Inspection on 03/02/09 for Willow House

This is the latest available inspection report for this service, carried out on 3rd February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Clover House

Dystlegh Grange

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Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Willow House Sunflower Grove off Hunt Lane Chadderton Oldham OL9 0JQ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Michelle Haller     Date: 0 3 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Willow House off Hunt Lane Sunflower Grove Chadderton Oldham OL9 0JQ 01616333850 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Debbie.Messam@oldham.gov.uk Oldham M.B.C. care home 5 Number of places (if applicable): Under 65 Over 65 0 0 learning disability physical disability Additional conditions: 5 5 No service user may be permanently accommodated in the service. The service is registered to provide personal care for service users who fall into the categories: Adults with learning disabilities LD (5) and Adults with physical disabilities PD (5). The service should at all times employ a suitably qualified and experieinced manager who is registered with the commission for social care inspection. Date of last inspection Brief description of the care home Willow House is a newly built and furnished two-storey property situated in a quiet culde-sac in Chadderton, Oldham. The service is registered to provide respite (short stay) support for up to 5 people with learning disabilities who may also have physical disabilities. Oldham Metropolitan Borough Council (OMBC) owns and manages the service. There is ample parking to the front and pleasant gardens at the side and rear of the building. The private accommodation is comprised of one flat and three large well-furnished bedrooms with en-suite facilities on the ground floor and another selfCare Homes for Adults (18-65 years) Page 4 of 31 Brief description of the care home contained flat on the first floor. There is also a staff sleeping-in room. The home is fully adapted for any person using a wheelchair and provides very comfortable and flexible communal accommodation for all service users. Service users generally receive short stay support in the home for periods of between one day and two weeks. The fees payable were not available to the inspector. The reader is advised to contact Oldham Council regarding fees payable. An inspection report is not available as this is the first key inspection of the service. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was a key inspection which means that the manager did not know that we were visiting to inspect on the day. We took into account the outcome of an Annual Service Review (ASR) completed by the Commission for Social Care Inspection on 29th January 2008. For this review we look at all the information we have received about a service during the previous year. We use this information to decide whether the service continues to provide good outcomes for service users or whether there is evidence that things have changed. The ASR indicated that there had not been any change to the quality of the service in the previous year. Care Homes for Adults (18-65 years) Page 6 of 31 The manager returned to us the Annual Quality Assurance Assessment that was sent to her. The information provided included data about staff training, the development of policies and procedures and compliance with health and safety checks. This information influenced the outcome of the inspection. The inspection process was conducted through speaking to the registered manager and a member of staff about working at Willow House. We also looked at the care and support received by three services users. We did this by looking at their health and social care assessments, risk assessments, care plans, communication reports and other correspondence and records concerned with their support and care. We also discussed their needs, and how these were met, with the manager and the member of staff. The people chosen were the most recent referral, someone with more complex communication needs and a person who was due to use the service on the day of the inspection. Other documents concerned with the running of the home were also examined, these included the staff training files and health and safety records. We sent out staff surveys so that people working for the service could give their opinions. We received eight back and the information has been included in relevant sections of the report. We sent three service user surveys direct their home and one was returned. The information provided is included in the appropriate sections of the report. People are charged 100 pounds each night for their stay at Willow House. What the care home does well: What has improved since the last inspection? We found that since the previous inspection the manager has familiarised herself with the charges made to service users for their stay at Willow House. This is important because she now has information that will help people budget for their care and also decide whether the charge is good value for money. Care Homes for Adults (18-65 years) Page 8 of 31 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: 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. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People going to Willow House have their needs assessed so that these can be met in a way which is personal to them and which promotes their independence. Evidence: We looked at the information in the care files for three people using the short stay respite service based at Willow House. The people chosen included a person recently referred and someone who was due to spend time at the home on the day of inspection. We found that each persons needs had been fully assessed and that the information gathered included: accommodation and specialist equipment required; the persons day activities; family and social contact; risk management needs; cultural and faith needs; physical and mental health needs and communication needs. The assessment also covered specific health conditions such as allergies and epilepsy. These assessments had been signed by the person or their carer, and were written in a Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: manner which showed that people had been asked about their needs and how these could be met. This means that the person was aware of the plans in place and showed that the manager treated people as individuals and respected their point of view. There were also records and reports which showed that the manager was involved in meetings to plan support that included other professionals such as, social workers, nurses, psychiatrist or speech and language therapists. This shows that the manager communicates with different agencies to ensure that the support offered during respite Willow House builds on what happens for the person when they are living in their own home. This helps people to settle into respite more quickly and helps their stay to be safe and enjoyable. We found that people had a period of introduction and daily records confirmed that people are supported to have overnight stays and spend time at Willow House before staying there for long periods. What happens during these visits are recorded and thought about by staff and discussed with the person, their family and the referring agency so that changes can be made if necessary. People said they were given a choice about using Willow House and commented that: We were shown round Willow House before she went and all our questions were answered. Care Homes for Adults (18-65 years) Page 12 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. 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 support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who attend Willow House are supported in a way that promotes their individuality and respects their choices. Evidence: We looked at three service user care files and found that the information they contained included detailed descriptions about how staff were to provide support in an individualised way. We found that the manager ensures that staff have sufficient information about other professionals involved in planning and providing support and care. This helps so provide a seamless approach to support, which then helps the person to make progress when they spend time in respite. Care plans informed staff of what they should in respect of following the instructions of professionals such as speech and language therapist, care managers and specialist nurses. Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: Records, reports and progress updates confirmed that, assessments and care plans were reviewed and changed if necessary before each visit to the respite unit. Furthermore staff also attended 6 monthly care review for people who used the service. Signatures confirmed that the plans had been drawn up with the person and their families. The plans could be improved if they were made available in more accessible formats so that the information could be more easily understood by people with different communication needs. The manager stated in the information she returned that this was an area that the organisation would like to improve on and develop. We found that the daily reports confirmed that people were able to choose, when and what they ate, the time they went to bed or got up, who they shared communal spaces with and what activities they joined in with, while at Willow House. We found that care plans were written in a manner which explained why choices were limited if this was the case- for example wakening someone to go to work, or encouraging a person to complete a self help skills such as preparing their own breakfast. Service users who commented confirmed that staff treat them well. I am treated very well by all the staff. Care Homes for Adults (18-65 years) Page 14 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her 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 care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual 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. 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. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who spend time at Willow House are treated with respect and their personal preferences, in relation to the lifestyle they lead, is carefully considered. Evidence: We found that daily records and the information received from service users and staff confirmed that people are able to continue to attend work and college placements while at Willow House. This ensures that they remain a part of their usual community and continue with routines that they enjoy. They said I attend day care during the day. Staff said, and comments written in daily records confirmed that, when possible people were supported to participate in community based activities. This included going to the local shops or restaurants, the cinema and pubs. Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: Staff who returned surveys and the service user said that there were times when people could not go out for leisure activities. Discussion with the manager also indicated that another reason for people not going out was to do with personal and individual budgetary constraints. The manager stated in the information she returned that, a request was made to families to arrange for changes in transport especially if the respite period was to be prolonged. This is so that people could travel to leisure activities. Staff and the service user also felt that there are activities and events arranged at Willow House for people to enjoy and, as previously identified, peoples education and occupational needs were fully met. Comments included: I am happy enough to watch TV or listen to music. And We go shopping, to the pictures but we also do lots here such as cooking, pamper sessions and film nights. And we have a relaxing time at the home. The care plans looked at showed that family contact and involvement is encouraged. Discussion with the manager also confirmed that this contact is flexible and tailored to meet the needs of the person receiving respite. For example, contact may involve a phone call direct to the person or, the family may want to check with staff that the person is has settling in. This is discussed and agreed at each visit as circumstances change depending on the reason for respite or the length of stay. The relative who commented wrote: I find the staff are always helpful and understanding and treat ......really well. Discussion with staff confirmed that they understand their role to provide privacy and promote dignity, empower people to make choices and support people as individuals. They said Not everyones the same and some do enjoy their own company. The agencys policies and procedures were looked at in relation to personal relationships. These offer guidance to staff in how to maintain peoples privacy and dignity, and also provides information about advocacy services and how and when this might be of use. The person who was interviewed stated that when she started working for Willow Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: House her induction training included learning disability awareness and this was all about peoples right to privacy, dignity and choice and how this could be achieved and maintained. We found that mealtimes are flexible and that service users are involved in food shopping. The menus are very flexible and change depending on the likes and dislikes of the people using the service each day. Two people were expected to use the respite facility on the day of the inspection. The larder and fridge were examined and held a wide variety of foods, including fresh meats, ready meals, fruit and vegetables and snacks. Care Homes for Adults (18-65 years) Page 17 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: 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 care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who attend Willow House have their health needs met effectively, however, the registered person needs to take more care over how controlled medication is managed in the home. Evidence: We found that each assessment and care plan examined held information about peoples routine and specialist health care needs. The emergency contact sheet provided details for the persons general practitioner, dentist and other health professionals involved in their care. We found that daily records and contact sheets confirmed that when people were unwell, they, their doctor and the persons main carer would be consulted about the best course of action. This differed in each care plan and dependent on the reason for the medical concern. We found that specialist care plans and risk assessments are in place for specific illnesses such as managing epilepsy. And records confirmed that staff receive training Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: in emergency procedures related to this. The manager stated that none of the people who use the service manage their own medication. And because the facility was not is use it was not possible to assess all aspects of medication practise within the home on the day of this inspection. We looked at the management of controlled medication. The policies and guidelines need to be reviewed and updated as, according to the information available, this was last done in 2005. We found that the guidelines provided information about about booking medication into the home, storing medication safely, and also made it clear that medication should only be accepted into the home in original containers or blister packs dispensed and sealed by a pharmacist. However we found that controlled medication policy was unclear in respect of booking medication in and out of the home. We looked at the Controlled Drug record book and found that this had not been filled in correctly. This meant that it was impossible to confirm the amount of controlled medication handled in Willow House or whether it had been returned home with the service user or destroyed. We discussed this matter with the manager who agreed to look at the policy and make sure that it is clear, and also update and train staff on how to manage controlled medication that comes into the home. We looked at the storage of controlled medication and this too needs to be changed. This issue was also discussed with the manager who agreed to make sure, through speaking with the appropriate professional, that the current arrangements for the receipt, administration, storage and disposal of controlled medication met with current pharmaceutical legislation. We found that there were no controlled drugs on the premises at the time of the inspection. Care Homes for Adults (18-65 years) Page 19 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: 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. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good 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 service feel listened to and able to make their concerns known, and staff know what to do in order to safeguard vulnerable adults. Evidence: We read through the complaints and adult protection procedures and these were clear and easy to understand. The complaints procedure was also available, in the Statement of Purpose, in clip art style format and was written in Plain English. The sharing of the complaints procedure could be further improved if it were put in the Short Term Support Service booklet which is given to all service users. The manager stated that there had not been any official complaints since the previous inspection, she said concerns and comments are dealt with immediately. In the information returned to us the manager wrote: We have hands on management that is able to observe staff and sit and listen to concerns or complaints service users may have. Staff who returned surveys felt that they received all the training necessary to do their jobs including how to protect vulnerable people. The training record confirmed that the majority of staff have completed Oldham Metropolitan Borough Council (OMBC) training partnerships Protection of Vulnerable Adult (POVA) training., and updates are Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: ongoing. The person who was interviewed was clear that her role included protecting people and taking action to promote their safety. Comments included: I would talk to the manager and record everything, I would make sure people were safe by reporting things, and taking action for example if two service users didnt get on this would be discussed with everyone to decide what was the best way to deal with it. The service user who returned the survey commented: The staff are always ready to listen to me and sort things out if I am not happy about something. and If I was unhappy I would make it known to the staff. Care Homes for Adults (18-65 years) Page 21 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. 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. This is what people staying in this care home experience: Judgement: People using this 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 physical design and layout of Willow House provides a safe, well-maintained and comfortable environment that encourages independence. Evidence: Willow House short term care unit was built approximately 2 years ago and all equipment, furniture, fixtures and fittings were put in at that time and assessed as meeting a wide range of needs. This included promoting independence and safety. We looked around the building and found that all the rooms including bedrooms, bathrooms and the communal areas were clean and free from unpleasant odours. All the bedrooms have en-suite facilities and are fitted with a track and hoist moving equipment. All the toilet and bathrooms areas were warm and comfortable. We found that the kitchen is equipped with small domestic appliances and it is possible for service users to prepare drinks, snacks and cook according to their interest. Willow house has been allocated domestic staff to carry out the majority of cleaning duties. Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: There were no service users using the facility on the day of inspection. The person who returned the service user survey stated: The whole building is spotless. Furniture is very comfortable. the cleaner is dedicated to her job and it really shows. it always smells pleasant. and Willow House is always clean and tidy. Care Homes for Adults (18-65 years) Page 23 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They 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 the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this 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 service employs staff using recruitment processes that promotes the employment of suitable people, staff are well trained and skilled enough to meet the needs of the people using the service. Evidence: We understand that the recruitment and selection process is lead by Oldham Metropolitan Borough Councils (OMBC) human resources department. We expect that this department adheres to the recruitment and selection guidelines concerning employing staff to work with vulnerable people. This includes conducting Criminal Record Bureau (CRB) checks, taking up two references and interviews. Staff comments about the recruitment process included: It was a very long wait from interview to start date. And The CRB and references are always checked and we have the CRB updated every year. We found that all the staff who returned surveys felt that the training they received prepared them very well for the work they had to do. The member of staff who was interviewed said that her induction included: Been shown around the service and working closely with the manager, we looked at files, fire safety, fire points, health and Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: safety and I attended a vulnerable adults briefing. I am completing an Induction Workbook, (which is kept at another establishment) and shadowing experienced members of staff. Other courses which she said she had attended included: an introduction to autism; moving and handling; medication safety and learning disability awareness. We looked at the training calender which confirmed that training is varied and informs staff about specialist care topics. The training since the previous key inspection in 2007 included: National Vocational Qualification (NVQ) level 2 in health and social care; medication; anti-discriminatory practise; moving and handling; epilepsy and administration of emergency medication; level 2 food safety; aspergers syndrome; autism; handling an emergency; health and safety training level 1; object of reference and visual time tables and dysphagia awareness. We noted that though staff had received updated POVA training in 2007 not many had benefited from this in 2008. The matter was discussed with the manager who, through documents and letters requesting this training, showed us that she was aware of and dealing with the issue. We found that the staffing ratios meets the needs of people using the service. On the day of inspection two people were expected to receive respite at Willow House and a member of staff and the manager were on duty in readiness for their arrival. The manager stated that staff ratios were flexible to meet the assessed needs of people spending time there. Staff who commented wanted more on duty so that outings could be arranged, however, there was no indication that the general staffing levels prevented people from attending their usual education or occupation establishments, and comments about care were positive. Staff said about each other We work well as a team and I find that our service is very person centred and people are very well catered for when they come to short term stay. Care Homes for Adults (18-65 years) Page 25 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use Willow House short stay service benefit from a manager who is competent and skilled in implementing the required protocols to make sure that their needs are met safely, however, she needs to make sure that issues which are specific to Willow House are always looked at. This is so that planning always takes into account the uniqueness of the building and the environment,and considers how this affects the people who go there. Evidence: We found that the manager at Willow House continues to develop her skills by attending training courses, briefings and updates. Since the previous inspection she has completed conflict resolution training and updated her moving and handling facilitators training. We looked at the Annual Quality Assurance Assessment which was returned to us, we found that some of the information in this document needed to be clarified. This is because a lot of references were made to another service. Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: We asked the manager of Willow House to re look at what was written, and to make sure that the information about, the strengths of the service, how the service could improve and future plans reflected the experiences of the people who use Willow House. Previously people attending Willow House respite were asked to complete a questionnaire about their stay and this formed a part of the quality assurance for the service. The manager stated that the Learning Disability Partnership were now working with professional research and quality monitoring analysts and they were conducting this task. She said that the process was independent of Willow House. We saw letters in peoples care files that confirmed that the questionnaires had been sent out in January 2009. We found that the manager takes her responsibilities for managing the building and health and safety protocols seriously. The information she returned to us confirmed that all maintenance checks were in place and up-to-date. The fire safety log book was looked at and this was up-to date with evidence that all checks had been undertaken regularly. We found that the manager at Willow House is cooperative and eager to assist with the CSCI inspection process. Care Homes for Adults (18-65 years) Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 The registered person must 01/05/2009 make sure that an accurate and clear record tracking the receipt, administration and return or destruction of controlled medication handled at Willow House is kept. This will make sure that controlled medication is administered to the correct person, in the correct dose and at the correct time. This will also reduce the risk of controlled medication been stolen and used illegally. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 39 The registered person should re look at the information provided in the Annual Quality Assurance Assessment to make sure that all the information fully reflects the strengths of and future plans for Willow House. This will Page 29 of 31 Care Homes for Adults (18-65 years) help to ensure that what happens is relevant and therefore effective. Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. 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