Inspection on 21/10/05 for Willows (The)

This inspection was carried out on 21st October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willows (The) 10/09/08

Willows (The) 08/10/07

Willows (The) 18/04/06

Willows (The) 29/06/05

Willows (The) 20/10/04

Willows (The) 30/06/04

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

CARE HOME ADULTS 18-65 Willows (The) The Old Grove High Pitfold Hindhead Surrey GU26 6BN Lead Inspector Susan McBriarty Unannounced Inspection 21st October 2005 10:00 Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 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 Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 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. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willows (The) Address The Old Grove High Pitfold Hindhead Surrey GU26 6BN 01428 609851 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) Robinia Care - South Region Mrs Sharron Ann Foulger Care Home 10 Category(ies) of Learning disability (10), Sensory impairment (2) registration, with number of places Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 18-50 YEARS Of the ten (10) service users in category LD (Learning Disabilities), two (2) may also fall within the category SI (Sensory Impairment) 29th June 2005 Date of last inspection Brief Description of the Service: Robinia Care Ltd provides a range of residential and day services for people with disabilities on the Old Grove Site at High Pitfold Hindhead. The Willows is a detached bungalow that offers long term residential care for up to 10 adults aged between 19 and 35, with learning disabilities who require a high level of support. The care home has 10 single rooms, three bathrooms and a shower room. The home can be viewed as having two units each providing support for five service users whose rooms are situated in each unit. Each unit has large lounge/dining rooms, although kitchen and laundry facilities are shared. Although designed as two units service users were able to access all areas of the home. Service users have ready access to the immediate grounds, which consists primarily of a hard surface area. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the second for 2005-2006. During the course of the inspection the senior care on duty and the Area Manager were spoken to. Observations were made by the Inspector of two staff members providing support through part of the lunch period. Six residents were present during the inspection. The residents have complex needs including limited verbal skills and challenging behaviour. It would not be possible to gain their views on the service without considerable support and planning. During the inspection a number of documents were sampled including care plans, review documents, correspondence from specialist professionals, training information and a number of policies and procedures. Following the unannounced inspection on the 29th June 2005 an enforcement notice was served on the 27th July 2005 and the home had received a compliance inspection on the 28th September 2005. The Commission for Social Care Inspection is continuing to review the Robinia South Limited homes in Surrey as part of an investigation into a protection of vulnerable adults allegation. In another forum from this report a number of recommendations were made and these are in the process of being planned or completed by Robinia South Limited. Further recommendations or requirements may be made as a result of the review. What the service does well: What has improved since the last inspection? What they could do better: A number of requirements were made during the inspection, for example the statement of purpose does not clearly identify the needs of the residents at The Willows and a requirement was made to ensure that the document is reviewed and updated. This will enable prospective residents and their relatives to decide if the home can meet the assessed needs of prospective residents. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 6 The Inspector was not able to locate evidence of individual statements of terms and conditions for the residents provided by either the purchasing authority or the organisation. The Inspector was informed that this work is taking place. A requirement was made that the organisation ensure that each resident has a statement of terms and conditions in order to ensure that the residents, where possible, and or relatives are clear about the services offered and which services the resident would pay for themselves. The organisation has also been required to provide an action plan regarding staff qualification targets and the provision of a quality assurance audit regarding the services provided. The requirements made are at the end of this report. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 7 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. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 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 Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Further work is required to ensure the information regarding the home can assist people in making a decision as to whether the home can meet their needs. EVIDENCE: The home’s statement of purpose needs amendment in order to ensure that all the information needed is provided including details about the level of challenging behaviour the home is able to support. Prior to moving into the home the residents are assessed and where possible trial visits offered. Due to the challenging behaviour presented by some of the residents a trial visit prior to moving in may not be suitable. The local authority purchasers had not provided most of the residents with a contract or statement of terms and conditions. The contract would set out what the service must provide, the fees and include information about services that the resident would pay for. During the inspection the Area Manager informed the Inspector that Robinia South Limited were completing draft statements of terms and conditions for each resident and that these would be available shortly. Given the complex needs of the residents they may not be able to sign the statement of terms and conditions and the organisation must be mindful of seeking signatures from relatives or representatives, where possible, and documenting where this is not possible. A requirement was made that the home ensure that each resident is provided with a statement of terms and Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 10 conditions to ensure that the details of the service purchased by local authorities and details of those services that must be funded by the resident are made clear. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10 The home has a good regard for ensuring risk assessments are completed. The organisation has a confidentiality policy. EVIDENCE: The Inspector sampled a number of care plans and found that each resident had detailed risk assessments completed on all aspects of their daily living. Some of the risk assessments were due for review at the time of the inspection. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15,16,17 The home provides for residents with complex needs and challenging behaviour and the home is mindful of the safety of others when friends and family visit. The daily routine of the home reflects the needs of the residents. EVIDENCE: Detailed records are kept of all contact with family and friends. The home keeps a record of those who have contact with specified residents and their relationship. In addition a record is kept of all telephone calls to and from the home to relatives or representatives. Observations made by the Inspector during the inspection noted that staff members were aware of the needs of the residents and that staff treat them with respect and dignity. The daily routine of the home recognises the level of challenging behaviour that specified residents might display. This includes restrictions regarding access to the wider grounds of the organisation and some parts of the home. The restriction is to safeguard residents, staff and visitors to the home. The restrictions had been assessed and documented within the individual care plans sampled by the Inspector. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 13 The Inspector observed lunch being served. The residents had either a salad or sandwiches for lunch on the day. The food appeared appetising and fresh. Where possible the residents were encouraged to maintain independence regarding feeding themselves. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 The home documents the needs of residents regarding ill health or dying. EVIDENCE: A number of care plans were sampled during the inspection. The Inspector found that wherever possible a clear record had been made of the preferred wishes or best interests of the resident regarding ill health and dying. A policy and procedure are in place to inform staff of what action they need to take in such circumstances. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has a complaints procedure that meets the standard. Further work is required regarding the policy and procedure for the protection of vulnerable adults to ensure that staff members are able to be clear about what action to take if an allegation were made. EVIDENCE: The homes complaint policy meets Standard 22 of The National Minimum Standards for Younger People. The home had not received any complaints since the last inspection on the 29th June 2005. The Commission for Social Care Inspection is reviewing key aspects of Robinia South Limited homes in Surrey. The review is being undertaken due to concerns relating to the protection of vulnerable adults. A number of recommendations were made as part of the review, further recommendations or requirements may be made as part of the review process. The information regarding the review was supplied in a separate forum and action agreed with senior representatives of Robinia Care Group Ltd the parent organisation of Robinia South Limited. The Inspector read through the organisations protection of vulnerable adults policy and procedure and found it to be confusing and unclear. A requirement is made that the organisation reviews the policy and procedure in line with local guidelines regarding the protection of vulnerable adults. The whistle blowing policy required a minor change to ensure that any staff member reading the detail was able to identify when an issue related to the protection of vulnerable adults. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The communal areas seen were appropriate to the needs of the residents. EVIDENCE: The premises were not assessed during the inspection of the 29th June 2005. The communal areas seen during the inspection of the 21st October 2005 were clean, fresh and airy. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35 Further work is required to ensure the home is able to meet the qualification standard of 50 of staff having The National Vocational Qualification Level 2. Appropriate training is provided to staff in line with the needs of the residents. EVIDENCE: The care plans sampled during the inspection documented the religious and cultural needs of the residents. Induction training is provided to staff and evidence was seen in the form of correspondence and assessments that specialist professionals are involved where necessary. The Inspector was unable to find the outcome for one specified resident following an assessment from a specialist health professional. It was recommended that a clear record of outcomes be kept by the home. The majority of residents are white, British and all are male. The staff team reflect a cultural and gender mix although the majority are female. The home records resident preferences for male staff where they cannot be provided. The Inspector sampled a number of staff training records. The staff members receive training in basic skills such as food hygiene and foot care as well as in challenging behaviour and the use of restraint. The Area Manager confirmed Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 18 that the organisation is providing staff with additional training in communication. Standard 33 was assessed during the inspection of the 29th June 2005. However during the inspection of the 21st October the Area Manager informed the Inspector that the organisation was nearing completion of a revised staffing rota that would clearly identify which staff members were providing one to one support for named residents. This will enable the staff team to ensure that appropriate and consistent support is provided to the residents. A requirement was made that a copy of the revised staff rota be forwarded to the CSCI. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 Some work is required to ensure the home can meet all the standards assessed. EVIDENCE: The manager was not available during the inspection of the 21st October 2005. The Area Manager informed the Inspector that the manager had the registered managers award and was qualified to The National Vocational Qualification Level 4. The Area Manager informed the Inspector that the home does not have a quality assurance process to enable an audit of the service to take place. A requirement was made that the organisation informs the Commission for Social care Inspection of a reasonable date when a quality assurance audit process may be in place. The Inspector looked a number of policies and procedures; the report highlights those that required some amendment, in particular the protection of vulnerable adults. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 20 The records sampled during the inspection of the 21st October 2005 were held securely in a lockable space and were up to date and accurate. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willows (The) Score X X X 3 Standard No 37 38 39 40 41 42 43 Score 3 X 2 2 3 X X DS0000013887.V261110.R01.S.doc Version 5.0 Page 22 NO 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 1 Regulation 4(1), 5 6(a)(b) Requirement The registered person must ensure that the homes statement of purpose is updated and includes all the information required to assist prospective service users and their representatives to make a decision about moving in. The registered person must ensure that each service user is provided with a statement of terms and conditions to ensure that they or their representatives are clear about the services to be provided The registered person must review the protection of vulnerable adults procedure to ensure that the procedure is clear and meets the local guidelines. The registered person must provide the CSCI with an action plan of how they intend to meet the staff DS0000013887.V261110.R01.S.doc Timescale for action 30/11/05 2 2 5(1)(c) 15/11/05 3 23, 40 13(6) 30/11/05 4 32 13(6) 30/11/05 Willows (The) Version 5.0 Page 23 qualification target of 50 of staff being qualified to NVQ 2 by 2005. 18(1)(a) The registered person must provide the CSCI with an action plan and timescale regarding the introduction of a quality assurance process to enable the organisation to audit the service provided. 5 33 18(1)(a) The registered person must forward a copy of the revised staffing rota to the CSCI. 24(1)(a)(b)(2)(3) The registered person must provide the CSCI with an action plan and timescale regarding the introduction of a quality assurance process to enable the organisation to audit the service provided. 11/11/05 6 39 30/11/05 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 19 Good Practice Recommendations It is strongly recommended that any action required by a specialist health professional including the outcome are clearly documented in the specific person’s care plan. Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willows (The) DS0000013887.V261110.R01.S.doc Version 5.0 Page 25 - 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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