Inspection on 14/05/07 for Willow House

This inspection was carried out on 14th May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow House 21/04/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Willow House 229 Portland Road Edgbaston Birmingham B17 8LS Lead Inspector Kerry Coulter Unannounced Inspection 14 and 16th May 2007 09:30 th Willow House DS0000068615.V335494.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 House DS0000068615.V335494.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 House DS0000068615.V335494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow House Address 229 Portland Road Edgbaston Birmingham B17 8LS 07974 206708 0121 4294744 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) Castlebeck Care (Teesdale) Limited Michelle Marston Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may admit up to 8 service users with a learning disability who may also display varying degrees of challenging behaviour, a mental disorder, physical disability or sensory impairment. Not Applicable. Date of last inspection Brief Description of the Service: Willow House is registered for eight adults who have learning disabilities who may also have additional needs such as mental health or challenging behaviour. The home is a new registration and opened in December 2006. The home is a detached house located on Portland road, Edgebaston. There are shops and services within walking distance to include supermarkets, hairdressers, restaurants, library and Churches. There are regular buses close to the home. The accommodation is located over two floors, a lift is available to the first floor for anyone who has mobility difficulties. The home offers single bedroom accommodation with ensuite facilities. There is a large dining room, lounge and second smaller lounge. The home has a large kitchen and a second training kitchen for use by people who live at the home. Information from the Manager provided on the 7th may 2007 records the fee levels for the home in the range of £1845.54 to £3082.75. CSCI reports can be viewed at the home on request. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one full day returning on a second day to complete the fieldwork. This was the homes key inspection for the inspection year 2007 to 2008 and the first inspection since the home opened. The Inspector met five people living at the home, three were not met as they were away on holiday. Time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. Prior to the inspection a pre inspection questionnaire was returned to the Commission which gave additional information about the home. Seven people living at the Home returned a survey to CSCI known as “Have your say about…” it was recorded that staff had assisted five people to complete the survey. All information looked at was used to determine whether peoples varied needs are being effectively met. What the service does well: The needs of the people being admitted to the home are assessed prior to admission ensuring staff are aware of their needs. People living at the home are consulted and have regular meetings. Staff were observed throughout the visit giving people choices about what they wanted to do. One person said ‘I like the freedom I have to make choices’. The home tries to provide an enabling environment for people, they are encouraged to try new activities and learn new skills. People are supported to go on holiday if they want to. The people living in the home receive attention from health care professionals as needed to help with meeting their health care needs. People living in the Home are supported to maintain contact with their family and friends and staff recognise the importance of personal relationships. The people living at the home were happy with the meals and commented ‘meals are good’. Menus were varied and nutritious and offered choices. All meals are freshly prepared by the Chef. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 6 The interactions observed between the staff and the people living in the home were very positive. Staffing levels are kept under regular review to ensure they meet peoples needs. An effective quality assurance and monitoring system has been implemented to monitor the quality of service provided and to ensure that the people living in the home benefit from good quality care. What has improved since the last inspection? What they could do better: The service users guide must be completed and provided to all people who live at the home in a suitable format that they can understand so that they are fully aware of the services the home offers. A copy of their contract / terms and conditions need to be available to the people who live in the home, preferably in a format they can understand so they are aware of the terms and conditions of their stay at the home. Some areas of medication practice need improvement to ensure people receive the medication they need in a safe way. To ensure the people living in the home are adequately safe guarded all the required documentation must be obtained prior to any new staff commencing their employment at the home. The home needs to ensure that for people where physical intervention may be needed a risk assessment on its use is completed, especially where there may be increased risks due to an individuals age or health needs. The Manager must ensure the CSCI is informed of any accidents or incidents in the home that effect the well being of people who live there. Fire alarm tests must be done weekly to ensure the fire alarms are working properly and people who live at the home would be alerted if a fire occurs. There are lots of other things that the Home should really think about making better this would really improve things for people living in the Home: Risk assessments should be reviewed to ensure they contain all the control measures in place to reduce risk to people living in the home. The complaints procedure needs to be more readily available in the home and in suitable formats to enable people to feel confident in raising a complaint. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 7 Agreement needs to be reached as soon as possible with the builders to ensure ‘snagging’ problems with the environment are rectified as soon as possible so that the home remains a nice place for people to live. Staff should not work excessive hours so they are not at an increased risk of stress and people who live at the home are supported by staff who are at their best and not tired. All staff should have regular formal supervision and staff meetings should take place more regularly so that they know how to support the people living in the home and that staff views are listened to. 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 House DS0000068615.V335494.R01.S.doc Version 5.2 Page 8 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 House DS0000068615.V335494.R01.S.doc Version 5.2 Page 9 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): 1, 2, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with most of the information they need to make a decision about moving to the home but further information needs to be provided to ensure an informed choice can be made. Individual needs and aspirations are assessed before they move into the home to ensure the home can meet people’s needs. EVIDENCE: All eight people who live at the home have lived there for under six months as it is a new home. Surveys received indicate people were generally consulted about moving in and all but one said they had been given enough information about the home before moving in. One person said ‘they asked me if I wanted to come here’, One staff described how she had spent about three hours with two prospective residents answering their questions on the home and that the Manager had also met with them before they moved in. Before people move into a new home they should be given a Service User Guide that tells them all about the home. This had not been produced when people moved in so they did not get a copy. The Manager said it was just in the process of being completed by involving people who live at the home in taking some pictures to go in the guide. The draft guide was seen, this did not include the restrictions on smoking inside the home. The Manager said that a Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 10 Speech and Language Therapist is booked to visit who will look at the guide and advise on any alternative formats needed for individuals. The home has a Statement of Purpose available and this was observed to be on display in hallway. Case tracking showed that full pre admission assessments are completed prior to people moving in, this includes assessment by the Manager, Consultant and Social Worker. The Deputy Manager said she had been involved in the assessment of one prospective resident but it had been decided the home was not suitable to their needs. Surveys received showed that individuals had the opportunity to visit the home before moving in. The Manager said that all individuals had been offered the opportunity to visit and have an overnight stay, and only one declined. Records are kept of individuals introduction and orientated into the home on the day they move in. A twelve week trial period is offered, with a review completed at end of the trial period. The Manager said that people who lived at the home did not have a copy of a contract or statement of terms and conditions but that these had been provided to relatives. Copies of the document were not in individual files. These need to be available to the people who live in the home, preferably in a format they can understand so they are aware of the terms and conditions of their stay at the home. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have detailed information in care plans as to how support each person so that their individual needs are met. People who live in the home are supported to make decisions about their lives to enhance their independence. Risk assessments in place were written in a way to enable people who live in the home to undertake activities and have wider experiences safely. EVIDENCE: Care plans were available for all people who lived at the home. Three were sampled and found to cover all areas of need and were up to date. People are involved in contributing to their plans and offered the opportunity to sign the care plan agreement. Reviews of the placement had been scheduled for an individual who had lived at the home for a short time. Some care plans were more in depth than others, based on the length of time the individual had been at the home. ‘Capacity to consent’ assessments are completed for all people who live at the home to assess their ability to make informed choices and decisions about Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 12 their lives. Staff were observed throughout the visit giving people choices about what they wanted to do, eat, drink or where they wanted to spend their time. Surveys from people who live at the home indicates they make decisions. One person said ‘I like the freedom I have to make choices’. Records show that where individuals leave the building without staff, and they are assessed as at risk staff, discreetly follow them, respecting their choice to leave the home but at the same time ensuring their safety. Meetings are held weekly with people who live at the home, minutes are produced and some times people are helped to produce a ‘newsletter’. Discussion topics have included how often meetings should occur, domestic rota, complaints, activities, holidays and healthy eating. Information on local advocacy groups was available on the resident’s notice board. One individual does not have any involved family, the Manager said she had tried to get advocacy services for this individual but with no success. Discussion with staff indicates the home tries to provide an enabling environment for people, they are encouraged to try new activities and learn new skills. Risks are assessed before a new activity is introduced, for example swimming or the gym. The majority of risk assessments were observed to be satisfactory, but one assessment on the suicide risk for an individual did not include all the control measures in place. However, discussion with staff did show those spoken with were aware of how to keep this person safe. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. People have the opportunity to attend college courses and to practice their self-help skills to enable them maximise their independence. People are offered a healthy diet that meets their dietary needs. EVIDENCE: Staff work with people who live in the home to agree a set of targets to work towards to help them achieve more independence. People have the opportunity to get involved in learning new skills. One member of staff described how she was taking one individual shopping to buy aids that would assist him in learning how to make a drink. At the time of the inspection visit three people were on holiday in Cornwall. Other people said they were going away soon. One said she was going on holiday to Newquay at end of the week and was excited about it. Another said he had chosen to go on holiday to Spain. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 14 Staff plan activities every Monday with people who live at the home and a time table drawn up. Whilst there are some group activities most activities on offer are on an individual basis. Records sampled and discussion with staff show activities on offer include shopping, pub, walks, helping make tea, library, Church with staff, cookery at college. It was excellent that staff were doing a session with one individual teaching Spanish. This was on his activity timetable as he said he wanted to learn a few basic phrases for his holiday there. Satisfactory number of drivers are available to make use of the homes vehicle to facilitate activities but use of public transport is also made. Information about local activities is available on the notice board, eg library, sea life centre and the theatre. The Manager said some individuals recently went to the show ‘Boogie Nights’. Some individuals have requested that they would like to go to a night club, this is being arranged by staff. Several people have chosen to move into the home as they want to be nearer family. Records show that staff support contact with family by telephone, visits and letters. People are also supported to maintain contact with friends, it was planned for the afternoon of the inspection that one individual would be supported to write to a friend where he previously lived. A newsletter produced by people who live at the home said that relatives and friends could visit and stay for a meal. Where restrictions are placed on people who live in the home this is generally recorded in their care plan and where possible people have signed their agreement. Restrictions in place were seen to be for the safety of individuals. People are restricted to not being able to smoke inside the home and have to smoke outside. This needs to be included within the Service User Guide so that anyone considering moving to the home is fully aware of this house rule. Food records are completed daily for each individual, these show a varied diet with lots of fruit and vegetables. The home’s menu was on display in the dining room, this showed that people are given the opportunity to try foods from different cultures. Staff spoken with described how menus were drawn up with the consultation of people who live at the home. Several staff said they were working on education people about healthy eating. Lunch time practice was observed during the visit. Condiments were available on the tables. Staff ate with people who lived at the home making lunch a social occasion. Choice of meal was available and fresh fruit or yogurt was available for dessert. One individual said she had chosen banana sandwiches for lunch instead of spaghetti as she does not like spaghetti. All meals are freshly prepared by the Chef. The Chef was observed making the evening meal, it was excellent that the Cornish pasties were being home made. The chef said that all the vegetables and fruit are fresh- the home does not use frozen or tinned. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home receive personal support in the way they prefer and require and their health needs are well met. Some areas of medication practice need improvement to ensure people receive the medication they need in a safe way. EVIDENCE: People who live at the home were generally observed to be well groomed and dressed according to age, gender and culture. Daily records show people are supported to go out with staff to buy their personal toiletries. One person said they had recently been to the hairdressers. They like their hair to be plaited by staff- it was observed to be plaited on both days of the fieldwork visit. Staff said that individuals had been given the opportunity to choose which staff supported them on their holiday. Full health assessments are completed for each new person moving into the home. People are referred to health professionals where appropriate. They also have check ups with the dentist and optician. Records of all appointments were kept including the outcome with any action that staff need to take to ensure Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 16 the individuals health needs are met. One CSCI survey was received from a health professional, this records that people’s health needs are generally met. Shortly after one individual moved into the home staff identified that he had very low blood pressure that had not been identified at his previous home. Medical advice was sought and new medication was prescribed. Regular blood pressure monitoring has also been introduced to ensure the pressure does not drop too low. Weight monitoring of people living at the home is undertaken to ensure they are a healthy weight. The home offers nursing care and all medication is administered by a qualified nurse. Storage of medication was satisfactory, the cabinet was clean and well organised. The Manager said she was currently trying to obtain a new medication cabinet, as the one in the home had no controlled medication storage facilities, however there is no controlled medication currently in use. Some people at the home are prescribed medication on an ‘as required’ basis. Written protocols were available for some of these but not all. Some people are prescribed medication for their behaviour, clear guidance is needed so that the Nurses administering the medication are consistent in when it is used. One person did have guidance but this said 1 or 2 tablets without clear directions on how the dosage should be decided. The medication administration chart (MAR) for one individual had two types of medication that had been added to the chart that were unreadable. It was very difficult to decipher the name of the medication and dose. This puts people at risk of being given the wrong medication or dose. The Manager said these had been written by the GP. The Manager must take steps to ensure the MAR clearly records the medication prescribed so that staff can check this against the medication they are administering. Some gaps were observed on the MAR’s sampled. The Manager said there had been an issue with a member of staff not signing the chart after administering medication and that further training would be provided. An additional audit had been introduced as a result to check that the charts had been signed. Unfortunately a gap was identified on a MAR chart after the audit had been introduced. Close observation of the audit record showed it had not been completed on the day the gap occurred. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Complaints procedure if followed would ensure that people would be listened to but the procedure needs to be more readily available in the home and in suitable formats to enable people to feel confident in raising a complaint. Arrangements are sufficient to ensure that people who live at the home are protected from abuse, neglect and self-harm. EVIDENCE: No concerns, complaints or allegations have been received by the CSCI about this home since it opened. The surveys received from people living at the home indicate they are aware of the complaints procedure. People who live at the home were made aware of the complaints procedure at a residents meeting, people were also asked if they had any complaints they wanted to raise. The procedure is currently only available in a written format and was not clearly on display in the home. The Manager said it would be discussed at the scheduled Speech and Language Therapists visit to see if any alternative formats were needed as one person who has a sight impairment may benefit form a Braille or audio version. The Manager has recently introduced a suggestions box in the hall as an alternative way of seeking people’s views but has yet to receive any comments. Records show some incidents when physical intervention has been used when individuals have attempted to physically attack staff. Records show low arousal techniques are tried before physical intervention is used. The majority of staff at the home have completed physical intervention training and it is arranged Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 18 for staff who have not yet done it. The training is provided by an organisation who is accredited with the British Institute for Learning Disabilities. Discussion with staff indicates that physical intervention is used as a last resort. One staff said that debriefing always takes place after such an incident to discuss if anything could have been done differently. Staff spoken with said they had done Protection of Vulnerable Adults training. Three staff were spoken with about what they would do if an allegation of abuse was made. Whilst their described actions would have generally protected the individual staff did not appear confident in their answers. The Manager confirmed that more in-depth training had already been scheduled for staff as it was recognised their initial training was quite basic. Procedures are in place to safeguard people’s money. The home has two separate safes, the bulk of money is stored in a safe that only the Manager and Deputy Manager have access to. Checks on monies held are completed daily and weekly. The Manager said that an external audit of finances had recently been completed and she was awaiting the report. Finance records for two people were sampled. No inappropriate spending was evident on things that the provider should purchase and receipts for expenditure were available. Where possible, staff encourage people who live at the home to take as much responsibility for their own money as they are safely able to. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People generally live in a homely, safe and clean environment that meets their individual needs. EVIDENCE: The Home is generally in good decorative order as it has been open for under six months and so is newly decorated and furnished. The Manager said there had been lots of ‘snagging’ problems with the building and the builders were slow to put things right. One staff spoken with said it could be very frustrating trying to get the builders to sort out problems with the environment. Things that still need to be put right include the floor covering in the dining room that has lifted resulting in a small ridge across the room. The small lounge was excessively hot. The Manager said the radiator has been repaired numerous times but the fault keeps re-occurring, they have tried to turn the radiator off with no success. A long snagging list was sent to the builders in March, the Manager said that Castlebeck may hold off on paying some of the builders fees until things are put right. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 20 The accommodation is located over two floors, a lift is available to the first floor for anyone who has mobility difficulties. The home offers single bedroom accommodation with en-suite facilities. There is a large dining room, lounge and second smaller lounge. The home has a large kitchen and a second training kitchen for use by people who live at the home. Two people who live at the home gave permission for their bedrooms to be seen. One person’s room had few personal possessions, the Manager said they had few possessions and it was hoped that staff would be able to support them to make the room more personal. The bedroom of the other person, who had lived at the home for a longer period was very personalised with possessions that reflected individual tastes and interests. Both said they were happy with their rooms and had everything they needed. Due to the home being newly opened bedrooms have yet to be repainted to personal tastes. All bedrooms are the same colour but are scheduled to be repainted. Discussions with staff and the Manager show that people had the opportunity to choose the bedroom they wanted before they moved in. Infection control procedures are satisfactory. Satisfactory hand washing facilities observed in bathrooms, toilets and kitchen. All areas of the home were observed to be clean with no unpleasant odours. Surveys received indicate the home is always clean. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home benefit from a well trained staff team that can support them to meet their individual needs and achieve their goals. Staffing levels are kept under regular review to ensure they meet peoples needs. The recruitment procedures have not been robust in some cases and so has not fully safeguarded people who live in the home. EVIDENCE: Staff were observed communicating with people who live in the home in a manner they understood that was polite and respectful. Surveys received indicate that people feel staff treat them well and listen to them. Staff spoken with said they felt supported by other members of the staff team. Staff new to working with people with a learning disability have been enrolled on the Learning Disability Award Framework, once this is completed they will commence NVQ training. The home is well placed for NVQ success as they will have 4 NVQ assessors. Evidence was seen that staffing levels are kept under regular review to ensure they met peoples needs. Staff spoken with felt the staffing levels in the home met peoples needs. Some commented on initial staffing problems when the Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 22 home first opened but these had been resolved. Staffing levels have recently increased due to the needs of one individual, current levels are 3 staff at night and 4 during the day. One person was observed to have 1:1 staff support throughout the fieldwork visit in line with his risk assessment. Care staff are supported by a chef, administrative and domestic staff. The staff rota shows it is not uncommon for staff to work a 14 hour day. The Manager and Deputy said staff had chosen to do this but they hoped to reduce this in the future. This was confirmed by one staff but another said they worked 14 hour days because that was what they were rota’d to do. They said they could be quite draining. Another said they had chosen the 14 hour shifts and that they offered consistency but they were tough if you had a bad day. There are no set break times when working 14 hours and staff cannot take a break off site. The Home’s own stress risk assessment identifies that long hours increase the risk of stress. The recruitment records for three members of staff were sampled. Recruitment procedures for two staff had been robust and an application form, Criminal Record Bureau check, two written references, health declarations and evidence of checks of nurses registration were available. However, for one staff there were no written references just confirmation of two verbal references. The Manager said several letters had been sent requesting written references but she was unable to evidence this. To ensure people are fully protected written references must be obtained for all staff before they commence work in the home. Castlebeck have their own training department. Four staff spoken with said they had completed a full induction to the home. This was about 3 weeks in length before the home opened. One staff member said that the company was very responsive to the training needs of staff. Staff said that they had done mandatory training, one gave examples of some training being done via ‘E Learning’ on the internet provided by Castlebeck. One staff has recently completed a four day ‘train the trainer’ course for manual handling so that she can train other staff. Copy of induction timetables were provided by the Manager, this showed topics covered were wide ranging to include autism, challenging behaviour, physical intervention, epilepsy, fire and protection of vulnerable adults. Information on what training each staff have done is recorded on a variety of records, the Manager will need to ensure this is all transferred on to staff individual training records. Staff spoken with said they got good support from the Manager and Deputy Manager. The Deputy Manager said dates were booked for staff to commence formal supervision. Supervision agreements have been signed with staff. One staff said she had her first formal supervision on the day of the inspection. Staff said there had been some staff meetings where they could talk openly. The Manager said she aims to have monthly staff meetings but since opening there has only been one general staff meeting and two qualified staff meetings. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager communicates a clear sense of direction so that individual’s needs are well met. People’s views underpin all self-monitoring, review and development of the home. Some areas of health and safety practice needs to be improved to ensure people’s wellbeing is always promoted and protected. EVIDENCE: The Manager of the home has completed registration with the CSCI. She is a qualified nurse and is undertaking a management course which she said is equivalent to NVQ level 5. The training records for the Manager show she has kept herself up to date and attended regular training. Staff spoken with said they got support from the Manager and Deputy. Discussions with the Manager demonstrate she realised there was still some work to do to improve the home and had a good understanding of what needed to be done to achieve this. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 24 The home is quite new but Castlebeck are an established provider and have over time developed good quality assurance systems. The Area Manager visits the home monthly and produces a report of his visit. Internally, quality audits are completed monthly and sample areas such as medication, environment, complaints, record keeping, activities and care planning. When an area for improvement is identified an action plan is completed. Peoples views of the home form part of the system. Castlebeck have their own survey forms which people living at the home can complete. These have not yet been done but have been printed off ready to give out to people. On the 2nd day of the inspection Castlebeck’s quality assurance team were at the home completing an initial audit. There are satisfactory written policies and procedures in place to promote and protect the health and safety of people who live at the home, unfortunately the implementation of some of these has not been satisfactory in some cases. Sometimes due to people’s behaviour physical intervention has been necessary to protect them and other people. The home needs to ensure that for people where this is likely to be needed a risk assessment on its use is completed, especially where there may be increased risks due to an individuals age or health needs. One person at the home recently attempted suicide. Staff 1:1 observations commenced immediately on their return from hospital but the Manager did not ensure a regulation 37 notification was made to the CSCI. The West Midlands Fire Service have visited and said fire precautions are satisfactory. Since their visit there have been some lapses in testing the fire alarms weekly. The Manager said that the staff responsible for testing the alarms had been spoken to and the date for tests have been recorded in the diary to try and ensure alarms are tested when they should be. A certificate was available to show the fire alarms had been serviced. A fire drill was conducted in January however new people have moved into the home since then so it is recommended another one is done soon to ensure everyone is aware of evacuation procedures. Staff spoken with confirmed they had received fire training. The Deputy Manager said the home had a Health and Safety (H&S) representative who attended the providers H&S meetings. The Deputy Manager said that although the builders were slow to do general repairs anything of a H&S matter was quickly acted on. Good systems are in place to monitor accidents. Monthly reports are sent to headquarters and identify any reoccurring trends in the accidents that have occurred. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 25 Water temperatures are monitored so that people are not at risk of scalding. Records show that water at the sink in the laundry and training kitchen is too hot. Records and discussion with the Manager show that new thermostatic temperature valves are to be fitted so that the water will not be too hot. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 26 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 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 27 Not applicable. 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 Regulation 5a Requirement A copy of their contract / terms and conditions need to be available to the people who live in the home, preferably in a format they can understand so they are aware of the terms and conditions of their stay at the home. Written protocols must be developed for individuals who are prescribed medication on an ‘as required’ basis to ensure staff have clear guidance as to when they should or should not be given. The medication administration record must be signed when medication has been given to ensure people have received the medication they need. Action must be taken to ensure medication recorded on the medication administration record is legible so reduce the risk of people receiving the wrong medication. Recruitment procedures must be reviewed so that the organisations procedures are fully implemented and people DS0000068615.V335494.R01.S.doc Timescale for action 30/07/07 2. YA20 13(2) 30/07/07 3. YA20 13(2) 30/06/07 4. YA20 13(2) 30/06/07 5. YA34 19 30/07/07 Willow House Version 5.2 Page 28 6. YA42 13 (4)(c) 7. YA42 37 8. YA42 23(4)(v) living in the Home protected from harm. For people where physical 30/06/07 intervention may be needed a risk assessment on its use is completed, especially where there may be increased risks due to an individual’s age or health needs. The CSCI must be informed of 30/06/07 any accidents or incidents in the home that affect the well being of people who live there. Fire alarm tests must be done 15/06/07 weekly to ensure the fire alarms are working properly and people who live at the home would be alerted if a fire occurs. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The service users guide should be completed and provided to all people who live at the home in a suitable format that they can understand so that they are fully aware of the services the home offers. Risk assessments should be reviewed to ensure they contain all the control measures in place to reduce risk to people living in the home. The complaints procedure needs to be more readily available in the home and in suitable formats to enable people to feel confident in raising a complaint. Agreement needs to be reached as soon as possible with the builders to ensure ‘snagging’ problems with the environment are rectified as soon as possible so that the home remains a nice place for people to live. Staff should not work excessive hours so they are not at an increased risk of stress and people who live at the home are supported by staff who are at their best and not tired. All staff should have regular formal supervision and staff DS0000068615.V335494.R01.S.doc Version 5.2 Page 29 2. 3. 4. YA9 YA22 YA24 5. YA33 6. YA36 Willow House meetings should take place more regularly so that they know how to support the people living in the home and that staff views are listened to. Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow House DS0000068615.V335494.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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