Inspection on 18/05/05 for The Willows

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 37 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 09/09/08

The Willows 18/09/07

The Willows 24/05/06

The Willows 01/11/05

The Willows 20/01/05

The Willows 22/07/04

The Willows 18/11/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Willows 1 Park Road Hockley Birmingham B18 5Th Lead Inspector Donna Ahern Unannounced 18th May 2005 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 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 Stationary 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 E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Willows Address 1 Park Road, Hockley, Birmingham, B18 5TH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 554 1427 0121 523 6073 Social Care & Health Care Home 18 Category(ies) of Learning Disability (18) registration, with number of places The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to accommodate 15 adults under the age of 65 in need of long-term personal care for reasons of learning disability. 2. Currently residing people who are over 65 may continue to be accommodated provided their needs can be met appropriately. 3. The minimum staffing level for 18 service users on weekends when daycare is off site are:7.00am - 9.00am 4 care assistants, 1 of whom is designated shift leader -9.00am - 4.00pm 3 care assistants, 1 of whom is designated shift leader -4.00pm - 10.00pm 5 care assistants, 1 of whom is designated shift leader - 10.00pm - 7.00am 2 care assistants both awake. At weekends and periods without off-site daycare,09.00am - 10.00pm 5 care assistants, 1 of whom is designated shift leader -10.00pm - 07.00am 2 care assistants, both awake,07.00am - 09.00am 4 care assistants 4. Areas of worn internal paintwork must be repainted by end June 2004. 5. Windows where paint is flaking away from the frame require repair by end June 2004. 6.Bedroom 13 requires repair by end of June 2004 7. An experienced, suitably qualified and competent manager to be recruited and an application for registration is made to the CSCI by end of June 2004 8. By end of September 2004 plans are agreed with the NCSC/CSCI with stated timescales for the future re-provision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group Date of last inspection 20th January 2005 The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 5 Brief Description of the Service: The Willows is a large two- storey purpose built home providing care and accommadation for up to 15 adults with learning disabilities. The range of needs of individuals living at the home are diverse and some of the residents have complex additional needs. The home is owned and staffed by Birmingham Social Care and Health. The home is situated on the corner of a busy street in the middle of Hockley. The Willows is cenral to a selection of bus routes and other amenities such as shops, pubs,leisure facilities and various places of worship. To the front of the building there is a large area used for off street parking and minibus drop offs. Disabled access to the building is variable. The home has a shaft lift and adapted toilet and bathing facilities. All residents rooms are single. The home has four lounges/quiet rooms for the use of residents. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The inspector met ten residents and time was spent observing care practices, interactions and support from staff. A tour of the building was made. Residents care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the deputy manager, senior, administrator and three of the support workers What the service does well: What has improved since the last inspection? What they could do better: The home must improve the care plans that they have on each resident. These tell the staff how to support each person. They must be clear about what help and support each resident needs and what staff must do to support the individual. These must be kept up to date. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 7 The home must improve how it says it will help residents reduce some of the risks that they may face in the home or when they go out on an activity. It would be helpful if the home tidied up the resident’s files and took off some of the old information and stored it safely. The home must improve the way that resident’s health needs are recorded and followed up. The home must start to do Health Action Plans with each individual. They must also keep up to date the support that residents need with their mobility. The home required a lot of work to make it a comfortable place for residents. Many of the bedrooms need decorating; painting of woodwork and windows was needed. Some of the tiles in the bathroom were in need of repair. The home must make sure that the bathrooms are suitable for all the residents and that they can safely get in and out of the bath. The home must let the people living in the home and CSCI know what the plans are for the future of this home. The home must keep a record of any complaints about the home and what the home did to sort the concerns out. The home must improve the records it keeps on Health and Safety. The Fire risk assessment required updating and a Fire drill was required. Staff must do more training so that they are up to date with their knowledge and skills. The home must keep all the required information on staff who work in the home such as their previous experience and training and evidence that all of the safety checks on their suitability to work in the home had been carried out before they started to work at the home. It will be good for residents and the development of the home when there is a permanent manager in place. 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 E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed at this inspection. EVIDENCE: The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 Care plans and risk assessments required development and had not been kept under review. These shortfalls are of concern and have the potential to cause inconsistencies in the care and support given to residents. EVIDENCE: Four care plans were sampled. Some progress had been made since the previous inspection. Individual Service Statements (ISS) that had been implemented in recent months were found to be a more detailed document. However, some of the I.S.S documents were not in sufficient detail or specific enough about the support required by the resident and how this is to be provided by support staff. Guidelines and behaviour management plans that were on sampled files required review. Resident’s profiles required completion. Sampled files had some information on loose sheets that had been put into the file but was not signed or dated. This information was regarding residents medication and family contact details and was clearly important. It is unclear from the set up of the current care plan systems, how the resident’s file is kept up to date and a live document. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 11 Review systems were in place; these were confusing with different formats used and not in any date order. It was unclear how these systems worked together and ensure that the care plan is kept under review. As raised at previous inspection information on resident’s files that is not current should be archived. It was positive to hear that the home had commenced Person Centred Planning with one of the residents. This is a more person centred approach to care planning and appropriate for the residents who live at the Willows. Progress will be monitored at future inspections. A number of risk assessments were sampled. These were all stored in one file with no index system; hence it was difficult to locate specific residents risk assessments. The two previous inspections raised that the home should review and improve access to the risk assessments. Risk assessments required further development. Risks that residents face must be assessed. It was very unclear from reading some of the risk assessments what actual risk was being assessed. There was evidence that many of the risk assessments had been reviewed in February 2005 and again in May 2005. However, there was no evidence of how the review had been undertaken, all that was recorded was a date and a staff member’s signature. There was no reference to any incidents that had occurred that was relevant to the risk assessment. For instance one risk assessment sampled was regarding a resident who becomes agitated when going out in the community. The risk assessment had been in place for a few years and although reviewed recently there was no reference to any progress or development, if the person was still going out, had any of the strategies and control measures in place been successful or required review, if they hadn’t it must be documented. Risk assessments must cross-reference to the residents care plan/I.S.S. Support for residents from waking night staff must be based on a risk assessment. Where checks are to be undertaken by night staff it must be specific about how this check is to be undertaken. Manual handling risk assessments required review. When there is a change in a resident physical care needs and mobility the assessment must be reviewed immediately. Risk assessments for residents with epilepsy must be implemented. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 12 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 standard(s) 11, 13 and 14 Residents are supported to take part in a range of activities at home and in the community. The home must improve and be able to evidence how they support residents to develop their independent living skills. EVIDENCE: Care plans required more detail and evidence of how residents are provided with opportunities to develop their social, communication and independent living skills. Residents said that they do sometimes use the small kitchen on the first floor to prepare snacks and their supper but not on a regular basis. Inspection of the facility identified that one or two people can only use the kitchen at a time. The fridge and cupboards were empty and staff said that they do not store food in the room due to the needs of one resident and the risks associated with access to food items. Residents said that they sometimes do some clothes washing and would use the washing machine in the small kitchen, however this was broken and required repair. Some improvement to how the home offers opportunities for residents to develop their independent and life skills was required. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 13 The home’s main kitchen is an industrial kitchen, which is run by Commercial Services. Residents are not allowed to use this kitchen. The previous report required the home to review access to drinks for the residents who can make their own drinks. An area in the dining room had been developed with a small work area for the making of drinks. The home fills large drink flasks so that residents can access tea and coffee. However, as raised in previous reports, milk and sugar were not available. The home agreed to review these arrangements. A fridge will need to be provided so that milk can be stored. The facilities could be improved to include snack-making facilities. Residents spoke positively about the different activities that they take part in. They talked about trips to the theatre, cinema and the local pub. Some of the residents were getting ready to go out for a drink on the evening of the inspection. Residents were also positive about some of the activities that are arranged in the house. The art session on a thursday night was one of the most popular activities. One of the residents showed their work that was on display in their room. Some of the residents can access community facilities independently. The home must ensure that relevant risk assessments are in place so that residents can experience a fulfilling lifestyle within a risk assessment framework. Some of the residents were really looking forward to a forthcoming holiday to Brighton and had been shopping for new clothes. Not all residents will be able to go away on holiday this year due to the difficulties that are placed on the home trying to ensure that the residents that go on holiday receive adequate staff support and that the home is still adequately staffed. The success of the holiday requires the good will of staff who will work rest days so that the holiday can go ahead. The National Minimum Standards for Younger Adults states that all long-term residents are to receive at least a seven-day (or equivalent) holiday per annum. The Organisation must review the current arrangements and demonstrate how it intends to meet this standard for all residents. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 14 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 standard(s) 18,19 and20 Further development of the homes personal and healthcare recording and monitoring systems was required so that the home can evidence that resident’s needs are properly monitored and kept under review. Manual handling assessments must be kept under review so that the home can evidence that residents are safely guided, moved and supported. EVIDENCE: Residents care plans sampled indicated that they are supported to attend a range of healthcare appointments. A healthcare log was on the care plan however; this gave no detail of the outcome of the appointment and any required monitoring or follow up. This must be developed so that the home can evidence that resident’s healthcare needs are monitored. The home must implement Health Action Plans for all residents (Department of Health Guidelines). Manual handling risk assessments had been completed however these had not been kept under review. There was evidence that some of the resident’s mobility had deteriorated presenting manual handling issues, however this was not reflected on the manual handling risk assessment. The assessments sampled had not been reviewed since November 2003. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 15 There was evidence on the one residents file that their epilepsy was under review and that staff had received training on epilepsy matters. However guidelines regarding how their epilepsy is managed required implementing. Resident’s medication details required updating on their care plan. Some changes to resident’s medication details had been added on to the file but not dated or signed. Each resident’s file must contain up to date information of the resident’s medication. One resident had a phone call at the time of the inspection regarding a dental appointment. The staff member supported the residents to take the call themselves and was very supportive to the resident. They also spoke afterwards with the resident to make sure that they knew what was happening and when, and that the resident was happy with the arrangements in place. This was an example of good practice and this practice must be evidenced through the homes recording systems. Guidelines were required for one resident who is diabetic; these must include what actions must be taken in the event of high/low sugar level. The support each resident requires from the waking night staff must be clearly documented and supported by relevant risk assessments. The homes medication storage was in need of replacement the cupboard openings were damaged and not fully secured. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 16 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 standard(s) 22 and 23 Some development of both the Adult protection Policy and the Complaints policy was required to ensure that individuals are fully safeguarded EVIDENCE: The home had a detailed Adult Protection Policy and Procedure. Some minor development was required so that there is clear information and relevant contact details for staff to access and follow in the event of abuse suspected or disclosed. The home’s complaints log could not be located at the time of the inspection. This is not satisfactory this information must be available in the home for inspection. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 17 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 standard(s) 24,26,27 and 30 The home is not suitable for the purpose of achieving its stated aims and objectives. Many parts of the home required redecoration and are not well maintained and comfortable for residents. EVIDENCE: The organisation is aware that the building does not meet the National Minimum Standards for Younger Adults. A condition of the homes registration was that by the end of September 2004 plans must be forwarded to CSCI for the future reprovision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. This timescale has lapsed and the proposals are outstanding. The managers on duty at the time of the inspection stated that there had been ongoing discussions and site visits regarding the outstanding building and repair work, however, to date, there had been no progress. A requirement of the inspection was that the organisation respond formally to these matter. A breach of condition may result in the commission taking further action. A tour of the building was made and many of the residents kindly showed the inspector their bedroom room. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 18 Decoration of some resident’s bedrooms viewed required decoration. Some of the bedroom furniture required repair and some of the bedrooms did not contain all of the required furniture as stated in the National Minimum Standards For Younger Adults. The condition of the mattress in some bedrooms required attention the home must audit all mattresses and where required these must be replaced. A full audit of bedrooms was required. Residents said that they would like their room decorated some residents had expressed this through their care plan review and it had been documented on their I.S.S. One of the bathrooms has had screening to the window to improve privacy as required at the previous inspection. There were cracked tiles in the bathroom on the first floor that required repair. Pipework in the bathroom on the ground floor required boxing in, also some tiles required replacing or repairing. Residents reported that the Malibu bath on the first floor was difficult to get into. An occupational therapy assessment was required regarding the suitability of the present bathrooms. In addition to above the additional conditions of registration remain outstanding. Areas of worn paintwork required repainting the timescale of June 2004 had lapsed. Windows where the paint is flaking away from the frame required repair. The timescale of June 2004 had also lapsed. The washing machine on the first floor that residents can use required repair. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 and35 Staffing levels were adequate for meeting resident’s needs. Information held in the home on Staff and recruitment practices are not adequate and fail to demonstrate that the home is safeguarding residents. Staff required training updates so that they have the required skills and knowledge to meet resident’s needs. EVIDENCE: The home had the equivalent of three full time support worker posts vacant. Sampling of the rota indicated that the home was complying with the conditions of registration with regard to the minimum levels of staffing, which is: 07.00hrs- 09.00hrs 4 care staff on duty, one of which must be a designated shift leader. 09.00hrs- 16.00hrs 3 care staff on duty, one of which must be a designated shift leader 16.00hrs- 22.00hrs 5 care staff on duty, one of which must be a designated shift leader 22.00hrs- 7.00am 2 care staff on duty, both on a waking night shift. At weekends between 09.00hrs and 22.00hrs there should be 5 care staff on duty one of which must be a senior. Sampled staff files did not contain all the required information that would demonstrate that a thorough recruitment process is in place. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 20 The home must have the required information on each staff member who is employed at the home, as detailed in schedule 2 of the National Minimum Standards for Younger Adults. Some progress had been made on staff training. Staff had recently completed Epilepsy training. Feedback from staff was positive about the quality and relevance of this training. Basic food Hygiene training had also been completed. Training on Challenging Behaviour, Diabetes, First Aid and Adult Protection remain outstanding and must be actioned for all staff. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Some development of Health and Safety practices and record keeping was required to ensure that resident’s welfare and safety is protected. Some progress had been made on recruiting a permanent manager for the home. This must be finalised so that the residents can benefit from having a consistent manager in post. EVIDENCE: The manager’s post at the Willows has been vacant for a protracted period. An acting manager has been in post and has many years experience of working as a manager. Recruitment for a permanent manager is in the final stages. CSCI have been informed that an application to register a manager for the home will be forwarded for processing by the end of June 2005. A number of Health and Safety records were examined. The work place fire risk assessment was due for review and a fire drill was required. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 22 The homes monitoring of accidents required some further development. More information was required regarding the treatment follow up and outcome of accidents. This information required adding to the accident log that was implemented following the previous inspection. Risk assessments regarding resident’s required considerable development. The storage of washing powder in the small kitchen on the first floor must be risk assessed. A container of powder was found in the microwave. The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 23 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 x x x Standard No 22 23 ENVIRONMENT Score 1 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 2 2 x x 2 Standard No 11 12 13 14 15 16 17 1 x 3 2 x x x Standard No 31 32 33 34 35 36 Score x x 3 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Willows Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 24 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 YA6 Regulation 12 (1) 15 Requirement Care plans required further development.They must be clear and specific about the support required by residents and kept under review. (Previous requirement 30/3/05). Guidelines and Behaviour management plans must be kept under review. Residents profiles must be updated and kept under review. Risk assessments must be further developed. They must be clear and specific about what the risk is and the support required by care staff. They must be kept under review. The review must be comprehensive. Risk assessments must cross reference to the care plan. Residents night time needs must be risk assessed. Manual handling risk assessments required further development. They must be kept under review. Risk assessments for residents with epilepsy must be implemented. The home must demonstrate how they provide and enable Timescale for action 31/8/05 2. 3. 4. YA6 YA6 YA9 12 (1) (a,b) 15 (1) (2) 13 (4) 30/6/05 31/8/05 31/8/05 5. 6. YA9 YA9 13 (4) 13 (5) 30/6/05 30/6/05 7. 8. YA9 YA11 12 (1) 12 (1) (a,b) 30/6/05 30/6/05 Page 25 The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 9. 10. YA11 YA14 11. 12. 13. YA19 YA19 YA19 14. YA19 15. 16. 17. 18. 19. YA20 YA20 YA22 YA23 YA24 20. YA24 residents to develop their independent living skills. 16 (2) The home must develop the (g,h) drink facilities available to residents. The home must provide all long term residents the opportiunity for a seven day holiday or equivalent. The home must develop the drink facilities available to residents. 12 (1) (a) The home must improve residents Healthcare recording and monitoring. 12 (1) (a) Health Action Plans must be implemented for all residents. 12 (1) (a) Individual epilepsy guidelines 13 (4) (c ) must be available for staff to 15 follow in the event of a seizure occurring. (Previous requirement 30/1/05) 12 (1) (a) Guidelines are required for the 13 (4) (c ) resident who has diabetes to 15 ensure that staff are aware of the action to be take in the event of a high/low blood sugar level. (Previous requirement 30/1/05). 17 (1) (a) Residents medication details Schedule required updating on their care 3 (3) (i) plan. 13 (2) (4) Medication storage required replacement. 22 (8) The complaint log must be available in the home at all times. 13 (6) Minor development of the homes Adult Protection procedure was required. 23 (1) (a) Plans must be forwarded to CSCI (2) (a) for the future reprovision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. (Previous requirement September 2004) 23 (2) (b) Cracked tiles in the bathroom on the first floor required repair. E54_S33630_TheWillows_V228069_180505 stage 4.doc 30/6/05 31/10/05 30/6/05 30/9/05 18/6/05 25/5/05 18/6/05 30/6/05 19/5/05 31/7/05 31/7/05 30/6/05 The Willows Version 1.30 Page 26 21. YA24 23 (2) (b) 22. 23. YA24 YA24 23 (2) (d) 23 (2) (d) 24. 25. 26. YA24 YA24 YA26 23 (2) (d) 23 (2) (b) Boxing in of the pipe work and repairing of some tiles was required in the ground floor bathroom. Areas of worn paintwork required repainting (Previous timescale June 2004) Windows where the paint is flaking away from the frame required repair. (Previous timescale of June 2004) Many of the residents bedrooms required decorating. Dented radiators required repair. 30/6/05 31/7/05 31/7/05 30/9/05 31/7/05 31/7/05 27. 28. YA26 YA27 29. YA30 16 (2) (c ) All bedrooms must be audited against the National Minimum Standards for Younger Adults . Any shortfalls must be provided. (Previous timescale 15/3/05) 16 (2) (c ) Mattress on residents beds must be audited and replaced where required. 23 (2) (n) An occupational Therapy Assessment is required regarding the suitability of the present bathrooms. 23 (2) (c ) The washing machine on the first floor that residents can use required repair. 7,9,19 schedule 2 18 (1) (a, c) The home must have on each staff file all of the information as detailed in schedule 2 of the National Minimum Standards for Younger Adults Staff must receive training in Challenging Behaviour. Adult Protection. First Aid Diabetes. (Previous timescale 30/4/05) A permanaent Manager must be recruited. (Previous timescale 30/4/05) The work place Fire Risk assessment required review. (Previous timescale 30/1/05) 30/6/05 31/8/05 30/6/05 30. YA34 31/8/05 31. YA35 31/9/05 32. 33. YA37 YA42 8 (1) (a,b) (i) 23 (4) 13 (4) 31/8/05 18/6/05 The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 27 34. 35. 36. 37. YA42 YA42 YA42 YA43 23 (4) (e) 17 (1) (a schedule 3 (j) 13 (4) 26 A Fire Drill was required. 31/5/05 The log of accidents required 31/5/05 more information regarding follow up and treatment. The storage of washing powder 19/5/05 in the first floor training kitchen must be risk assessed. A representative from Social care 30/6/05 and Health must visit the home unannounced on a monthly basis. Reports of the visits must be available in the home. Copies of the report must be forwarded to CSCI. (Previous timescale15/3/05) 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 Good Practice Recommendations The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor , Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows E54_S33630_TheWillows_V228069_180505 stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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