Inspection on 21/04/08 for Willow House

This inspection was carried out on 21st April 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow House 14/05/07

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 28/09/2008.

CARE HOME ADULTS 18-65 Willow House 229 Portland Road Edgbaston Birmingham B17 8LS Lead Inspector Kerry Coulter Key Unannounced Inspection 21st and 24th April 2008 09:45 Willow House DS0000068615.V363593.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.V363593.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.V363593.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 Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories:- Learning Disability (LD 8) and Learning Disability over the age of 65 (LD(e) 8). The maximum number of service users to be accommodated is 8. 3. Date of last inspection 14th May 2007 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 opened in December 2006. The home is a detached house located on Portland road, Edgbaston. 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 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. The service users guide did not state the fees charged to live at the home. A copy of the last inspection report is available in the home for visitors to read if they wish to. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The visit was carried out over two days; the home did not know we were going to visit. This was the homes key inspection for the inspection year 2008 to 2009. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and the manager completed a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Two surveys were received from relatives of people who live at the home. Surveys were sent to health professionals but none had been returned at the time of writing this report. Three people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The people who live at the home, the manager and the staff on duty were spoken to. 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. 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. 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. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 6 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. One relative said ‘willow house gets 10/10 from us they deserve it’. 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. People generally live in a homely, safe and clean environment that meets their individual needs. 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 people’s 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 needs further development so that people are fully aware of the services the home offers and how much it costs to live there. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 7 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. Staff need more guidance about when they should give ‘as required’ medication to people, so that they get the medication they need. Staff need to know what to do to keep people safe if an allegation of abuse is made. 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. When new staff are recruited thorough checks need to be done to make sure they are the right staff and people are not put at risk of having unsuitable staff working with them. An application needs to be made without delay to register a manager for the home to ensure the home is managed by a suitably qualified and experienced person. The way in which fire drills are recorded could be improved to make sure they are happening regularly and people know what to do when the fire alarms sound. 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.V363593.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.V363593.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, 3, 5 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have most of the information they need to make a choice of whether or not they want to live there. Before people move into the home their needs are assessed so it is clear they can be met at the home. EVIDENCE: The statement of purpose of the home included the relevant and required information so that prospective service users are able to make a choice of whether or not they want to live there. The service user guide needed to be up-dated as it did not include details of the new manager for the home or information about the range of fees charged. The manager said that the guide was already in the process of being updated and was being further developed to include photographs of the home. The manager said that people who live at the home were to be consulted about what information they would like in the guide at their next house meeting. One person had been admitted since the last inspection. Before they moved into the home an assessment of their needs was completed to ensure their needs could be met at the home. The person visited the home before they moved in to meet the other people living there and the staff and to see what it was like to live there. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 10 It is good that before people move in they are consulted about what their expectations of the home are, views of their social worker and involved health professionals are also obtained to ensure people’s expectations are realistic. It was identified at the last inspection that people who live at the home did not have a copy of a contract or statement of terms and conditions. This was still the case at this visit, the manager said that Castlebeck were still working towards completing these. 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.V363593.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 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 are written in a way to enable people who live in the home to undertake activities and have wider experiences safely. EVIDENCE: The records of three of the people living there were looked at. These included individual care plans. These detailed how staff are to support the individual to meet their needs and achieve their goals. Care plans had been regularly reviewed to ensure that the care plan was still effective in meeting the individual’s needs. People are involved in contributing to their plans and offered the opportunity to sign the care plan agreement. On the day of the inspection visit one person was having a care plan review meeting that they attended with their social worker. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 12 ‘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 their lives. These are regularly reviewed. 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. Records showed that regular meetings are held with the people living there. Minutes of these showed that people talked about topics such as activities, holidays, the menu and household chores. Discussion with staff indicates that the format for the meetings has recently been improved with an agenda being set prior to the meeting that people have an opportunity to contribute towards. Records included individual risk assessments. These detailed how staff are to support individuals ensuring that they are safe and the risks to their health and welfare are minimised. As with care plans these had been reviewed as often as necessary to ensure they are still effective in ensuring the safety and well being of individuals. A requirement was made at the last inspection visit to make sure risk assessments detailed all the control measures in place. This was seen to have been done for the assessments sampled. Willow House DS0000068615.V363593.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 to maximise their independence. People are offered a healthy diet that meets their dietary needs. EVIDENCE: 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. 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 are supported to learn cooking skills in the home’s training kitchen. One staff said that one person goes weekly to a social club and had just started to go without staff support which had been successful so far. One person had been awarded a certificate of achievement after attending a Castlebeck ‘power workshop’ where he spoke publicly. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 14 Each person has their own timetable of activities. 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 are wide ranging and include shopping, pub, walks, library, college, numeracy and literacy, art galleries, museums, concert visits and computing. One person at the home is doing a college course on car mechanics. His care plan indicates he would like to get a job in this area. To support him in achieving his goal his activity timetable includes being supported by staff in searching for employment. One person spoken with said that the activities were ‘excellent’. Staff said that the recent poor health of one person had impacted on the activities they could do away from the home. To ensure the person continues to be able to access the community regularly the home have acquired a wheelchair for the person and are awaiting training on its use. The manager said that Castlebeck contribute up to £310 towards an annual holiday for people. One person had recently come back from a holiday to Jamaica, the manager said it had always been somewhere he wanted to go to. People who lived at the home said they could choose where they went on holiday. One person said that he had met with staff that day to choose his holiday destination, to a caravan in Devon. He said he also chose what staff he would like to go with him. 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. At Christmas a party was arranged to celebrate the anniversary of the home opening, people’s relatives were invited to attend. Photographs of the party are on display in the home and it looked like people enjoyed themselves. One relative commented that they were made to feel welcome when visiting. Where restrictions are placed on people who live in the home this is 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. 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. One person who lives at the home has started to attend ‘Slimming World’ and has their own healthy eating menu. The person said they liked going and said they were pleased they had lost some weight that week. Several staff said they were working on educating people about healthy eating. Observation of the activity time-table showed that healthy eating sessions were arranged. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 15 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. All meals are freshly prepared by the chef. The chef said that all the vegetables and fruit are fresh and that the home rarely uses frozen or tinned produce. People who live at the home said that the ‘food is good, we get a choice’ and ‘food is nice’. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. 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. Medication practice needs minor improvement to ensure people receive the medication they need in a safe way. EVIDENCE: People who live at the home were 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. The annual assessment (AQAA) completed by the manager indicates that people are provided with support for personal care by staff of the same gender where possible. 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 the individuals health needs are met. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 17 One person who lives at the home has been unwell and records and discussions with staff show that advice has been sought from other health professionals when needed. Nurses at the home are also undertaking regular health checks for this person to include blood pressure. The care plan showed that advice had been given by the GP that the individual should sit with their legs elevated. To assist in this a new chair has been purchased that has a foot rest. We saw that this was being used during our visit to the home. Discussions with staff indicate they were aware of the individuals health needs. As stated earlier in this report staff are working with people on eating healthily. Weight monitoring of people living at the home is undertaken to ensure they are a healthy weight. Staff said that some people are also attending a healthy lifestyle clinic. One person who lives at the home said they were trying to be healthy by giving up smoking. 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. At the last inspection visit the manager said that she was trying to obtain a new medication cabinet, as the one in the home had no controlled medication storage facilities. This has now been obtained but currently there is no controlled medication used. Some people at the home are prescribed medication on an ‘as required’ basis. At the last inspection visit it was observed that written protocols were available for some of these but not all. The manager said that protocols have not yet been completed for all medication. Protocols need to be in place that state when and why the medication should be given to the individual so it is not misused which could have a negative impact on the person’s health. The medication administration chart (MAR) were sampled for four people. These were seen to have been satisfactorily completed. The commission has not been informed of any medication errors occurring since the home’s last inspection. The manager confirmed she was not aware of any errors occurring. Where possible, opportunities are provided for people to take responsibility to administer their own medication. The manager said that one person had started self administration the previous week. A risk assessment had been completed prior to the person starting to self administrate medication to assess if they would be safe to do so. The medication is kept in a locked drawer in their bedroom. At the moment staff are prompting the person and counting the tablets in the evening to make sure the person is taking them safely. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for the homes response to complaints needs improvement to ensure that the views of the people living there are listened to and acted on. Not all staff have the knowledge they need to protect people at the home from harm. EVIDENCE: At the last inspection visit the complaint procedure was only available in a written format and was not clearly on display. A new easy read complaints booklet has been developed and is on display in the home. The home has a suggestions box in the hall as an alternative way of seeking people’s views but the manager said no suggestions have been received. One person spoken with said that if they were unhappy about something they could talk to any of the staff. No concerns, complaints or allegations have been received by the CSCI about this home since it opened. The annual assessment (AQAA) completed by the manager recorded that one complaint had been received by the home. The letter from the complainant showed that this was not related to the care of people living at the home and was about parking of cars. This complaint was not recorded in the home’s complaint log. The complaint log showed that three complaints had been received from people who live at the home. This information had not been provided on the annual assessment. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 19 The manager said that when completing the AQAA she thought that the commission only wanted information about complaints from external sources. The log showed that the complaints received had been about the behaviour of people at the home. Unfortunately the log did not detail the action taken in response to the complaint to show if they were investigated and if the complaints were upheld or not. The manager said that for one of the complaints the complainant had not wanted a written response. For another of the complaints she said a written response was sent but evidence of this could not be found during the visit. For one of the complaints the manager did not know what action had been taken as she was not the manager at the time. Records show some incidents when physical intervention has been used when individuals have attempted to harm themselves or physically attack staff. The use of physical intervention is agreed in people’s care plan in consultation with involved care professionals. Records and discussion with staff show low arousal techniques are tried before physical intervention is used as a last resort. Staff at the home have completed physical intervention training and a rolling programme of refresher training is in place. The training is provided by an organisation who is accredited with the British Institute for Learning Disabilities. 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 has restricted access. Checks on monies held are completed daily and weekly. 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. Staff training records and discussion with the manger shows that most of the staff have had training on protecting people from abuse. The manager said that all care staff had done the training but not all of the nurses had. This means that some of the nurses are having to rely on knowledge that has been gained from previous employment that may not be up to date or reflect Castlebeck procedures. As it is the nurses who often are in charge of the home they need to have training so they know how to respond to keep people safe if an allegation of abuse is made. Three staff were spoken with about what they would do if an allegation of abuse was made about a member of staff. Generally staff seemed unclear of what to do and not all staff said they would inform social services, the commission and the police if needed. The home has a policy on protecting people from abuse but does not have a copy of the Birmingham Multi Agency Guidelines, it is recommended they obtain a copy of these so that staff have the information they need. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 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 two years and so is relatively newly decorated and furnished. Since the last inspection the home has had the services of a handyman for a few hours every week, staff said that this had speeded up getting minor repairs completed. 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. The annual assessment (AQAA) completed by the manager indicates that in the coming Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 21 year the home is hoping to have a new conservatory built. The manager said that it is intended to use this for activities and hopefully get a pool table. As at the last inspection, the floor covering in the dining room need attention where it has lifted from the floor lifted resulting in small ridges. This spoils the appearance of the room and if the floor covering lifts further could become a trip hazard to people who have poor mobility. Three people who live at the home gave permission for their bedrooms to be seen. One person’s room had few personal possessions, however their care plan recorded the reasons for this and this appears to be in the person’s best interests. The other bedrooms seen reflected individual tastes and interests and contained individual’s person possessions that reflected their age, gender and cultural background. Since the last inspection people’s bedrooms have been repainted in line with their personal choice. All three people spoken with said they were happy with their bedrooms. Infection control procedures are satisfactory. The home was clean with no unpleasant odours at the time of the visit. Satisfactory hand washing facilities were observed in bathrooms, toilets and kitchens. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 people’s needs. The recruitment procedures have not been robust in some cases and so have 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. Care staff have the opportunity to complete the Learning Disability Award and then go on to completing an National Vocational Qualification (NVQ). One relative commented ‘‘staff are friendly and have sound knowledge’. Evidence was seen that staffing levels are kept under regular review to ensure they met people’s needs. Staff spoken with felt the staffing levels in the home met peoples needs. Current staffing levels are usually one nurse and three support workers during the day and one nurse and one support worker at night. Care staff are supported by a chef, administrative, maintenance and Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 23 domestic staff. The home does not use agency staff to cover any staffing shortfalls but uses their own bank staff to make sure that people are supported by staff they know. As identified at the last inspection, sometimes staff work long hours. One member of staff was working a twelve, fourteen and a fifteen hour day all in the same week. This could result in staff not performing at their best and being more prone to making mistakes through being tired. 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 and two satisfactory written references were available. However for one staff it was not clear from their application form and written references if a reference had been obtained from their last employer. The manager was unable to provide any further information about this as the member of staff had been recruited by the previous manager of the home. To ensure people are fully protected people’s previous work history should be fully explored at interview where insufficient information is included on their application form. It is also suggested that a detailed audit is completed of all staff files to make sure they contain the right information as issues in recruitment practice were also identified at the last inspection. Staff spoken with said they received the training they need. One recently employed staff said that the induction they received was ‘really good’ and that they had initially shadowed other staff for a month. Training records and discussions with staff show that staff receive training in physical intervention, fire, first aid, epilepsy, challenging behaviour, health and safety and the mental capacity act. Planned training in April and May includes person centred planning and communication. Discussion with the manager and staff indicate that the manager is arranging training for staff in the use of the newly acquired wheelchair and in sensory impairment. Staff spoken with said they got good support from the manager and acting deputy manager At the last inspection staff were not receiving regular supervision. The manager has set up new systems for supervision and annual appraisals, these have commenced so that staff were supported in their role and their training and development needs could be identified. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 24 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, 38, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements generally ensure that people benefit from a service that is run in their best interests. The health and safety of people who live at the home is promoted and protected. EVIDENCE: Since the last inspection the registered manager has left the home. The previous deputy manager was appointed as the manager for the home at the beginning of March but has yet to make an application to the commission to become the registered manager. The manager is a qualified nurse and is currently undertaking a management course. The training records for the manager show she has kept herself up to date and attended regular training, but needs to complete prevention of abuse training. Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 25 Discussions with staff at the home indicate that the manager is approachable and listens to what people have to say. One staff felt it was good that the manager spent time working with people at the home and not just spending time in the office. One relative commented ‘willow house gets 10/10 from us they deserve it’. The home is still relatively a new service 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. These audits included seeking the views of the people living there and staff. Initially, the more recent reports were not available on the first day of the inspection visit but copies were speedily sent to the commission and the home when we asked for them. 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. Castlebeck have their own survey forms that people living at the home can complete. The manager said that these had recently been given out to people to complete. When we visited the home last year Castlebeck were visiting the home at the same time to complete their own quality assurance report. The manager said that she had not received the report of this visit and has recently requested a copy. 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. A certificate was available to show the fire alarms had been serviced. Staff test the fire equipment regularly to make sure it is working. Training records and discussions with staff indicate they have had regular fire training so that they know how to protect people if a fire occurs. A calendar records that regular fire drills are planned, however the fire log needs to record that they have actually taken place. The manager and a member of staff said that the most recent evacuation had been unplanned as some burnt toast had set the alarms off and the home was evacuated. An incident record had been completed for this event. The home was observed to have a fire risk assessment in place, the manager said she intended to review this soon. Staff test the water temperatures weekly to make sure that the water is not too hot or cold and people are not at risk of being scalded. An electrician had completed the annual test of the portable electrical appliances in April 2008 to make sure they are safe to use. A Corgi registered engineer had completed the annual test of the gas equipment in March 2008 and stated that it was in a safe condition. Willow House DS0000068615.V363593.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 3 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 4 12 4 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 3 X Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 27 Yes, number 3. 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 YA22 Regulation 22 Requirement The complaints log must detail the action taken in response to complaints received so that people can be sure they are listened to and action is taken. All staff must receive training in adult protection and the prevention of abuse. This will ensure that they know how to protect the people living there from abuse, neglect and self harm. Recruitment procedures must be reviewed so that the organisations procedures are fully implemented and people living in the Home protected from harm. Previous requirement. Timescale for action 30/06/08 2. YA23 13(6) 30/08/08 3. YA34 19 30/06/08 Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 28 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 updated to include details of the new manager and state what the fees charged to live at the home are. This will give prospective service users all the information they need so they can make a choice as to whether or not they want to live there. 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 should 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 home is advised to obtain a copy of the Birmingham Multi Agency Adult Protection guidelines so that staff have the information they need on how to respond to and report allegations / suspected abuse. The floor covering in the dining room needs repair to ensure it remains in good condition and does not pose a trip hazard to people. 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. An application needs to be made without delay to register a manager for the home to ensure the home is managed by a suitably qualified and experienced person. The recording of fire drills needs to improve to show they are completed regularly, outcome of drill and to monitor who has participated. 2. YA5 3. YA20 4. YA23 5. 6. YA24 YA33 7. 8. YA37 YA42 Willow House DS0000068615.V363593.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V363593.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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