CARE HOME ADULTS 18-65
The Willows Halvarras Park, Halvarras Road Playing Place Truro Cornwall TR3 6HE Lead Inspector
Lowenna Harty Unannounced Inspection 18th July 2006 09:30 The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Willows Address Halvarras Park, Halvarras Road Playing Place Truro Cornwall TR3 6HE 01872 865588 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) Spectrum Miss Deirdre Elizabeth Kent Care Home 3 Category(ies) of Learning disability (3) registration, with number of places The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: The Willows is a home providing personal care and accommodation for up to three adults with a learning disability. The registered provider is Spectrum, an organisation that provides specialist care in small units for people with autism. The aim is to provide them with specialist support in a domestic style environment. There is a manager in charge of the home on a day-to-day basis. A team of care staff assists them. Senior managers from within the organisation are available to provide specialist support and assistance where necessary. The home is located in the village of Playing Place, close to the city of Truro. There is reasonable access to public transport and the home has its own vehicles to assist service users to access the local community. The home is a single storey building, set in its own grounds and is set off the main road. There are three single bedrooms for use by the service users. The home has a combined lounge and dining room, a kitchen, separate laundry room and two bathrooms. There is a lockable office, which also functions as a sleeping in room for staff at night. The home has a large garden and some offstreet parking space. There have been some adaptations, with the provision of grab rails to assist people with specific physical disabilities to access the building. Fees range from £650.00 - £3750.00 per week, according to information provided by the registered manager at the time of the inspection. There are additional charges for hairdressing, private chiropody, personal newspapers, dry cleaning, alcoholic beverages, off-site entertainment, confectionary and stationary. The costs of these are variable. Information about the home is contained in the home’s statement of purpose and inspection reports, which are available on request. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an annual key inspection, which took place on 18 July 2006 and was unannounced. It lasted for approximately six hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved interviews with them and observation of the daily life and care provided. There was an inspection of the home’s premises and of written documents concerning the care and protection of the service users and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the home’s manager. The principle method used was case tracking. This involves examining the care notes and documents for a select number of service users and following this through with interviews with/ observation of them, staff working with them and their relatives or representatives. This provides a useful, in-depth insight as to how residents’ needs are being met in the home. At this inspection, all three of the service users were case tracked. There was evidence of some improvement in care standards at this inspection and work is continuing to improve it further to provide service users with a safe and comfortable home in which they can develop their skills and independence. What the service does well:
The service users are well matched as a group, having been carefully assessed prior to their admission to the home. The parent of one of them said that the move to this home was a positive one for the service user concerned. Prior to their admission they were provided with information about it, in suitable formats so that they were aware of what they could expect from the home and what would be expected of them. Service users have detailed written care plans, which set out how the home will meet their personal, health and social care needs, including needs relating
The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 6 to their individual backgrounds and culture, age, sex, religion, individual abilities and sexual orientation. They, their relatives and representatives are invited to regular reviews so that their care plans can be agreed with them and updated. They are encouraged to make important decisions about their lives, such as what activities to take part in during the week and how to spend their free time so that they develop their confidence and independence. Identified risks are carefully managed, to minimise restrictions on service users and enable them to take part in activities that develop their skills and enhance the quality of their lives. Service users enjoy a good quality of life in the home. Staff support them to take part in a wide range of activities in the home and the local community, which vary according to their individual needs and preferences. Activities are age and culturally appropriate for them. They attend a variety of social activities including visits to pubs and cafes with staff, in the community. They are actively supported and encouraged to maintain contact with their families so that they maintain and develop valued relationships outside of the home. They take part in planning, shopping and preparing meals independently or with staff support, depending on their needs, so that they enjoy their meals, eat healthily and develop their independent living skills. Staff help the service to independently attend to their personal care so that they look smart and appropriately dressed. They are helped to access a range of NHS healthcare providers, such as doctors, opticians and specialist services when they need them so that they maintain good general health. Their medicines are safely stored in the home and staff have clear written guidance on how to manage them safely, to service users are protected from medication errors. Service users and their relatives are able to make their views known and are taken seriously, especially if they wish to complain about any aspect of their care. There are systems in place to ensure that they are safe and well cared for in the home and staff are provided with training and guidance on how to effectively support and protect service users from harm and abuse. Staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting. The home’s environment provides service users with a comfortable and homely setting in which they can develop their skills and independence and be part of a local community. It was clean and tidy throughout at the time of the inspection, which was unannounced. Staff are recruited fairly, safely and effectively to ensure that they are suitable to work in a care setting with vulnerable adults. The relative of a service user said that they have confidence in them, which is important. They have good access to ongoing training to ensure they have the knowledge and skills to be able to work safely and effectively with service users. The home is generally well managed for the benefit of the service users. The manager is registered with the Commission as a fit person to run the home on
The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 7 a day-to-day basis. Service users and their representatives are given opportunities to contribute their views and opinions to the ongoing planning, development and improvement of the service. What has improved since the last inspection? What they could do better:
The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 8 Service users should be given clearer information about the cost of their placements in the home, with regard to information on how the contributions they make are calculated so that they are fully aware of their financial rights and obligations. Service users would benefit from being provided with more detailed and specific goals in their care plans so that they and their representatives are better informed of their progress and achievements in the home over time. Staff should be provided with training in communication skills so that they more effectively assist service users who do not have verbal communication skills to participate more directly in making decisions about their lives. There is an urgent need for a review of service users’ risk assessments, which do not currently take account of risk factors associated with the low level of staffing in the home at night. Currently there is only one member of staff, who sleeps overnight in the home, but night care records indicate that service users are often awake and up at night and on occasions have caused disturbances to each other. One service user’s dental check-up was very overdue and they should be assisted to access dental health care when they need it. There should be improved security with regard to medicines management in the home, with a designated key holder to the medicines cabinet at each staff shift and staff need access to full training in the safe handling of medicines so that service users receive improved protection from medication errors. None of the staff working in the home has a formal qualification in care practice and the recommended minimum is 50 . Quite clearly, the proportion of qualified staff needs to be increased. As previously stated in this report, there need to be sufficient staff deployed at all times, including at night. Risk assessments, particularly with regard to fire safety also need to account for the reduced staffing levels at night and there need to be risk management plans in place to fully address any risks identified. 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. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 9 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 The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 10 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): 2&5 Quality in this outcome area is adequate. Service users undergo detailed assessments prior to their admission to the home so that they can be confident it will be suitable to meet their needs. They have written statements of the terms and conditions of their placements, but need to be provided with more clear and detailed information about their financial rights and obligations. EVIDENCE: There were no observable changes in the service user group since the previous inspection and the registered manager said that none are currently planned. The service users appeared to be well matched and those who were interviewed confirmed that they get on well together as a group. There is detailed assessment information on their personal files to show that their needs were fully considered prior to their being placed in the home. The statement of purpose contains information on how they can obtain independent advocacy if they wish. A relative of one of the service users said that they felt that their move to this home was a positive change for the better. Service users have written statements of the terms and conditions of their placements in the home, which are provided to them in translated formats if they need them. These set out their rights and obligations and are also sent to their relatives/ representatives, which a relative of a service user who was interviewed, confirmed. The information given to them does not include the total cost of their placement or a detailed breakdown of how their personal The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 11 contributions towards the total cost is calculated to provide them, which they should be provided with so that they are made aware of their welfare rights. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 12 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, 7, 9 & 10 Quality in this outcome area is adequate. Service users are aware of their care plans, which address their health, social and personal care needs in full, including needs relating to their age, sex, sexual orientation, disability, cultural and ethnic backgrounds and religion. They would benefit from more detailed and specific goals to work towards so that they can monitor their own progress and achievements. They are encouraged to develop their skills in making decisions for themselves to develop their confidence and independence and to take managed risks in this respect, but staff should undertake training so that they can communicate with them more effectively. Specific risks relating to nighttime staff cover need to be addressed so that service users are protected. Personal information relating to individual service users is now stored securely in the home so that their confidences are kept. EVIDENCE: Service users interviewed were aware of their care plans and confirmed that they attend their reviews. Copies of their care plans are held on their personal files, including copies of their care plan summaries, which have been translated into meaningful formats for them, although they continue to lack clear and specific goals. A relative of one of the service users said that they are invited to reviews every six months and provided with written copies of them.
The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 13 Service users were observed making choices about what activities to engage in during the inspection and about meals at breakfast and lunchtime. Their care plans consider their decision-making skills and the registered manager has undertaken training in communicating with service users who use non-verbal forms of communication so that she can help them to be more actively involved in making decisions. This should be extended to all staff working with them. There are detailed written risk assessments for each of the service users on their personal files to guide staff on how to enable them to take risks to develop their skills and independence in managed ways. These also address specific activities that service users engage in, but do not specifically address risks attached to the reduction of nighttime staff cover to a single member of staff. Night care records indicate that service users are often active at night and there have been instances when they have disturbed each other, when there has only been a single member of staff sleeping in the home. The home has a lockable office, so that confidential information relating to service users can be safely stored away. A staff member who was interviewed demonstrated a clear understanding of the need to ensure that service users’ confidences are maintained and awareness of the policies in place to support this. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 14 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, 15, 16 & 17. Quality in this outcome area is good. Service users access a range of activities, in accordance with their individual needs and preferences, so that they develop their skills and independence. They regularly access resources in the local community and are supported to maintain valued relationships with their friends and relatives so that they are not isolated and they enjoy a good quality of life. Their rights and responsibilities are recognised and promoted as far as is practicable and they are well fed so that they stay physically healthy and enjoy their meals. EVIDENCE: A staff member who was interviewed said that service users have individual activity plans, which are developed with them, according to their needs and preferences. The home’s records confirmed this and service users were observed engaging in different activities in and out of the home during the day. The registered manager said that staff are employed in sufficient numbers to be able to work with each service user individually, which they confirmed. Service users said or indicated that they enjoy a good lifestyle in the home and are satisfied with the activities provided. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 15 Service users were observed accessing community resources during the day. One attends a local college on a regular basis and the daily care records confirmed this. The registered manager said that they are well known in the local community. The registered manager said that service users are encouraged to maintain contact with their families and other valued relationships. Daily care records confirmed this. The relative of a service user who was interviewed confirmed this and said that there are no restrictions on them maintaining contact with the service user. Service users’ guides set out clearly expectations of service users as residents of the home and their rights, with regard to the conditions of their placements. They are provided with clear advice on how to access independent advocates and/or the commission via their notice board. Service users’ care plans set address their nutritional needs and preferences. They were observed making choices at breakfast and lunchtime and said or indicated that they enjoy meals in the home. They are able to assist in the preparation of meals, with staff support as necessary. The Willows DS0000009122.V304839.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. Service users are helped to maintain and develop their independence with regard to their personal care. They are assisted to access most of the healthcare services they need so that they stay well and enjoy their lives, but need improved access to dental care. Arrangements for managing medicines are mainly safe but some improvements in staff training are needed to ensure that service users are protected from medication errors. EVIDENCE: Service users were observed to make use of the bathrooms and facilities for maintaining their personal care independently, whilst staff were available at all times to prompt and assist them in low key ways, where necessary. The home’s records provide staff with detailed instructions on how to support service users appropriately and safely with regard to their personal care. The home’s records show that service users regularly attend health checks at a range of NHS healthcare facilities, including doctors and specialist services, where necessary. Relatives and representatives interviewed stated that they are satisfied that service users’ health care needs are managed appropriately. Records relating to one service user indicated that they are very overdue a dental check up and this should be arranged for them. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 17 There are secure storage facilities for service users’ medicines, although there is not a designated person in charge of the keys, which there should be so that there is a clear line of responsibility in this respect. Staff have clear written guidance for the safe management of medicines in the home, which were seen in the medicine storage area and are readily available to them. The home’s training records indicate that whilst most staff have undertaken basic “in house” training on medication, none have undertaken full training in the safe handling of medicines and this needs to be arranged so that service users have improved protection from medication errors. The Willows DS0000009122.V304839.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. There are formal and informal systems in place so that service users’ views are taken into account in the dayto-day running of the home. Service users’ welfare and best interests are well protected so that they feel safe and well cared for in the home most of the time, but action needs to be taken to fully protect them from disturbances by each other at night. EVIDENCE: Service users interviewed said or indicated that they are satisfied with the care and services provided to them at the home, which a relative, who was interviewed, confirmed. Records in the home indicate that there have not been any formal complaints recently. Service users and their representatives are invited to reviews on a regular basis and invited to contribute their views and concerns. Quality assurance surveys have been supplied to service users and their relatives, offering further opportunities for them to make their views known. Service users interviewed said or indicated that they feel safe in the home. The home’s written procedures to guide staff on what action to take if they suspect a service user has been abused have been updated so that they have clear information on what to do to protect them. The registered manager has attended multi-agency training on the protection of vulnerable adults from abuse and staff have been provided with “in-house” training by Spectrum. The home’s records showed that staff are recruited on the basis that they are suitable to work with vulnerable people in a care setting. Service users are not isolated and are encouraged to take part in community activities and maintain contact with relatives and representatives from outside of the home. Night care
The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 19 records indicated that service users are frequently awake and active during the night and one incident occurred between two service users, which caused distress to one of them, when there was only one member of staff, sleeping in the home. Night staffing arrangements need to be urgently reviewed in light of this, so that service users are protected at all times. The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. Service users benefit from living in a comfortable, safe and homely environment so that they can develop their skills and independence in a non-institutionalised setting. Good hygiene is maintained so that service users are adequately protected from infection. EVIDENCE: The home is an ordinary, domestic building, well situated in a local community, which service users were observed to be a part of at the time of the inspection. It appeared well decorated and several improvements were observed at this inspection. Service users appeared to be comfortable and at home and had ready access to all parts of it. The relative of one of them said that they are very satisfied with the home’s environment. The home appeared clean and tidy throughout at the time of the unannounced inspection. There are written guidelines in place to ensure good hygiene is maintained and suitable arrangements in place for heavily soiled laundry to protect staff and service users from cross-infection. Suitable facilities are in place to ensure good hand hygiene and shower trays and baths were clean. The Willows DS0000009122.V304839.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is poor. None of the staff have formal qualifications and the recommended minimum is that 50 should have them, so that service users can have confidence in their abilities to work competently with them. Night time staff cover has been insufficient to protect service users from intrusion by each other. Recruitment policies and practices are fair, safe and effective so that staff are employed on the basis of their suitability to work with vulnerable adults in a care setting and staff have good access to on-going training so that they have the skills they need to work safely. EVIDENCE: Records held in the home indicate that none of the staff working there is qualified to NVQ level 2 or above although the registered manager said that they are currently working towards achieving formal qualifications. There were sufficient staff on duty at the time of the inspection to provide service users with the support they need in and out of the home to carry out their care plans. Staffing records and interviews confirmed this with regard to staff cover during the day. Night staffing levels reduce to one person sleeping in and night care records indicate that this is insufficient to protect service users from disturbing each other. Records held in the home indicate that staff are recruited on the basis of formal applications, equal opportunities interviews and checks to ensure they are suitable to work in a care setting. Staff interviewed confirmed this.
The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 22 A staff member who was interviewed said that they have good access to ongoing training, which records held in the home confirmed. New staff undergo a five-day induction programme to equip them to work in the home, which is held at Spectrum’s head office. They then undergo competency-based ongoing induction training in the home. The registered manager monitors staff training via the team training plan, so that they are deployed on the basis that the team as a whole has the skills necessary to provide effective care to service users. The Willows DS0000009122.V304839.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this area is adequate. The home is generally well run for the benefit of the service users living there. Service users are able to contribute their views to the ongoing management of the home. The home is mainly kept safe for service users, but staffing levels at night need to be reviewed so that they are protected at all times. EVIDENCE: The relative of a service user who was interviewed said that they feel the home is well managed for the benefit of the service users living there. The manager is registered with the Commission as a fit person to undertake the running of the home on a day-to-day basis. She is experienced at working in the home and knows the service users well. She undertakes regular training to update her knowledge and skills. Service users and their representatives have formal and informal opportunities to contribute their views to the running of the home, including care plan reviews, during weekly and daily activity planning with staff, through formal quality assurance questionnaires and the home’s formal complaints procedure. There are records in the home to back this up. Senior managers from
The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 24 Spectrum visit and inspect the home on a monthly basis and make reports on the basis of this. The registered manager ensures that staff and service users are provided with a safe environment through written guidance for staff, regular equipment tests and checks, with records kept and written risk assessments. Service users and staff who were interviewed said that they feel safe in the home and there are low rates of recorded accidents. Risk assessments should take into account the risks of a single staff member being on duty at night, particularly with regard to fire safety and ensure that risk management plans to address this are adequate. The Willows DS0000009122.V304839.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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 YA23 YA33 YA42 Regulation 18(1)(a) 12(1)(a) 13(4) Requirement Night staffing levels must be reviewed so that service users’ needs are properly met at all times, with particular reference to protecting them from disturbances by each other at night. Service users must be assisted to access the healthcare services they need, when they need them, with particular reference to dental care. There must be safe systems in place to manage service users’ medication, including a designated key holder from the medicines storage cabinet and suitable training for staff who assist service users with their medication. Timescale for action 25/07/06 2. YA19 12(1)(a) 01/09/06 3. YA20 13(2) 18(1)(c) 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No.
The Willows Refer to Good Practice Recommendations
DS0000009122.V304839.R01.S.doc Version 5.2 Page 27 1. Standard YA5 2. 3. YA6 YA7 Service users should be provided with clear information about the costs of their placements, including more detailed and accurate information on how their personal contributions are calculated. Service users’ care plans should contain clear and specific goals. Staff should be provided with formal training on effective communication with service users who are non-verbal in the ways in which they communicate their needs and preferences. At least 50 of the care staff team should have qualifications to NVQ level 2 or above. The home’s fire safety and environmental risk assessments should be reviewed with regard to nighttime staffing levels. 4. 5. YA32 YA42 The Willows DS0000009122.V304839.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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