Inspection on 13/09/05 for The Willows

This inspection was carried out on 13th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 19/06/08

The Willows 27/06/07

The Willows 22/06/06

The Willows 25/04/05

The Willows 19/10/04

The Willows 04/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Willows (The) 72 Boreham Road Warminster Wiltshire BA12 9JN Lead Inspector Roy Gregory Unannounced Inspection 13th September 2005 09:15 Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willows (The) Address 72 Boreham Road Warminster Wiltshire BA12 9JN 01985 215757 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) karen@exalon.net Exalon Care Homes Ltd Karen Jane Wilkinson Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated at any one time is 8 Only the male service user referred to in the variation application dated 10 November 2004 may be aged 65 years and over. 25th April 2005 Date of last inspection Brief Description of the Service: The Willows is registered to provide care to up to eight people with a learning disability. It is owned by Exalon Care Homes Limited. Karen Wilkinson has managed the home since April 2004 and was registered in September 2004. The Willows is a sizeable detached Victorian property with a large enclosed garden to the rear. Two lounges, a dining room, kitchen, utility and office accommodation are on the ground floor, whilst the service users’ bedrooms are located on the first and second floors, together with shared bathrooms with toilets. The home is situated a walk away from the centre of Warminster, with shops and amenities close by. As well as the home having its own car for the use of residents, there are very good public transport links to neighbouring towns and further afield. At the time of inspection, work was just beginning on an extension to the building. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9:15 a.m. and 7:15 p.m. on Tuesday 13th September 2005. The inspector, Roy Gregory, spoke at length with three residents, and talked with each of the other four people resident at the time. The inspector joined residents and staff at the evening meal. There was a discussion with some visiting relatives. The registered manager, Karen Wilkinson, was available throughout the day and made documentation available. Additionally there were conversations with a team leader and three care staff. The inspector selected a number of care plans and daily records to compare observations of care and residents’ perceptions with written records. Other records consulted included those relevant to recruitment and staffing, to assist investigation of a complaint received prior to the inspection. All communal areas of the building were visited and three bedrooms were seen. A further visit to the home was made on Wednesday 5th October for clarification of matters arising from the inspection. “Comment cards” have been received from four residents and four relatives of residents. What the service does well: There is a culture of openness between staff and residents, which has been enhanced by making the office more routinely open to residents, and conversely staff spending much less time in the office. Communication skills with residents are a strength of the staff team, some relatives of a resident commenting on a noticeable increase in the resident’s repertoire of signing, and confidence to use it, since living at The Willows. Meaningful interaction was seen between that resident and a support worker. There was to be a staff training course in Makaton the week following inspection, in which a resident was to be included in order to promote their skills in communication with nonverbal residents. Provision for staff training overall was good. Relatives and residents have been complimentary of how staff provide care. Staff changes were not thought to have undermined this. The inspector found a sound common value base among staff members, and this was reinforced by the depth of monitoring and engagement in monthly unannounced visits conducted by the company’s operations manager. There was evidence of support to residents in respect of bereavement and loss. Specific support to some residents with regard to relationship issues, including liaison with external professionals, was considered to show very good practice. So too was the company’s regular use of external quality audit, which could be seen to promote development of the service. Relatives identified the nature of activity provision as an ongoing enhancement to residents’ lives. Records showed a wide variety of individually provided or encouraged activity, and several residents spoke enthusiastically of tailored holidays recently or about to be taken, which they had helped to plan. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 6 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 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 Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prospective residents can be confident that a placement will be agreed only if their assessed needs can be matched by the home’s resources. EVIDENCE: Standards 1 to 4 were assessed in detail at the previous inspection, when a resident had been recently admitted. This same person was able to confirm on this occasion that there had been a review of the placement. They were satisfied that the home was meeting the needs identified at the assessment stage, with ongoing dialogue between them and home staff about settling-in issues encountered. The manager had considered referrals in respect of a current vacancy, but had assessed each as inappropriate. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 & 9 Residents are aware of the care planning process and its links with the inputs of other professionals, but some care plans lag behind changing needs. There are good systems in place for consultation with residents about every-day and special events in the home, resulting in a culture of participation. On an individual level there is appropriate support to risk-taking in order to promote independence, although there have been instances of delay in identifying areas of risk needing assessment. EVIDENCE: Care plans showed evidence of review, although for most this process was behind schedule, particularly as regards objectives set with residents, some of which had been met in entirety whilst others had not been revisited for some time. For the most recently admitted person, the care plan had clearly been constructed by way of a steady consultative process with the resident, and the manager intended this to be a model to follow for others. Another resident considered their plan was set up to help achieve their goal of a more independent placement. Another commented on staff understanding of their needs and “difficult days”, seeing the care plan as giving agreed guidance. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 10 The home has the benefit of good support, including regular reviews, from the majority of residents’ care managers, and from other professionals such as speech therapist and behaviour nurse, such that care plans reflected the resultant degree of joint working. In respect of three residents, specific records were being kept to track the incidence and nature of particular respective traits, in order to assist the service users and their care managers in review by way of an objective record, and also to promote consistency of approach by staff. Some relatives visiting at the time considered they were provided with good information about care reviews, their own choice being not to be directly involved. Risk assessments seen in care plans were relevant, and staff had signed them to show their acknowledgement. Residents were aware of the risk assessment process and appeared comfortable with this as a means of promoting safety. One described an agreement very recently reached with staff about accompaniment for medical appointments, fitting with the manager’s description of the same issue. This had yet to be confirmed as a rewritten risk assessment. It was acknowledged that an instance of allowing one resident to accompany another to a local shop, found now to be risk-assessed as inappropriate (although benefits to each resident were apparent) should have been assessed before having been initially allowed. In the light of disciplinary matters involving staff member’s non-compliance with risk assessments, or taking inappropriate actions in the absence of permissive risk assessment, the company’s monthly unannounced regulatory visits to the home are now incorporating checks on risk assessments, and also on individual staff knowledge and understanding of the content of care plans. An Environmental Health Officer reviewed all risk assessments in the home in June 2005 and considered them to be of a good standard and relevant to the setting. The home has a strong tradition of involving residents in spontaneous decisionmaking, and of residents’ meetings to share ideas and opinions about everyday and special issues in the home. Karen Wilkinson said these were now to be scheduled such that matters arising may be taken forward to the senior team meeting and full staff meeting to be held during the same week. A resident was pleased with the opportunities available to have a say. Another strength of the home is in communication between staff and residents. A course in Makaton was to take place the week following inspection. On speech therapist advice, a resident was to be included in order to assist their communication skills with some other residents. This has been done in the past with another resident. The visiting relatives said the person they visited had improved greatly in communication ability since placement at The Willows. That resident and a staff member demonstrated some of their communication skills. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 & 17 The nature of working relationships between service users and staff, mean that residents have access to planned and spontaneous activities that fit their individual wishes and needs. These provide for access to the wider community, and maintenance of significant relationships. Good quality meals are served, taking account of individual needs. EVIDENCE: Four residents were able to benefit from varying degrees of independent access to the community, for example going to work or college, visiting friends and family, or simply using a local shop. Social activities were being recorded. For one resident, the last four entries were: a pub outing with other residents, going to watch horse trials, a beach trip and a meal out with a relative. This person said it was home staff that had helped them develop interests in riding and theatre. Other activity records showed similar variety and realisation of individual interests. Most residents had had, or were about to take, supported holidays that also demonstrated choice, involvement in planning, and particular interests. For one, there was an agreed decision not to risk the potential disruption of time away, whilst another confirmed their own choice to have some supported day trips rather than go away. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 12 Within the home, residents made constant choices between using the home’s facilities, including TV and stereo, and engaging in leisure pursuits in their bedrooms. The garden showed evidence of use. During the inspection, staff played a cricket game with a resident for so long as he wanted this, whilst two residents enjoyed watching. Some residents were receiving planned advice or guidance about relationship issues. For one, there was an agreed plan for how to manage an important friendship for the benefit of all concerned. In respect of another, two members of staff had been on a training course, together with the behaviour nurse, in order to better support the latter’s work on a resident’s sexual understanding. A relative of a resident expressed through a “comment card” that they greatly appreciated the efforts made by home staff to sustain contact between the resident and other members of their family. Residents expressed themselves “mostly” satisfied with the meals in the home. One was vegetarian, and there was evidence of staff collecting information to assist that person to make choices. The resident concerned confirmed their involvement in shopping and advising about menu planning. At the evening meal served during the inspection, there was a variety of different vegetables, salads and potatoes served to meet the dietary needs of different residents. The food was well presented and staff shared the meal with residents. Snack foods and drinks were available to residents throughout the day, with support to those who could get their own. One resident spoke of their involvement in preparation of cakes and puddings. Another would have liked more such opportunities. This should be more possible when the new kitchen comes into use. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Staff offer personal support that matches service users’ needs and recorded preferences. Healthcare needs are recorded and their management includes use of external consultation and guidance in order to identify and meet needs. EVIDENCE: Preferred ways to receive personal care were well documented, and further assisted by the key worker system. A staff member described their key work role as being based on trust, and this was reflected in comments by the resident concerned. Another role for the key worker is to track medical appointments, including dental and optical. Recording of these was good, showing outcomes including action plans agreed with GPs and psychiatrists. Where residents had specific medical conditions, there was evidence of the manager and staff collecting and sharing relevant information to enhance understanding. Currently resources in respect of an individual’s condition were being sought via the behaviour nurse. Residents felt supported in respect of feelings in the aftermath of the death of a resident in June 2005. There was open acknowledgement by staff of residents’ feelings of loss with regard to a number of staff who had left. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Vulnerable adults procedures are in place, compliant with local inter-agency procedures and readily available to staff. Recent experiences in the home, when residents suffered risk and harm, have led both to implementation of these procedures, and application of resultant learning to the provision of a protective environment. Systems are in use to promote security of residents. Residents understand and use the complaints procedure, and trust staff to act on their views and concerns. EVIDENCE: There had been five recorded complaints in the home since the previous inspection. One of these was made by a member of staff on behalf of a service user without verbal skills, which was considered good practice. This highlighted the need to better consider that particular resident’s needs when addressing an issue posed by another. The other complaints concerned an ongoing dynamic between two residents, which was being addressed through care practices. A complainant raised two issues with the provider company, and referred these on to the Commission when a response had not been received within an acceptable time. Whilst one of these matters was properly investigated by a company director who found no grounds for complaint, the other revealed a breach of regulations had occurred by way of employment of a person before vetting had been undertaken, in order to resolve an emergency situation of under-staffing. By the time of this inspection, however, when the investigation was completed, the company had put in place sufficient extra guidance and procedures to ensure this poor practice should not be repeated, and the manager had made arrangements for use of agency workers in the event of existing staff being unavailable to fill staffing shortfalls. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 15 Residents and visitors were aware of the location and purpose of the complaints procedure, and were confident about using it if necessary. A resident said staff took complaints seriously. Security and safety of the home had been improved by introduction of pincoded locks on the front door and office door. Residents identified as able to access the community unsupervised, were provided with the front door pin code. Automatic closers fitted to some fire doors now allowed easier staff awareness of the whereabouts and behaviours of residents. Discussions with staff showed an understanding of pre-emptive and distraction techniques that ensured physical interventions being reserved as last resorts. Recording of incidents, including the nature of staff intervention, was satisfactory. Staff were being required to sign for having read certain documentation about risk assessments and procedures, to underline their responsibility for doing so and for working within such parameters. A form had been introduced for signing by any contractors required to work on the site, which acknowledges the nature of the establishment and working protocols to be abided by. This was recognised as good practice. The home has a vulnerable adults procedure that fits with local inter-agency arrangements. Three incidents that had occurred since previous inspection resulted in three suspensions of members of staff, and subsequent dismissals and referrals to the Protection of Vulnerable Adults List. One of these matters is currently subject of Police investigation, with which the home and provider company have been co-operative. The manager of another of the company’s homes carried out an internal investigation. This not only informed the disciplinary process, but also assisted the directors and home manager to review and improve management procedures and communications within the home. In the first instance, the company’s decision to suspend a member of staff was made somewhat late, whereas in the case of the later incidents, actions to secure service user safety were taken at the first opportunity, demonstrating lessons learned. One service user said they thought the home “definitely a safe place to be.” Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 & 30 The Willows provides a homely environment where residents enjoy private and communal facilities in comfort and in line with their respective needs. Individual rooms are well proportioned and lend themselves to being made personal and private. Within the constraints of the building as it is at present, a satisfactory level of cleanliness is maintained. EVIDENCE: The dining room and smoking room had both been redecorated since previous inspection and, together with the sitting room, were presenting well. Service users confirmed they had helped with choice of colour schemes. All windows had been refurbished. The kitchen, bathrooms and toilets, as at previous inspection, were in a poor state, as also commented on by a resident, although cleaning standards had improved. Building contractors were on site making preparations to commence building an extension to the home. Within this project a new kitchen is to be provided, and bathrooms will be upgraded. An Environmental Health Officer visiting the home after this inspection was satisfied with arrangements made for safe use of the existing kitchen whilst building work was underway. Two bedrooms were seen, in which residents had made themselves fully at home and said they were very satisfied with their rooms. An empty room, Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 17 ready for occupation, was also seen. Carpets in halls and stairways were considerably worn. The home now had three vacuum cleaners sited at various parts of the home, leading to reasonable standards of basic cleanliness being upheld. As noted earlier, the garden had become a true extension to communal space, whilst the entrance to the home had also been made more welcoming. The inspector noted that the office was now being routinely left open to the rest of the home, and that some residents were accustomed to spending time in staff company there, emphasising the whole of the home as the residents’ space. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 36 Staffing is sufficient in numbers and quality to ensure service users are safely and consistently supported. Following a significant individual lapse, recruitment practice has been made safe. Staff are supported in their roles by regular supervision and by employer support to training, including to NVQ, that is relevant to the needs of service users. EVIDENCE: A shortfall in staffing complement earlier in the year was compounded by the loss of some staff, to the regret of residents and some relatives, as a result both of natural movement, and disciplinary actions by the provider company. There were three staff vacancies at the time of inspection. The home has the benefit of some “bank” staff, and had begun some use of agency workers, in order to uphold staffing levels without over-dependence on staff offering to work extra hours. New staff recruitment was also proceeding. Apart from the unacceptable practice of commencing one employment contract before obtaining the statutory vetting clearances, as detailed earlier in this report, all other recruitment practice was found to have been safe, and this was reinforced by good procedural guidance that had been recently issued by the company. There has been written acknowledgement by the company that a breach of regulations had occurred and must not be allowed to recur. This area of practice will be subject of ongoing scrutiny, with any similar breach likely to lead to enforcement action. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 19 The proportion of staff with NVQ level 2 or higher remained at 50 and rotas showed there was generally a mix of experience level and gender on duty. Recently recruited staff had received training in working with challenging behaviours, the medications system and first aid. For the week following inspection, external trainers were booked to deliver training sessions in Makaton and vulnerable adult awareness. Such sessions were of half-day duration, enabling one staff group to participate whilst another provided care to the resident group, and exchanging roles at midday. One member of staff spent some duty time on work for a distance-learning course in infection control, and said she would be moving onto a health and safety element as a next stage in her training. Staff commented that they appreciated training and supervision opportunities at the home. Supervision was shared by shift leaders, who themselves were supervised by the manager. The latter said it had emerged that a group of staff had not been supervised regularly during the previous year. A former employee considered supervision and appraisal to have been inadequate. Records showed any shortfall had been put right. A consistent recording format was in use for supervision. Staff meetings had also been made more regular, with staff required to sign minutes. These showed that developments for each service user were shared at the meetings. Other documents in the home showed evidence of being signed by staff members as they had read them. Rotas confirmed that shift leaders had the opportunity for at least one shift handover directly between themselves each week. Service users expressed and indicated confidence in the staff and said there were sufficient to support them at any time. Relatives, visiting the home and by way of “comment cards”, saw continuity of quality of care regardless of changes of staff, and were complimentary of the range of tasks undertaken and the manner of care delivery. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 The registered manager provides a lead to the home, by monitoring the delivery of care and encouraging participation by both residents and staff. Quality assurance systems are centred around service users, producing information that is used to improve the service. There are systems in place to identify and promote the health and safety needs of residents and staff. EVIDENCE: A strong common value base among staff was in evidence. A recently appointed shift leader felt very supported by both staff and manager and confirmed there was plentiful contact between members of the senior team. The manager, who was awaiting certification for having achieved the Registered Managers Award, had improved organisation of the office since previous inspection. There was evidence of work on improving daily record keeping, as required at previous inspection, with further useful discussion around this topic. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 21 The quality of minutes from residents’ and staff meetings had been improved. Partly in response to incidents of poor care practice that had arisen, the manager was now spending more time at the home during evenings and weekends. The inspector had been supplied with the results of the home’s most recent 6-monthly quality audit, for which the company engages an independent assessor. During inspection the fire alarm was set off by burnt toast. All service users left the building for the assembly point calmly and swiftly. New self-closers fitted to three fire doors operated correctly. Fire precautions equipment had been serviced and records of routine testing were in order. Arrangements had been made to keep residents and staff safe with regard to the building works that were due to take place over the coming weeks. All staff received health and safety training. There was a good record of safety checks of the home’s people carrier. In response to one of the incidents at the home during 2005, a notification was necessary to the health and safety executive. In response there was a visit by an environmental health officer, who reviewed risk assessments in place and considered them appropriate to the needs of the home. Monthly visits by the company operations manager, as reported to the Commission under Regulation 26, are an effective system for monitoring health and safety and other provisions in the home, and ensuring actions are taken to avoid shortfalls developing. Willows (The) DS0000028543.V250112.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willows (The) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 4 X X 3 X DS0000028543.V250112.R01.S.doc Version 5.0 Page 23 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. 1 Standard YA6 Regulation 15 (2)(b,c) 19 (1)(b) Requirement Care plans, including any objectives agreed with service users, must show evidence of review at least every six months. There must be no commencement of employment of any individual until statutory checks have been completed and the related company procedure followed. Timescale for action 30/11/05 2 YA34 13/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA9 Good Practice Recommendations Where a need to commence or review a risk assessment is identified, this should be treated as a priority task. 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