop in ways that meet the changing needs of the residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. Evidence: Since the last key inspection a new manager has been appointed. This was in January 2007. Her previous experience includes working at a managerial level in a care setting for this client group for 4 years. She has completed an NVQ level 4 qualification and will commence the RMA in March 2009. She continues to update her knowledge and skills by attending short training courses and sessions. These have included training in respect of the Mental Capacity Act, a leadership skills course and training in first aid, Care Homes for Adults (18-65 years) Page 26 of 33 Evidence: manual handling, fire safety and infection control. Members of staff praised the support given by their manager and 1 member of staff said that the manager is very good, that she always is supporting members of staff and that she checks with members of staff about things. They also said that they can see the manager any day. When asked on the survey form whether their manager meets with them to give them support and to discuss how they are working each of the 3 members of staff ticked regularly. A member of staff added that the support given by the manager made their job enjoyable and easy. Members of staff praised the ethos of team working in the home and one person described it as one team, all working together. We discussed quality assurance monitoring systems with the responsible individual. The policy of the home is that an external auditor visits the home on a six monthly basis. A thorough audit of the home takes place and the report of the last audit from November 2008 was available. The scope of the audit is linked to the National Minimum Standards and provides a good assessment tool for the company to use to identify the need for change. Areas within the audit included service access and information and service provision and support. During the audit the auditor meets and talks with residents and sends surveys to stakeholders. After the auditors report is received an action plan is drawn up that can then be monitored on future audits. Members of staff have received training on quality assurance. This is an excellent and robust system that accompanies the other means by which feedback is received. Other means include feedback from residents on a day to day basis, during meetings with their key worker or during review meetings and feedback from relatives and funding authorities during review meetings. We looked at the certificates for checking or testing systems or equipment in use in the home. There were valid certificates in respect of the electrical installation, the portable electrical appliances, the emergency lighting, the Landlords Gas Safety Record, the fire extinguishers and the fire alarms. The fire risk assessment had been reviewed in May 2008. Fire alarms are tested on a weekly basis and the last fire drill was held in November 2008. Members of staff receive training in safe working practice topics. Care Homes for Adults (18-65 years) Page 27 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 17 15 Care plans must be clear 01/05/2009 about religious and dietary needs when residents have chosen to eat food that does not form part of their cultural background. This will enable the home to demonstrate that the resident has chosen not to adhere to religious or cultural expectations. 2 17 17 When writing the weekly 13/04/2009 menu details of each lunch and details of alternatives to the main meal must be included. The type of vegetables needs to be recorded. This will demonstrate that choices are available to residents and that there is sufficient information to enable residents to make an informed choice from a menu that offers a wholesome and varied diet. Care Homes for Adults (18-65 years) Page 29 of 33 3 22 22 When reviewing the complaints procedure a format must be agreed that meets the needs of the residents. This will enable residents to understand and to use the procedure more easily. 01/05/2009 4 22 22 A copy of the complaints procedure must be on display in the home. This will enable residents, members of staff and visitors to the care home to be aware of what to do if they wish to complain. 06/04/2009 5 24 23 When planning the future development of the home the needs of prospective residents with limited mobility or the needs of current residents whose mobility has deteriorated over time must be included. To enable residents to have access to all facilities inside the home and to access the garden. 01/07/2009 6 24 16 After reviewing the condition 01/07/2009 of the carpet on the stairs and in the lounge it is either cleaned or replaced. To enable residents to enjoy communal areas where their upkeep is to a good standard. Care Homes for Adults (18-65 years) Page 30 of 33 7 30 13 When drawing up the training needs analysis for the staff team the need for infection control training is included and provided. to enable members of staff to develop their understanding and care practice so tht the risk of cross infection is minimised. 01/07/2009 8 34 19 When reviewing staff files a check must be made of the validity of all documents. This will ensure that documents that have expired are brought to the attention of the member of staff and a copy of a valid updated document is placed on file. 13/04/2009 9 35 13 That the new training programme starting March 2009 includes training in manual handling. This will enable members of staff update and refresh their knowledge on an annual basis in accordance with good practice guidelines. 01/07/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 6 That the manager contacts the funding authority, on behalf of the residents, to request copies of the minutes of the review meetings that took place in November 2008. Care Homes for Adults (18-65 years) Page 31 of 33 2 13 That the number of members of staff that are able to drive the companys transport increases so that the manager does not have to leave her duties to drive residents to and from day centres. That greater care is taken when weighing a resident or when recording the weight in the residents case file. If fluctuations in weight appear excessive the accuracy of the weighing scale is checked. 3 19 Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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