Care Home: Willowbeck Care Centre

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What the care home does well People who wish to use the service and their representatives are able to receive the information they need to make an informed decision. The people are assured that the home is able to meet the needs of those who want to move in. The service users have their needs assessed and a contract drawn up by the management at the point of moving into the home. The staff ensure that individual service users are involved in making decisions about their lives, and play an active role in planning the care and support they receive. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 The activities team arrange the social, educational, cultural and recreational activities for the service users in order to meet the individual`s expectations. The service users are encouraged to have a healthy diet. There is always a choice of meals available for people at each mealtime. The people who use the service are able to express their concerns and know that the management listens to them. The service users are protected from abuse, and they have their rights protected by the home`s training programme and its policies and procedures. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The present layout of the building complements the ethos and the aims of the home. The staff employed at the home are trained, skilled and in sufficient numbers to support the people who use the service. Commitment to staff recruitment, training and development contributes to the smooth running of the service. The management and administration of the home is based on openness and respect for those who use the service. It has an effective quality assurance system, which monitors the standard of care they deliver. What has improved since the last inspection? The staff continue to maintain their enthusiasm in driving up the standard of care they deliver to the vulnerable adults. The staff have attended mandatory training and the records were up to date. The daily records refer to the identified needs of service users and the progress made. What the care home could do better: The management and the staff should continue their commitment to the service and maintain the high quality of care and support they deliver to the people who live at Willowbeck. Staff should be encouraged to liaise with the families and keep them informed of changes. The management should continue their open and transparent style, which makes the service users and their family feel included. Key inspection report CARE HOME ADULTS 18-65 Willowbeck Care Centre 95 Holywell Road Sheffield South Yorkshire S4 8AR Lead Inspector Marina Warwicker Key Unannounced Inspection 7th April 2009 10:00 Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willowbeck Care Centre Address 95 Holywell Road Sheffield South Yorkshire S4 8AR 0114 261 7771 0114 261 9779 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) Willowbeck Health Care Limited Miss Dawn Tracey Oakes Care Home 82 Category(ies) of Dementia (11), Mental disorder, excluding registration, with number learning disability or dementia (82), Physical of places disability (82) Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Physical Disability - Code PD, maximum number of places: 82 Mental Disorder, excluding learning disability or dementia - Code MD, maximum number of places: 82 2. Dementia - Code DE, maximum number of places: 11 The maximum number of service users who can be accommodated is: 82 10th April 2007 Date of last inspection Brief Description of the Service: The head office of Willowbeck Health Care Limited is in Rotherham. It was originally opened in May 1999 and in 2006 the home changed to trading under the name Willowbeck. Willowbeck is divided into five units with lounges and dining areas in each area. Each unit specialises in areas such as Mental disorder, Dementia and Physical Disabilities. There are 82 single bedrooms with en-suite facilities. The fee for a week at Willowbeck is between £588.52p and & £2792.51p and is based on the assessed needs of the individuals. The service users have easy access to the city centre, hospitals, shopping complexes using the public transport or the home’s own transport. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The quality rating for this service is three star – excellent service. This means that the people who use this service experience excellent quality outcomes. An unannounced inspection was carried out on Tuesday 7th April 2009 between 9.30 am and 3 pm. Nine residents and one relative were consulted and fifteen staff were spoken with. Approximately a month before the site visit twenty surveys were sent out between service users, their Key workers, the staff and also to their care managers by post seeking their feedback on the care at the home. Comments received from the surveys have been included in the body of the report. Time was spent sitting with service users and observing interaction between the staff and the service users. The registered manager and the operations manager were present during the inspection. They were informed of our findings on the day. The premise was inspected which included bedrooms of service users and the communal areas inside and outdoors. Sample of records were checked. They included care plans, medication records, some service users’ financial files, staff recruitment and training files. I would like to thank the service users, the relatives, the staff and the management for their contribution towards this process. What the service does well: People who wish to use the service and their representatives are able to receive the information they need to make an informed decision. The people are assured that the home is able to meet the needs of those who want to move in. The service users have their needs assessed and a contract drawn up by the management at the point of moving into the home. The staff ensure that individual service users are involved in making decisions about their lives, and play an active role in planning the care and support they receive. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 6 The activities team arrange the social, educational, cultural and recreational activities for the service users in order to meet the individual’s expectations. The service users are encouraged to have a healthy diet. There is always a choice of meals available for people at each mealtime. The people who use the service are able to express their concerns and know that the management listens to them. The service users are protected from abuse, and they have their rights protected by the home’s training programme and its policies and procedures. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The present layout of the building complements the ethos and the aims of the home. The staff employed at the home are trained, skilled and in sufficient numbers to support the people who use the service. Commitment to staff recruitment, training and development contributes to the smooth running of the service. The management and administration of the home is based on openness and respect for those who use the service. It has an effective quality assurance system, which monitors the standard of care they deliver. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 7 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 Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 8 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2&4 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people who wish to use the service and their representatives have the information needed to make an informed decision about the service. The management of the home at the point of each admission assures the people and their families that they are able to meet the needs of those who move in. The service users have their needs assessed and they are able to ‘test drive’ the service if they so wish. EVIDENCE: Five people using the service and a relative were consulted during the site visit. Four staff were interviewed and the documentation relating to this outcome area was checked. The evidence suggested that the management ensured the service user guide was up to date to reflect the service. Although the new unit for people suffering with dementia was ready for admission there were no occupants on the day of the site visit. Four service user files were checked for evidence of referrals by the funding authorities and the individual needs assessments. These were available Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 9 together with the home’s assessments of the service users and we found them to be comprehensive. The surveys confirmed that the management accepted service users only if they were satisfied that they had the means to deliver the identified care. The unit managers and the staff spoken with said that unplanned admissions were avoided and that they encouraged introductory visits of service users. Sometimes these visits were not suitable for some of the individuals therefore they were given settling in periods at the home and monitored through reviews. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 &10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual service users are involved in making decisions about their lives, and play an active role in planning the care and support they receive. This gives them the independence to choose the support they need. EVIDENCE: Four service user plans were checked with the help of the nurses and the care staff who were allocated to those service users. The care staff were interviewed to test their understanding of the identified needs of the service users and find out their input in the service users’ daily living. The care staff had a good understanding of the service users’ conditions and the problems caused by the illnesses and how they were to support them. These were some of the comments made by the care staff. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 11 “ Some people can be challenging and can be difficult. I ask the nurse or the seniors if I need help.” “We take in turn to sit with people when they are allocated 1:1 care; this gives all of us an opportunity to get to know the person and moreover the service user will not get fed up with having contact with just one person. But if changing staff was to be a problem to the individual service user then we keep the same person. We are here to look after them” “I read the care plan if I want to check any specific information; usually I ask the nurse or the senior on duty and they are very helpful.” “ I try to allow plenty of time and not rush the residents so that they are able to help themselves. Especially when they are walking to the bathroom, washing themselves and changing their clothes. Some clients take a long time. But if they have an appointment to keep then I try to help them along so that they are ready when the transport arrives.” The documentation and the staff interviews confirmed that the service users’ right to make decisions were respected. The staff imposed limitations only following risk assessments, consultation with multidisciplinary team and after involving the service users themselves (e.g. how many cigarettes are allowed and how often and who was to facilitate the service user whilst s/he was having a cigarette.) These limitations were regularly reviewed and changes made according to the progress and these were found in the individuals’ care plans. The management were in the process of reviewing their policies and procedures to encompass the aspect of Deprivation of Liberty under Safeguards of the Mental Capacity Act 2005. They have already removed unnecessary keypad locks and have made available the information to all the visitors to the home and the staff. During direct observation we noted that the service users were able to influence their daily routines. (For example two service users wanted to have breakfast before having a wash in the morning, one service user wanted to have a shave in the afternoon.) The care staff were seen supporting and supervising the service users when they took risks e.g. go out to the pub/ or shopping, go out into the garden. The staff respected individual’s aspiration. The staff said that they shared confidential information passed on to them by the service users with the management in the best interest of the service users. The service users whom we spoke with were happy for confidential information to be shared among the staff at the home. Two members of staff said that they had read the policy on confidentiality and that sharing information was part of the continuity of care and that information was only shared if it was relevant. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 12 These were some comments we received. “Handover is the time we use for sharing most of the information. But if I feel uncomfortable about sharing information then I go to my unit manager and let him/her know.” “The unit manager is very supportive and I feel that I can share any information. We work well as a team and the manager encourages it”. Willowbeck Care Centre DS0000068463.V374932.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): This is what people staying in this care home experience: 12,13,15,16&17 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services of Willowbeck are able to make choices about their lifestyle, and receive support to develop their life skills. The activities manager and her team arrange social, educational, cultural and recreational activities for the service users so that individual’s expectations are met. The service users are encouraged to have a healthy diet by the home offering a good choice of food, which is high in nutritional value. EVIDENCE: Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 14 The service users in each unit had specific needs and therefore required specially skilled staff to maintain and develop skills (i.e. physical disabilities, mental illness). The feedback from the surveys confirmed that the service users were given opportunities to fulfil their spiritual and emotional needs. The key workers and the activities team played a big part in facilitating and encouraging individuals to fulfil their life ambitions. The activities team made an invaluable contribution to each service user. They meet with people to spend 1:1 and also have group activities and take people out. Visitors were able to join in or observe activities and spend time with the residents. It was noted that the staff always knocked on the doors of service users before entering their bedrooms. Three care staff were asked how they respected the rights and responsibilities of the people who lived at Willowbeck. Their comments follow. “I see myself as a helper to the residents. I help them have a good quality life. I ask the resident whether they need help. I close the bedroom door and the curtains when I start helping with personal hygiene.” “We always knock on the resident’s door before entering. We always discuss with them what they want to do and ask whether they need help, in some cases we know that they need help but we let the residents dictate what help they want.” “I look after the personal belongings of the people whom I am a key worker to. I liaise with the family if they needed things bought for them. I respect residents’ wishes.” The staff said when service users received mail the unit co-ordinators took the letters to the service users and read it to them or left the letters for the family to read them out to the service user. However there has been an incident where an important mail had been opened by the staff at the home, which should have been left for the family. This has been investigated and the manager had taken action to prevent this happening again. (This incident has been reflected under the outcome area ‘Concerns, Complaints & Protection’.) Breakfast and lunchtime for service users were observed on different units. The mealtimes were flexible to suit service users’ activities and schedules. It was relaxed and not rushed. Service users were given a choice and they appeared to enjoy their meals. The care staff said that there was always a choice of meals. The cook showed us a four week menu and the food looked well balanced and a good choice was on offer. When we asked a care staff if a person did not like whatever was on offer what they did. S/he said, “ We will either ring the kitchen for what the individual had asked for or cook something in the kitchenette which was to the person’s liking.” Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 15 Another member of staff said, “If a resident continues not to eat or refuse food then we inform the unit manager and also start recording on the daily food chart. We offer food supplements and yoghurts.” Nurses supervised those service users who were reliant upon artificial feeding. Willowbeck Care Centre DS0000068463.V374932.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care of those people who live at Willowbeck is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff so that the people are able to live in a caring and comfortable setting. EVIDENCE: The direct observation on the day of the site visit, consultation with the people using the service and the staff interviews established that service users received appropriate personal care and support in private. The service users were encouraged by the staff to take care of their own hygiene by taking a wash/bath, having a shave and cleaning their teeth as part of self-help. One staff was seen helping a service user choose his/her clothes. To promote and maximise the independence of the service users, technical aids and equipment were made available by the management of the home. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 17 The service users’ health was monitored and potential complications and problems were identified and dealt with at an early stage by the nurses on each unit. The daily recordings confirmed this. The general practitioner visited the home every Tuesday so that the staff were able to consult with the doctor if there were to be any problems. The GP visited the home on the day of our visit and we witnessed the nurses seeking medical attention from the GP. Four medication administration sheets and one medicine trolley were checked. They were satisfactory. The last pharmacy audit by the supplying pharmacist had taken place in March 2009 and the action points had been complied with. The service users occupying the home were unable to self-medicate due to their medical conditions and the assessments to support this decision were seen on the individuals’ care plans. Willowbeck Care Centre DS0000068463.V374932.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most of the people who use the service are able to express their concerns and know that the staff at Willowbeck listen to them. The service users and their representatives have access to a complaints procedure. The service users are protected from abuse, and they have their rights protected by the homes training programme and its policies and procedures. EVIDENCE: The records kept by the home on complaints showed that the staff and the management at the home took all complaints seriously. There had been three complaints in the last year and the areas of complaints were staff not keeping the relatives informed of issues relating to the service users and one occasion personal mail belonging to a resident was opened by the staff at the home without their permission. These had been investigated and appropriate action had been taken to prevent them happening again. All allegations of abuse had been dealt with correctly by the home. Most staff employed by the home had received training on safeguarding vulnerable people from abuse, neglect, discrimination or self-harm. The staff verbalised the action to be taken if they were to witness abuse of service users or other staff. The management of the home continue to refer any allegations of abuse within the home to the Adult Safeguarding department and work in partnership with the different organisations. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28,29&30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The present layout of the home complements the ethos and the aims of the service. EVIDENCE: The home was divided into five units. Four units were occupied on the day of our visit. We found the premises used by the service users safe, comfortable, bright, airy and clean. There was sufficient ventilation and heating on each unit. The home was accessible to all service users and accommodated wheelchair users. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 20 All bedrooms were single rooms and they were able to accommodate wheelchair users and service users with complex needs. There was adequate space in each bedroom for providing additional equipment for turning, transferring and to contain medical equipment. The bedrooms were individualised by the service users bringing in their own pieces of furniture or other personal items. Rooms looked homely and personalised. The service users had ensuite facilities in their bedrooms as well as access to specialist baths and showers. There were toilet facilities near the communal areas so that the service users were able to use them instead of going back to their bedrooms. Each unit had a lounge and dining area which were suitably furnished and were accessible to service users. There were designated areas for the service users to smoke within the home. The staff and the service users said that the home continues to provide enough aids and equipment to deliver the care. The laundry was sited away from the kitchen and food delivery area. When we questioned the care staff they said that were fully versed with procedures that they follow in order to control the spread of infection. A large section of the lower ground floor housed the activities, which took place at the home. A large room was used to do exercises with the residents, cooking, baking and play games. There were three more rooms, which were used as beauty therapy and hairdressing, a snoozlem and a crafts gardening activities room. We witnessed the area used well during our visit and people attending activities and enjoying them. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff employed at the home are trained, skilled and in sufficient numbers to support the people who use the service. This is in line with the terms and conditions of the service. The management commitment to staff recruitment, training and development contributes to the smooth running of the service. EVIDENCE: The number and skill mix of staff on duty on the day of the site visit was noted to be sufficient for the dependency of the service users. The duty rota for the week ensured that there was an adequate number of staff on the roster for each shift. The activities staff said in the event of sickness as a short-term solution they helped the care staff on the units. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 22 The staff team reflected the cultural, gender and the diversity of the community and the people occupying the home. Four staff files were checked to establish whether the home’s recruitment process was rigorous and complied with equal opportunity legislation. This protected the service users and others working at the home. We found that the information within the files complied with the relevant regulations. Two staff interviewed were able to go through their recruitment process, which included application, interview, awaiting a satisfactory CRB check and references. Training and development of staff was ongoing. The staff surveys indicated that there was a variety of training offered to them. Four staff training and supervision files were checked. They were up to date and had the necessary information in them. Four staff said that they received regular supervision approximately every 8 to 10 weeks. The unit managers said that supervision was cascaded from the senior managers to the care staff and these meetings were recorded and copies of the supervisions were kept on staff personal files. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect for those who use the service. Regular Quality monitoring of the service contributes to the good progress. EVIDENCE: The home has a management structure, which suits the purpose and its aims. There were several quality audit tools used by the local management team to monitor the standard of care. These audits were available for inspection. The responsible individual carried out monthly monitoring and produced written reports for the service. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 24 We sent out staff, service users and visiting professional surveys and the following comments were received from the feedback with regards to the service. “It is difficult to see how staff cope with peoples’ needs since they all seem to have very special needs. I have found the staff supportive to the residents.” “I am happy with the care at this home. I like some carers better. It is like anywhere we can’t be expected like everyone.” “Some staff don’t keep us informed of the changes / incidents occurring to the service users. We often have to chase staff up to get information.” “The home is clean and fresh and the staff treat me well. They help me join in activities. I like going downstairs.” Several staff suggested that they would like staff meeting for the whole of the home at least twice a year so that they are able to contribute to decisions about the home. The present arrangement did not enable staff at all levels to be involved. The records kept by the administrator on the service user finance were accurate and were kept safe to protect the service users and the business. The pre-inspection information, i.e. the annual quality assurance audit confirmed that the management of the home maintain the health and safety of the service users and the workers by staff training and maintenance and replacement of equipment. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 25 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 4 3 X 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 4 32 3 33 4 34 4 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 x 3 X X 3 X Version 5.2 Page 26 Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 27 Care Quality Commission Yorkshire and Humberside Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshireandhumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Willowbeck Care Centre DS0000068463.V374932.R01.S.doc Version 5.2 Page 28 Willowbeck Care Centre DS0000068463.V374932.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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