Care Home: Willow House

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What the care home does well The management team are committed to improvement in the home, identify areas for improvement and address these creatively. The risk assessments are of a particularly good standard and people`s care plans are up-to-date and reflect their needs. Staff working in the home are good at supporting people to develop their independent living skills, which increases their confidence and self-esteem. A lot of energy is being put into making sure that people get a chance to engage in social, leisure, work and educational activities. Medication is well managed, which protects people`s health and well being. The staff encourage contact between people living in the home and their friends and family. The home is well maintained and comfortable which makes it a pleasant place to live. There is an effective complaints procedure which means complaints are taken seriously and people feel their views are valued. The home the adult protection policy and procedure and staff have received training, which means people living in the home can be safeguarded from potential abuse. People are protected by adequate recruitment policies and procedures being in place. Staff are given a lot of training and are well supported. Health and safety is taken seriously and effective health and safety records are in place. What has improved since the last inspection? It is worth noting that this is the second inspection for this home as it is relatively newly opened. We were impressed by response of the management team to the requirements made at the first inspection. A lot of thought and work had been put into the areas that were identified as needing improvement and the team had been thorough and creative in tackling the tasks. As people have settled into the home the risk assessments have been improved and are now of a very high standard. There were good guidelines in place for when people living in the home exhibit aggressive or inappropriate behaviour. This makes sure that the staff have clear information about to how to respond in these situations. The ways in which people are involved in decisions about their care and support have developed and improved. People are being actively encouraged to take more responsibility for their health care and are getting better at going to their health care appointments. The recording of activities has been improved and the records show that people are being encouraged to take part in meaningful activities. In the AQAA the home told us that the areas that they have been focussing on for improvement since the last inspection include, the annual training plan for staff, the staff skill mix, recording health and safety checks, the contract with a local pharmacist, the key worker system, displaying information on community resources, information which empower residents and information on health related issues, medication profiles on each resident, modernising and extending the home, a structured activity program, both in-house and in the wider community setting, a training and development group for all team leaders and regular internal audits. At this inspection we saw evidence that improvements had been made in all of these areas. What the care home could do better: Three areas have been identified for improvement at this inspection and have been made as good practice recommendations. They include keeping a record of the assessment of how competent staff are in administering medication, expanding the risk assessment about people smoking in the home and the redecoration of one person`s bedroom. CARE HOME ADULTS 18-65 Willow House 11 Osborne Road Enfield Middlesex EN3 7RN Lead Inspector Caroline Mitchell Unannounced Inspection 25 October 2008 11:50 th 25/10/08 Willow House DS0000068774.V371870.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 DS0000068774.V371870.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 DS0000068774.V371870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow House Address 11 Osborne Road Enfield Middlesex EN3 7RN 020 8804 5039 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) sanjeev@conniferscare.co.uk Connifers Care Limited Sanjeev Sunil Soobdhan Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 6 25th October 2007 Date of last inspection Brief Description of the Service: Willow House is part of Connifers Care. It is a home that is registered to provide care for six people who have mental health problems. Willow House is located in Brimsdown, which is an area in the Borough of Enfield. It is in walking distance of Enfield Highway and Edmonton shopping centre. The home has six bedrooms. There is a kitchen/dining area. The kitchen leads onto a lawned garden with a covered patio area. There is a staff office and adequate bathroom and toilet facilities. The stated aim is to offer care and support in a supportive and friendly environment. The service works towards meeting people’s needs by encouraging their involvement and exercising choice and independence whilst building on key daily living skills to enable independent living in the community. The fees range from £875 to £1,700 per week. People using the service pay for their own toiletries, outings, holidays, and clothing. Following “Inspecting for Better Lives” the provider must make information available about the service, including inspection reports, to the people who use the services and other stakeholders. Willow House DS0000068774.V371870.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 3 star. This means the people who use this service experience excellent quality outcomes. This was an unannounced inspection so the manager did not know that we were coming. It took place on a Saturday and took the afternoon to complete. All of the people who were living in the home at the time of the inspection were men. We spoke to four of them in private and at length. We met several members of the management and staff team and all were very helpful. We looked at written records for two of the people living in the home. This included their assessments and care plans and the regular reviews of these, risk assessments, daily records, notes of 1-1 meetings, review meetings and Care Programme Approach (CPA) meetings. We looked at the personnel records for one staff member. These included their applications, recruitment and pre-employment checks, training records, minutes of 1-1 supervision meetings with their managers and induction records. We looked at the complaints records. We checked the arrangements that are in place to maintain health and safety in the home and checked the staff rotas. We used information that was in the annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment, done by the people who run the home that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. What the service does well: The management team are committed to improvement in the home, identify areas for improvement and address these creatively. The risk assessments are of a particularly good standard and people’s care plans are up-to-date and reflect their needs. Staff working in the home are good at supporting people to develop their independent living skills, which increases their confidence and self-esteem. A lot of energy is being put into making sure that people get a chance to engage in social, leisure, work and educational activities. Medication is well managed, which protects people’s health and well being. The staff encourage contact between people living in the home and their friends and family. The home is well maintained and comfortable which makes it a pleasant place to live. There is an effective complaints procedure which means complaints are taken seriously and people feel their views are valued. The home the adult protection policy and procedure and staff have received training, which means people living in the home can be safeguarded from potential abuse. People are protected by adequate recruitment policies and Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 6 procedures being in place. Staff are given a lot of training and are well supported. Health and safety is taken seriously and effective health and safety records are in place. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 7 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 DS0000068774.V371870.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 DS0000068774.V371870.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. EVIDENCE: In the AQAA that the home sent to the Commission the home told us that the statement of purpose highlights their aim to promote equality and diversity. The service user guide and welcome pack, which is given to all residents shows how well the home recognises the diverse needs of people using the service. The AQAA told us that there is a robust referral procedure. For instance an initial assessment is always carried out prior to a resident being admitted and residents visit the home before deciding. At this inspection we found lots of evidence to show that what the home told us is the case. We looked at the statement of purpose and this had been regularly updated. The service has its own brochure, which explains the homes mission, values and approach. There is also a service user guide which explains were the home is located, what the Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 10 home offers and has information regarding the accommodation provided to people who may wish to live in the home. This document explains what makes a person eligible for a place at the home, explains the assessment and admission process and confirms how fees will be paid. If English is not a person’s first language then the document can be translated on request, which ensures that the document is accessible to all The people living in the home have their needs assessed before they moved in, which makes sure that the staff that are employed to support them can meet their needs. On the day of the inspection we examined the written records for two people living in the home and saw the very clear and well-presented assessments, which had been done by the manager of the home. We were told that these are then seen and discussed by the staff before people move in. There was also a lot of other information that the home had received from other people, such as reports from occupational therapists and from people’s previous placements, so that they were really clear about what people’s histories and needs were, before they moved in. Willow House DS0000068774.V371870.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, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with the support they need. This is because the staff are good at promoting people’s rights and choices. People are supported to take risks to enable them to be as independent as they can. This is because the staff have very good information on which to base decisions. The staff help people to make decisions and informed choices. EVIDENCE: We looked at the care plans for two people and these were clear and easy to read. The care plans clearly set out people’s needs and the ways these need were to be met in the home. The steps that needed to be taken for people to make progress were also set out clearly. The care plans had been reviewed each month, by the person and their key worker in their 1-1 session, and the key worker had written a summary. There were lots of records showing that people’s key workers made sure that they were fully informed and involved in planning their care and people had signed their plans and their risk Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 12 assessments. The plans talked about the history of the person, their mental state, health needs, dietary needs, medication, personal care, activities and social skills. The care plans were being kept up to date which makes sure people’s individual and changing needs can be met. This improves the quality of life for the people living in the home. On the day of the inspection the people we spoke to said that they make decisions and choices about their daily lives. They said that they were involved in planning their care and support and they said that the staff listened. One person said, “I can talk to the manager about anything” and that the home was like, “a breath of fresh air.” The home has a regular residents’ meeting and we looked at the notes, which were written by one of the people who lives in the home. In the AQAA the sent to the Commission the home told us that residents have a key to the front door and to their own rooms and that no unreasonable restrictions are put on their movements. During the inspection we saw lots of evidence that this is the case. The risk assessments that we saw showed the risks for each person. They were being kept up-to-date and this helps to minimise the potential risks of harm for people living in the home and the staff working with them. At the last inspection the registered person was required to make sure that risk assessments were developed for one person who was diabetic, another person who was reluctant to attend their medical appointments and one person who has challenging behaviour. At this inspection we found that a lot of very good work had been put into this. The risk assessments that had been developed were of a very good standard. It was very positive to note that as people settled into the home the ways in which they are involved in decisions about their care and support have also developed and improved and their risk assessment have been developed. This is linked with them being encouraged to take more responsibility for their lives generally, and particularly their health care. Willow House DS0000068774.V371870.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, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person is treated as an individual and the home is responsive to their race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The home supports people to follow their personal interests and activities. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. People are able to keep in touch with family and friends and the home supports them to have appropriate personal and family relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. EVIDENCE: Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 14 In their AQAA the home told us that residents are asked to invite relatives and close friends to any BBQ’S or birthday celebrations held at the home. The home has helped residents to access work experience and continue with social activities such a day centres and drop-in services. The home has helped residents access local facilities like the library and leisure services. At this inspection e found lots of evidence that this is the case. We saw evidence that people were being given support to develop their daily living skills. They did their own laundry and cleaned their own bedrooms and this was part of each person’s activity plan. One person’s plan said how they were supported to make lunch and to help to cook dinner for the other people living in the home. There were planned times to allow people to relax. As people have settled into the home the staff have helped them to find things that they were interested in doing. One person said that the staff were very good at “keeping me motivated.” Another person, who moved in recently, said he was interested in doing plumbing at college and that his key worker was helping him to find and contact the colleges in the local area. Most people were able to go out on their own and one person needed someone to go with him, as he doesn’t yet have the confidence to go out alone. This person had recently gone on a shopping trip, with staff support and chosen some new clothes and when we met him he was very well presented. Everyone we talked to said they really liked going out to another, similar home nearby to play pool. They were all very enthusiastic about it. They said they were doing this regularly and they liked meeting up with their friends who live in the home. One of the people we talked to said that a few weeks ago he had gone a trip to Brighton with some of the other people living in the home. We were also told about some of the people who live in the home going on a trip to Belgium and planning a trip to France. People living in the home are encouraged to keep in touch with their families and friends. One person was away for the weekend, staying with a relative. Another person showed us pictures of their family and friends, which were displayed in their room and said that they were expecting one of their friends to visit that afternoon. One person’s records showed that he has a girlfriend who he sees regularly. On the day of the inspection the kitchen was clean and tidy and food was stored properly. There were staff from different cultures in the staff team and one person told us that staff bring different ideas to the home so people get the chance to try different types of food. We looked at the menu and this showed that the meals are varied and included fresh fruit and vegetables. At the last inspection a recommendation was made for the registered manager to review the menu and not continue to buy value food, which can be high in sugar and salt. At this inspection we found that the management team had responded to the requirement in a very positive way and had put a lot of Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 15 thought, work and resources into improving the quality of the food provided in the home. They had also put a lot of work into finding ways to support and advise the person with diabetes. Willow House DS0000068774.V371870.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, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the home supports them with it in a safe way. EVIDENCE: We looked at the written records for three people living in the home. We found that there were excellent records being kept of people’s health care appointments, that there were very good risk assessments about their health and that their health was being monitored closely. One person was diabetic and was having a lot of support from people like the diabetic nurse and other health care professionals and they were getting counselling and support from staff in the home and from others outside the home. At the last inspection a requirement was made about keeping people’s health care appointments up to date. At this inspection we found that the management team had looked at this issue properly and had found creative ways of supporting people to take more Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 17 responsibility for their health care generally, and particularly their appointments. This was being monitored closely and was proving quite successful, as people were getting better at going to their appointments. The home has clear policies, procedures and guidelines about medication, including the use of as and when medication (PRN). We looked at the medication cupboard and records of medication. The records we looked at showed that medication was being managed well. The medication was stored properly. The possible side effects of the medication people were taking were also noted on people’s records, and there were photographs of people on their medication record sheets to help make sure that the right people were given the right medication. The staff who gave out medication had received training and the team leader told us that when staff are giving medication for the first few times, to make sure they are competent they are supervised by a member of the management team. However, a note wasn’t being kept of this assessment on staff’s files and a recommendation is made about this. In the AQAA the home told us that they have placed more notice boards in communal areas displaying useful information for residents on local day services, organisations that help people gain work experience and other information on health promotion and healthy living. Willow House has offered residents the opportunity to engage with local drug and alcohol services when this is required. Willow House DS0000068774.V371870.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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. EVIDENCE: The service has a complaints procedure that is on the notice board in the hall way and also provided to the people who live in the home in their information pack, which is given to them when they move in. It tells people who they should speak to at the home and who to contact outside the home to make a complaint. All four of the people we talked to were very clear about how to make a complaint and said they’d go first to one of the Directors or the manager. They all said that they had no complaints to tell us about and one person particularly wanted us to mention in this report, that he felt very safe in the home. He said, “The staff are lovely people.” One of the people we talked to had only moved it recently and said that he liked the home a lot more than the home he was living in before. He said the main reason for this was that the rules were more reasonable. Another said, “When I moved in they explained and gave me a copy of the complaints procedure. I have never had to use it because we talk about things before they turn into a problem.” We looked at the complaints file and one complaint had been made since the last inspection. The records were good and showed that the complaint had been dealt with properly and in a reasonable timescale. Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 19 The home keeps a book for visitors to make comments in and we saw that a social worker had recently written that their client had “made noticeable improvement since being in the home”, and that their appearance was much better. The staff had attended training in safeguarding people from abuse. The local authority adult protection procedures were available, “you have the right not to be abused”. The organisation also has its own policy about safeguarding people and preventing abuse. The home has a whistle blowing policy and procedure. Staff have also had training in how to deal with challenging behaviour and violent situations. This means that people living in the home are supported by staff who have the necessary guidance and training to protect them from potential abuse. Willow House DS0000068774.V371870.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People stay in a safe and well-maintained home that is homely, clean, comfortable and pleasant. The home has enough space and facilities for them to lead the life they choose and to meet their needs. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. EVIDENCE: Willow house is an ordinary house located in a residential street. It is near to local shops, pubs, cafes and local transport, which helps people to be part of their local community. The home had been extended since the last inspection, to add two new bedrooms. The existing bathrooms had been refurbished, and a conservatory and outside smoking shelter and an activity suite/staff training room had been added. Improvements had been made to the look of the outside of the house and the garden and new tiles, worktops and a new sink had been put in the kitchen. People living in the home have their own Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 21 bedroom. There is a toilet and bathroom upstairs and one downstairs toilet and shower room. The kitchen diner was well furnished and was clean and tidy on the day of the inspection, which benefits people’s health and wellbeing. The home has an office with a telephone computer and photocopier to assist people to carry out their daily work. Four people showed us their rooms. All of them said that they were very happy with them. People had posters and pictures on their walls and their rooms very much reflected their backgrounds, personalities and interests. One person had a large television, another a sound system, another lots of photographs of friends and family. People said they had a SKY TV connection in their rooms. In one person’s room the paintwork and walls were looking a bit worn and he said he would like the room redecorating. A recommendation is made about this. One of the people we spoke to said that the home was more relaxed and more homely and there was more space, than where he lived before. Another said, “It’s my home.” Willow House DS0000068774.V371870.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, 34, 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have safe and appropriate support, as there is enough competent, qualified staff on duty. They can have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get very good training, supervision and support from their managers. EVIDENCE: A senior member of the staff team, a team leader was doing his Registered Managers’ Award training and, although it was his day off he came and joined the inspection, “for the experience.” We looked at the staff rota and there were adequate numbers of staff on duty to meet people’s needs. In the AQAA the home told us that there and two staff on duty each shift during the day, in addition to as manager a male staff member on duty at night. There is a rota for managers who cover out of hours, so staff are clear who to call for support in an emergency. In the AQAA the home told us that the organisation has a recruitment director and there is a strict recruitment procedure in place. The records we looked showed that the proper checks had been done on staff before they started Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 23 work in the home. As the staff personnel files were judged good at the last inspection, at this inspection we looked at the staff personnel file for one person, who had started work in the home since the last inspection. The staff member had a criminal record bureau check (CRB) and two written references. The referees had also been contacted by telephone as an extra check that the references were valid. The staff member’s file contained proof of their identity and their application for employment. We saw the records of the 1-1 meetings staff have with their managers and these showed that staff were having this kind if supervision regularly, which makes sure that staff are supported properly. Overall, we saw very good monitoring records of staff supervision and training. The records we saw about staff training showed that all of the staff had completed, or were completing training at National Vocational Qualification (NVQ) level 2 in care. About half had completed, or were completing training at NVQ level 3. There was a good, planned programme of training and the staff that had recently joined the staff team had been given all of the core training, such as health and safety, fire safety, food hygiene, safeguarding people from abuse during their induction period, or very soon after they started work in the home. Staff had also had training in moving and handling, mental health awareness, control and restraint, managing challenging behaviour, training regarding the mental capacity act, medication and diabetes. This makes sure that they have the necessary skills and knowledge to make sure that people’s needs can be met. Each member of staff had a training folder and these had their training certificates and their individual training records. The staff induction was based on the “Skills for Care” induction programme and was of a very good quality. New staff spend at least two weeks having an “orientation” and training and spending time at the home, along with visiting the other homes in the organisation. Willow House DS0000068774.V371870.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, 41, 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have confidence in the care home because it is run and managed very well. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the home because the management team run it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear procedures, keeps very good records and makes sure staff understand the way things should be done. EVIDENCE: The management team are very good at looking for things that can be improved and good at making improvements. There are checks done every six months, by different managers in the organisation, to look at the quality of the service. People living in the home, their families and friends and other people like the care co-ordinators are asked what they think of the home regularly. Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 25 The home asks them to fill in a questionnaire and we saw the summary of the most recent feedback. The summary said that the feedback was generally very positive and the suggestions that people had made were taken seriously and put into an improvement plan. There was also a suggestions box in the home for the people to make suggestions about how the service can be improved. There were very good systems in place to help the management team to monitor the quality of the service on a day-to-day basis and these were being put to good use. The manager is experienced and qualified to run the home. In the AQAA he told us that he had completed the Registered Manager’s Award, and as mentioned in this report, the team leader is also undertaking this training. The organisation holds monthly managers’ meetings and quality assurance meetings, which helps the managers to work together and support each other. The information that the home gave us in the AQAA about health and safety in the home showed that the specialist checks, such as electrical and gas safety, were being done. We looked at the records about fire safety and found that the fire extinguishers had been serviced, the weekly alarm test had taken place, the smoke detectors had been checked, and the fire drills had taken place. Smoking is covered in the fire risk assessment. However, as so many of the people living in the home were smokers it is recommended that the fire risk assessment deals with smoking as a separate topic, and in more detail. At the last inspection the registered person was required to make sure that activities are fully recorded on the activity sheet including when an activity is declined. At this inspection we found that the records of people’s activities had been improved. Generally, we found that the quality of the records and monitoring was very high. In the AQAA the home told us that there is effective communication between management and staff through the use of a daily diary, handovers (verbal and written), a communication book and monthly staff meetings. There is regular staff supervision with the manager and the policy folder is accessible to staff. At this inspection we found that all of these methods of communication and information sharing were being used well, and effectively. Willow House DS0000068774.V371870.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 4 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 4 X 3 2 X Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard YA26 YA20 Good Practice Recommendations It is recommended that the manager discuss and arrange the redecoration of their bedroom with one person. It is recommended that the assessment of staff competence in the administration of medication be recorded in their personnel records. It is recommended that the fire risk assessment be written to include smoking as a separate topic, and in more detail. 3. YA42 Willow House DS0000068774.V371870.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 DS0000068774.V371870.R01.S.doc Version 5.2 Page 29 - 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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