Inspection on 18/09/07 for The Willows

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 4 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 24/05/06

The Willows 01/11/05

The Willows 18/05/05

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 Willows, The 1 Park Road Hockley Birmingham B18 5JH Lead Inspector Donna Ahern Key Unannounced Inspection 18th September 2007 11:30 Willows, The DS0000033630.V347740.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 Willows, The DS0000033630.V347740.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. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows, The Address 1 Park Road Hockley Birmingham B18 5JH 0121 554 1427 0121 523 6073 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) N/A Social Care and Health Thelma Gurion Floresca Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Currently residing people who are over 65 may continue to be accommodated provided their needs can be met appropriately. The minimum staffing level 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 4 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 4 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 Reprovision plans to progress at a pace, which is acceptable to CSCI to allow continuation of registration. 24th May 2006 3. Date of last inspection Brief Description of the Service: The Willows is a large two- storey purpose built home providing care and accommodation for up to 14 adults with learning disabilities. The range of needs of individuals living at the home is diverse and some of the people 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 central 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 bedrooms are single. The home has four lounges/quiet rooms for the use of people living in the home. Birmingham City Council sets the fee level for the home. The CSCI inspection report is available in the home. Staff said the outcome of inspections is shared with the people living at The willows. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care inspection (CSCI) is based upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that needs further development. The inspection took place over one day; the Home did not know we were coming. The inspector met people living at the Home, spent time observing support and interactions from staff, had a tour of the premises including peoples bedrooms, looked at care records and health care records and medication management. Health and safety records and staffing records were also assessed. All information looked at was used to determine whether peoples varied needs are being effectively met. Three people were identified for close examination this included reading their care plans, risk assessments daily records and other relevant information. This is part of a process known as “case tracking” where evidence is matched to outcomes for service users. What the service does well: The home has a core team of staff who know people’s individual needs well. People made positive comments regarding the support they get from staff. People living in the home said that they have made very good friends with some of the people that live at the Willows. They said that their friends and relatives are made welcome to the home. Interactions between people living in the home and staff were friendly and respectful and indicated that people felt comfortable with the staff. Regular meetings take place with the people who live in the home to ask their views about menu planning, trips out and activities. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: People must be provided with opportunities to maintain and enhance their independence so they are fulfilled and reach their potential. When additions are made to Medication record sheet mid cycle these should be witnessed and signed to minimise errors and to provide an audit trail. People’s consent to receive medication should be sought and recorded in their care plan. Risk assessments must be kept under review to ensure the risk to people is well managed. Arrangements must be made to ensure all staff has a clear understanding of adult protection procedures to ensure that people are not put at risk of harm. Staff training updates is required in mandatory areas including first aid, food hygiene, adult protection and health and safety. So staff have the required skills and knowledge to meet peoples needs. Arrangements must be in place to ensure that any health and safety risks have been appropriately dealt with to ensure the safety of people living in the home. The smoke room used by people living in the home must be made comfortable for people to use. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 7 Plans with timescales for improvements to the physical standards of the home should be available so that people know what areas will be improved and when so that their home is comfortable. 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 summary of this inspection report can be made available in other formats on request. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Not assessed. EVIDENCE: There are currently fourteen people who live at The Willows many of the people have lived at the home for a number of years. The range of needs of individuals living at the home is diverse and some of the people have complex needs. There have been no new admissions to the home for several years. The homeowners who are Birmingham Council plan to eventually reprovide the service. In the interim no new admissions will be made. It was therefore not possible to assess these standards. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some further development of care plans and risk assessments would provide staff with the information they need to know to meet peoples assessed needs. EVIDENCE: Three peoples care plans were looked at for the purpose of this inspection. Previous inspection report stated that the Individual Service Statements (I.S.S) are not sufficient as a care and support plan for people living in the home. Information on the I.S.S was not in sufficient detail regarding how best to support people and how their assessed needs were to be met. It is positive that at this visit and the random inspection in March 2007 some progress had been made with the development of care plans so that there is a detailed plan in place to inform staff about how people’s needs should be met. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 11 One of the care plans looked at required review. Care plans must be kept under review and reviewed every six months or when needs change. A number or risk assessments were looked at. Some of the risk assessments were due to be reviewed to ensure that the control factors in place to manage the risk are adequate. Behaviour guidelines were in place and gave information about how people should be supported and had been developed with input from a community nurse. Choices and decision-making are restricted to day-to-day things such as what to eat, drink, and whether to take part in activities. Some people have limited communication and were not able to give their views about the home. Staff were observed making some attempts to offer basic choices such as offering activities and sitting alongside people to support and interact. People were seen to move freely around the home and had full access to their own bedroom. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s):12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported to take part in activities at home and in the community. Opportunities are limited for people to develop their independent living skills. EVIDENCE: Many of the people attend local day centres Monday to Friday. Since the previous visit progress had been made on supporting people to access facilities in the local community including supporting people to return to day centres they attended previously and had expressed an interest in returning too, and some people have been supported to attend new day centres. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 13 Previous reports have highlighted the limitations of the homes environment, which limits people’s opportunities to develop their independent living skills. The kitchen and laundry areas are industrial in lay out and design and people are not allowed to access the kitchen and therefore have no opportunity to shop, cook and only limited opportunities to prepare their own food. An area had been developed in the dining room so that people can make their own drinks during the day. The manager said that there are plans to refurbish this facility so it is more pleasant for people to use. People said that they sometimes use the small kitchen on the first floor to prepare snacks and their supper depending if there is staff available to give support. They said that they sometimes do clothes washing and use the main laundry. The domestic washing machine located on the first floor had been replaced with a new machine, and had recently broken down and required repair. Conversation and observations indicated that the manager and staff team recognise the limitations of the physical environment and are trying to utilise the facilities and change some practices so that people are supported with living more independent life styles. In the evenings people seem to go out a lot together. People said they go out to the gateway club, meals out, shopping and to the local pub. One of the people was planning a meal out for their birthday and said they had asked two of their friends from the home to go with them. People are encouraged to keep in contact with their relatives and friends. One person said they had been out the night before with their friend who they see regularly another person said they go to stay with their family a few times a year another person said they see their family each week and can ring them when they want to. People have been supported to develop and maintain personal relationships. People said that they are free to use all the communal areas of the home and go to their bedroom when they want to. The food served looked really nice. People said they liked the food. Staff did not sit with people at meal times but were present to support when required. Menus seen indicated that choices are offered at meal time and the menu was currently under review. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate arrangements are in place to ensure peoples health care needs are met. EVIDENCE: Many of the people have lived at the home for a long time. As they become older some of the people have experienced an increase in health problems and changes in needs and mobility. Staff spoken to demonstrated a good understanding of the potential impact of changes in peoples needs and the need to keep peoples needs under review and liaise with other professionals. People who live in the home had been supported to dress appropriately to their age, gender, the weather and the activities they were doing this indicates that people receive good support from staff. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 15 Guidelines and risk assessments are in place regarding the support people require from staff during the night. Manual handling assessments were on sampled files and should ensure that people are supported safely. Progress had been made on implementing Health Action Plans for people so that people living in the home have a plan about their heath care needs and how these will be met. There was evidence that some people receive good support with some complex health care matters. It was positive that health action plans detailed the person’s response to health care appointments. This should ensure that people receive consistent support from staff and that any issues raised by the person about their health care needs are followed through. The systems for medicine management were satisfactory. All audits undertaken were correct indicating that the medicines had been administered as prescribed. A new medication cabinet had been installed to improve medication storage. There were protocols in place for medication taken on an as required basis. None of the people living in the home were self administering their medication. It was advised that when people are prescribed additional medication that is added mid cycle to the MAR sheet, this information should be checked and witnessed by a second person to minimise any errors being made and to ensure an audit trail of prescribed medication is available. The consent to receive medication of people living in the home should be sought and recorded in their care plan. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate procedures are in place however these are not always followed through in practice and could put people at risk. EVIDENCE: People spoken with said they could talk to the staff or manager if they are not happy about something. Minutes of residents meetings indicated that staff discuss with people living in the home what to do if they are not happy about something and what they should do. The manager had implemented a system for recording minor concerns that people raise and this is seen as good practice and evidence that people are listened to. The complaint procedure was not available in a format suitable for people living in the home and should be provided to ensure people do know what to do and have something visual to refer to. Systems are well established for the reporting of incidents to CSCI via a regulation 37 reporting form and the policy on abuse and whistle blowing policy was available in the office for staff to refer to however, following a recent incident procedures were not followed by senior staff in the home. The manager was on holiday at the time and has ensured that the matter was dealt with on her return. Staff have received training in safeguarding people. In light of the recent incident and the failure to follow procedures the manager is Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 17 arranging for one of the service managers to present an adult protection briefing to reinforce what staff must do to safeguard the people living in the home. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s):24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home does not provide people with a comfortable, well-maintained environment, which encourages their independence. EVIDENCE: As stated in previous inspection reports the physical standards of the home do not meet the needs of the people living in the Home. There have been limited changes to the physical standards since the last key inspection in May 2006. The owner plans to reprovide the service provide by The Willows however, at the time of the visit there was no proposed timescale for this to happen. The ground floor toilet has been refurbished, major works have been done to the drains and trees in the front garden to stop the incidents of flooding to the Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 19 front of the building and a shower has been repaired. Requests have been made for the shower on the first floor to be replaced so that it is easier for people to use. Work to improve the smoke room, which is in a poor state of repair, remains outstanding. The manager has also requested that the drinks area in the dining room is improved and the lounge is painted so that it is comfortable for people to sit and relax in. One person’s bedroom has been painted but painting and decorating work to another five people bedrooms remains outstanding. There is evidence that the manager does generally report emergency repairs so that people’s safety is protected and evidence was seen of the request made by the manager to the homeowners to improve the environment for the benefit of the people living in the home. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are generally well supported, and supervised. Recruitment procedures are robust and protect people living in the Home. Some staff training updates will ensure staff have the required knowledge and skills to support people. EVIDENCE: During the visit staff interacted with people living in the home in a friendly and respectful manner. Four support workers and the manager were on duty, which the rota indicated is the usual level of staffing across the day and at night there are two waking night staff. Staffing levels were adequate to meet people’s individual needs. Observations of interactions between people living in the home and staff were positive. Staff were seen engaging with people and specifically spending time Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 21 with people who have very limited verbal communication and taking time to communicate. Staff responded to peoples request and needs. Two staff recruitment files were examined completed application form, references, criminal bureau checks and training details were all on file indicating that robust recruitment procedures are in place to protect the people living in the home. The training matrix and training records were looked at. Some staff requires updating in mandatory areas 5 staff members require first aid, 4 require food hygiene, 1 requires adult protection and 1 requires health and safety. The manager said this would be actioned. Ten staff have completed NVQ level 2 in care and training is planned to take place in-house from September to December 2007 on risk management, fire safety, makaton and autism. This should ensure staff have the required knowledge and skills to support people living in the home. It is advised that the manager and staff complete training on the new Mental capacity Act so that they are fully aware of issues of consent and the implications of how the new Act will protect the financial, healthcare and legal rights of people living in the home. Daily handovers of information at the point of a staff change over take place and regular staff meetings are held to ensure that staff receive the information they need to support people consistently and to raise any concerns they may have about meeting peoples needs. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s):37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and safety is generally well managed ensuring the health, safety and well being of people living in the home. EVIDENCE: The manager has a number of years experience and has NVQ level 4 and the registered managers award. The manager facilitated the inspection process and was open and welcoming to the inspection process and informed the inspector of relevant information. She interacted well with people living in the home and staff on duty. People living in the home said “she is easy to talk to “ “nice” “helpful”. Good progress had been made on previous requirements indicating compliance with the Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 23 regulations and a commitment to improve the Home for the benefit of the people who live there. Fire tests and servicing had been undertaken as required. Fire evacuations took place in March and August 2007 and good records were kept of the outcome and peoples response. This should ensure that in the event of the alarm sounding people are supported to evacuate safely. The electrical and gas supply had been serviced and tested as required and maintained so they are safe. Water temperature checks are completed of water outlets weekly. A wash hand basin in a person’s bedroom periodically showed high temperature readings, which could put the person at risk of scalding. It was unclear from records seen what action had been taken. Senior staff spoken with said the matter had been reported and agreed to follow this up. When high temperatures are recorded in the future there must be evidence of what action has been taken to protect people. Regular staff meetings take place. Minutes seen indicate that issues to do with people living in the Home are discussed and information is shared with the staff team so they know how to meet people assessed needs. The manager’s said she receives good support from the line management structure. Regular monthly visits are made by the team manager to assess that the homeowners, Birmingham City Council are fulfilling their responsibility to oversee the overall management of the home. The health and safety department carries out health and safety audits and financial audits take place. Regular meetings are held with the people who live in the home to seek their views on day-to-day matters such as menu planning, organising trips out and how to spend money or donations received. The manager said that she plans to work on developing surveys to seek the views of people living in the home, their relatives and other stakeholders this should enhance the homes quality assurance system. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 24 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 N/A 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 25 No 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 2 Standard YA9 YA23 Regulation 13 94) a, b, c 13 (6) Requirement Timescale for action 31/10/07 3 YA35 18(1)(a, c) 4 YA42 13 (4) Risk assessments must be kept under review to ensure the risk to people is well managed. Arrangements must be made to 30/11/07 ensure all staff has a clear understanding of adult protection procedures to ensure that people are not put at risk of harm. Staff training updates is required 31/12/07 in mandatory areas including first aid, food hygiene, adult protection and health and safety. So staff have the required skills and knowledge to meet peoples needs. Arrangements must be in place 31/10/07 to ensure that any health and safety risks have been appropriately dealt with to ensure the safety of people living in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 26 No. 1 2 3 4 5 6 7 8 Refer to Standard YA6 YA12 YA13 YA20 YA20 YA23 YA24 YA24 YA24 Good Practice Recommendations Some further development of peoples care plans is required so that a detailed plan and up to date plan is in place for staff to follow People must be provided with opportunities to maintain and enhance their independence so they are fulfilled and reach their potential. When additions are made to Medication record sheet mid cycle these should be witnessed and signed to minimise errors and to provide an audit trail. People’s consent to receive medication should be sought and recorded in their care plan. The complaints procedure must be available in a format suitable for the people living in the home to understand and follow. The detergents in the laundry room require boxing in to minimise any risks to the people living in the home. The smoke room used by people living in the home must be made comfortable for people to use. Plans with timescales for improvements to the physical standards of the home should be available so that people know when and what areas will be improved for their general comfort. It is advised that the manager completes training on the new Mental capacity Act so that she is fully aware of issues of consent and the implications of how the new Act will protect the financial, healthcare and legal rights of people living in the home. Quality assurance systems require further development so that the views of the people who live in the Home underpin any development. 9 YA35 10 YA39 Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Willows, The DS0000033630.V347740.R01.S.doc Version 5.2 Page 28 - 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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