Inspection on 24/05/06 for The Willows

This inspection was carried out on 24th May 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 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 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 Unannounced Inspection 24th May 2006 11:20 Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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.V291518.R01.S.doc Version 5.1 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.V291518.R01.S.doc Version 5.1 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) Social Care and Health Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. Currently residing people who are over 65 may continue to be accommodated provided their needs can be met appropriately. 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 Areas of worn internal paintwork must be repainted by end June 2004. Windows where paint is flaking away from the frame require repair by end June 2004. Bedroom 13 requires repair by end of June 2004 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 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. 1st November 2005 4. 5. 6. 7. 8. Date of last inspection Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 5 Brief Description of the Service: The Willows is a large two- storey purpose built home providing care and accommodation for up to 15 adults with learning disabilities. The range of needs of individuals living at the home is 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 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 residents’ rooms are single. The home has four lounges/quiet rooms for the use of residents. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was Unannounced and took place over one long day. The inspector met all 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 records were examined, and a number of Health and Safety records were inspected. The inspector spoke to the manager, deputy manager and four support workers. The manager completed and returned a pre-inspection questionnaire prior to the inspection. Information within the questionnaire was used to inform the inspection and this report. The conditions of registration for the home are under review with the provider. When this process is completed some will be removed to reflect the current requirements. What the service does well: What has improved since the last inspection? There is now a permanent manager in place and there was an open and inclusive style of management. The service has continued to work towards meeting outstanding requirements. Twenty-two of the previous 36 requirements had been actioned in full and many of the remaining had evidence of progress. Although the new care plan format had not been implemented there was evidence of some good work towards developing residents care plans. A new risk assessment format has been implemented a number were sampled and had been kept under review. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 7 Training since the last inspection has included epilepsy, autism, challenging behaviour, sex and sexuality, diabetes and Fire safety training. Which provides staff with specific skills and knowledge to support the individual needs of residents. The manager was in the process of reviewing the use of rooms with residents. One communal room was in the process of being adapted so that it could be a bedroom. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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.V291518.R01.S.doc Version 5.1 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 the following standard(s): No new admissions will be made to the service. EVIDENCE: There are currently fifteen 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 residents have complex additional needs. There have been no new admissions to the home since the previous inspection. CSCI were informed that the reprovision process has commenced in the Birmingham Council homes and no new admissions will be made. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Further development of residents care plans was required so that a plan of care is in place that details resident’s needs, aspirations and goals. EVIDENCE: Three care plans were sampled. The previous inspection report stated that the Individual Service Statements (I.S.S) are not sufficient as a care and support plan for residents. Information on the I.S.S was frequently repeated and not in sufficient detail regarding how best to support each resident and how their assessed needs were to be met. The provider informed CSCI (Action plan December 2005) that they were waiting departmental guidelines for a holistic, person centred plan of care that would provide a uniform document for all Birmingham City Council Learning Disability homes. It was anticipated that the new format would be implemented from February 2006. No progress had been made on implementing a more person centred care plan. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 11 However there was evidence of improvements to the current care plan information. One of the plans had been developed in a pictorial format so that it is more appropriate for residents. There was some good detail regarding the individual needs of residents including specific cultural needs. Some of the sampled care plans required more detail regarding how the person needs to be supported with their care. Information was also required regarding residents communication needs. Two of the care plans were in the process of being reviewed and updated and required completion. Resident’s profiles had been updated. Behaviour management guidelines are in place and there was evidence that these are kept under review. A new format for risk assessment had been implemented and risk assessments sampled had been kept under review. There was evidence that when an incident had occurred the risk assessment had been kept under review ensuring that the control factors in place are adequate. Staff were observed supporting residents to make choices about what activities they wanted to do, if they wanted to make a drink, and how they wanted to spend their evening. As raised under “Lifestyle outcomes” the environment is institutional in layout and directly impacts on resident’s lifestyle choices. Resident’s individual records were generally kept in good order and stored appropriately in the main office. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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 the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are supported to take part in activities at home and in the community. Staff must continue to improve opportunities and be able to evidence how they support residents to develop their independent living skills. EVIDENCE: Many of the residents attend local day centres Monday to Friday. Some of the residents do not attend any formal day care and depend on input from staff to support them during the day. The level of activity is variable depending on staff availability and the individual needs of residents. This does require some closer monitoring by the manager to ensure that all residents who do not attend formal day care receive the level of support they require to engage in appropriate daytime occupation. Previous reports have highlighted the limitations of the homes environment, which limits resident’s opportunities to develop their independent skills. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 13 The kitchen and laundry areas are industrial in lay out and design and residents 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 residents can make their own drinks during the day. Since the previous inspection a fridge has been installed. The practice of drinks being served from a trolley to residents had ceased. Residents are enabled to make their own drinks in the designated area in the dining room. Residents 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 again. Staff said that five of the residents are supported to do their own washing and ironing and they are hoping to gradually support more residents to do this. 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 residents are supported with living more independent life styles. In the evenings people seem to go out a lot together. Residents said they go out to the gateway club, meals out, shopping and to the local pub. Some of the residents had recently been on holiday to Scarborough they said they had a really good time and another holiday might be planned for later in the year. Residents are encouraged to keep in contact with their relatives and friends. One resident said they were going to see their parents soon and will be staying with them for a week another resident said “I see my family on the weekends and I like it when they visit”. One of the residents said they look forward to visits and going out on trips with their advocate who they have known for many years. Residents have been supported to develop and maintain personal relationships. Residents said that they are free to use all the communal areas of the home and go to their bedroom when they want to. One resident said they like to spend a lot of time in their own room and like to watch the soap’s on television. Other residents said they “like sitting in the main lounge so that they can talk to other residents and staff.” The food served looked really nice. Residents spoken to said they liked the food. Some of the residents cleared away their own plates. Staff did not sit with residents but were present to support when required. Residents said they are encouraged to eat healthy food. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 14 Staff said they work closely with staff at the local day centre who are also promoting healthy eating supported by the dietician services. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 15 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. This judgement has been made using available evidence including a visit to the service. Improvements must be made to resident’s health care information so that the manager and staff can demonstrate that residents have received the medical and health input they require. Residents are protected by policy and practice relating to the safe storage of medication. EVIDENCE: Many of the residents have lived at the home for a long time. As they become older some of the residents have experienced health problems and changes in needs and mobility. Staff spoken to demonstrated a good understanding of the potential impact of changes in residents needs and the need to keep residents needs under review and liaise with other professionals. Guidelines and risk assessments are in place regarding the support residents require from staff during the night. These must include how any checks by night staff are done. The risk assessments that underpin the guidelines were due to be reviewed. Manual handling assessments were on sampled files and were due for review. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 16 Residents receive medical and health in put and there are recording systems in place for the recording of health and medical intervention. These require more detail regarding the outcome of appointments so that there is clear information documented on individual residents files to assist with monitoring and any further follow up. On the day of the inspection a delay in arranging a routine health appointment for a resident resulted in staff supporting the person to attend out of hours emergency service, which required follow up the next day. This raised concern about how request to health appointments are dealt with by the senior person on duty and must be addressed. Guidelines for staff to follow had been implemented for residents who are diabetic regarding signs of illness, acceptable blood sugar levels and circumstances where medical treatment must be sought. This was a previous requirement. Risk assessments must be implemented for the use of wheelchairs. If lap or posture belts are used there must be clear guidelines for there use. The wheelchairs must be used in accordance with manufactures guidelines. Progress had been made on the implementation of Health Action Plans. People who have input from community nurses were being supported to complete these. 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 residents were self administering their medication. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 17 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. This judgement has been made using available evidence including a visit to the service. Development of the Complaints policy is required so that the manager can demonstrate that individuals are listened to. General practice promotes the protection of residents. EVIDENCE: The previous inspection required that some minor additions were required to the Adult Protection Policy and Procedure, so that there is clear information and relevant contact details for staff to access and follow in the event of abuse being suspected or disclosed. This had been actioned. Residents spoken to 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 residents what to do if they are not happy about something. The manager had implemented a system for recording minor concerns that residents had raised. The manager acknowledges that there is scope for concerns by residents to be followed up more formally. The complaint procedure was not available in a format suitable for residents although Social Care and Health have produced one; this was not available in the home. Incidents of concern have been appropriately reported to CSCI via a regulation 37 (National Minimum standards For Younger Adults-Requirement to report notification of death, illness and other events) and demonstrated that the manager and staff team are committed to protecting residents and promoting good practice. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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 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 poor. This judgement has been made using available evidence including a visit to the service. The home is not suitable for the purpose of achieving its stated aims and objectives. Many parts of the home required redecoration and were not well maintained and comfortable for residents. EVIDENCE: 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 would be forwarded to CSCI for the future reprovision of this service to ensure standards commensurate with fitness for purpose and for the needs of the client group. A meeting has been arranged with the provider for 3rd July 2006 to discuss long-term plan for this and other City Council homes. The previous report raised a number of maintenance matters that required attention these had all been actioned apart from repairs to some tiles in one bathroom. Some residents had requested bigger bedrooms and the manager was in the process of reviewing the use of rooms with residents. One communal room was in the process of being adapted so that it could be a bedroom. The resident Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 19 who is having the room had requested more space, which is really needed due to their mobility needs. They showed me the room which was still having work done to it and they were really looking forward to having more space. Another resident showed me their room, which had just been decorated whilst they were on holiday they were really pleased with the new wallpaper. The home was clean and hygienic. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Information held in the home on Staff and recruitment practices was not adequate and failed to demonstrate that the home was safeguarding residents. Staff are generally well supported, trained and supervised. EVIDENCE: Staffing levels are a condition of registration. The following level of staffing is required. 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. Sampling of the rota identified there continues to be a shortfall on some evening shifts after 20.00hrs. The provider must ensure that minimum staffing levels are maintained as detailed above. There was 90 care hours vacant. Which had been advertised. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 21 The provider has formally agreed with CSCI that a proforma will be in place on each persons file evidencing that required records have been seen. On the three staff files seen there were incomplete profiles indicating that for one person the CRB check had not been seen, and for two staff their references had not been signed as seen. The provider 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. Sampled records indicated that supervision sessions take place on a monthly basis. Staff spoken to said that they are supported to attend a range of training including mandatory and training specific to the needs of people who have a learning disability. Training since the last inspection has included epilepsy, autism, challenging behaviour, sex and sexuality, diabetes and Fire safety training. A number of certificates for individual staff members are held in a central file as evidence of a range of training completed. The training records and matrix was dated 2004 and must be updated to reflect the training that has taken place. CSCI have requested an up to date copy of the training matrix so that an overview of staff training achieved and outstanding can be obtained. Observations of interactions between residents and staff were positive. Staff were seen engaging with residents and specifically spending time with residents who have very limited verbal communication and taking time to communicate using different forms of communication. Staff were seen to respond to residents request and needs. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 42, 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Health and safety is generally well managed. Residents benefit from a permanent manager. EVIDENCE: The manager’s post at the Willows had been vacant for a protracted period. A permanent manager was appointed in December 2005 and registered with CSCI in February 2006. She was previously a registered manager at another Council home and has significant management experience. At the time of the inspection the inspector was advised that the manager was supporting another registered home for a two-month period from May 2006 to July 2006 and still has responsibilities at the Willows. CSCI must be informed of any changes to these arrangements. There is evidence that the registered manager was making positive changes at the home and it is disappointing that her responsibilities have been significantly increased. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 23 The manager is supported by a deputy manager and two assistant managers who have worked at the home for a number of years and have supported the home through a period of temporary management arrangements prior to the registered managers appointment. Residents and staff made very positive comments about the management style of the home. Comments received included “routines have been changed for the better” “the manager explains things well” “the manager is very approachable”. The manager was very welcoming to the inspection process. There was evidence of consultation with staff and residents about how the home could be developed. The development plan for the service was not assessed. As previously stated CSCI has arranged to meet with senior managers to discuss future plans for the Willows. A number of Health and Safety records were examined and were generally in good order with evidence of regular tests and servicing taking place. The work place Fire Risk assessment required some amendments the outstanding work to the homes fire safety measures must be highlighted in the assessment and kept under review as the work is completed. The weekly testing of the water temperatures had not been completed for two weeks in May 2006 but otherwise regular had taken place. Where the provider is an organisation they are required to nominate someone to carry out unannounced visits to the home and carry out interviews with residents, their representatives and persons working at the home. A written report on the conduct of the home must be produced and a copy available at the home for inspection and a copy sent to CSCI. The manager’s perception is that the she receives good support from the line management structure. However this cannot be evidence through the required regulation 26 reports. The last report on file was dated September 2005. The owner’s representative must evidence that such visits have been undertaken in accordance with the regulations, and that they are fulfilling their responsibility to oversee the overall management of the home. Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 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 3 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 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 3 X X X 2 2 Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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)(5) Requirement Timescale for action 31/08/06 2 YA11 3. 4 5 YA18 YA18 YA18 6. YA19 7 8. YA22 YA24 Care plans required further development. Progress made further development required. 12(1)(a,b) The Provider must provide opportunities for residents to develop their independent living skills. Progress made further development required. 13(4)(a,b,c) Risk assessments for waking night staff required review. 13(5) Manual handling assessments required review. 13(4)(c)(5) Risk assessments must be implemented for the use of wheelchairs. If lap or posture belts are used there must be clear guidelines in place for there use. 12(1)(a) The home must improve residents healthcare recording and monitoring. Previous requirement 30/06/05. 22(2) The complaints procedure must be available in a format suitable for residents. 23(1)(a) Redevelopment plans for the (2)(a) service must be forwarded to CSCI. DS0000033630.V291518.R01.S.doc 31/08/06 31/07/06 30/06/06 26/05/06 31/07/06 31/07/06 03/07/06 Willows, The Version 5.1 Page 26 9. 10. 11 12. YA24 YA24 YA24 YA26 23(2)(a,b) 13(4) 23(2)(b) 16(2)(c) 13. 14. YA30 YA34 23(2)(c) 7 9 19 Sch 2 18(1)(a,c) 23(4) 13(4) 13(4) 26 15. 16. 17 18. YA35 YA42 YA42 YA43 Some information received further up date required. Meeting arranged 03/07/06. A planned maintenance and renewal Programme for the building was required. The detergents in the laundry room required boxing in. An area of tiles in the bathroom required replacing All bedrooms must be audited against the National Minimum Standards for Younger Adults. Any shortfalls must be provided. Previous timescale 15/03/05. The washing machine on the first floor for residents use required repair. 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. The training plan and matrix required updating a copy must be forwarded to CSCI. The work place Fire Risk assessment required review. The testing of water temperatures must be undertaken weekly. A representative from Social care 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 requirement 15/03/05. 31/07/06 31/07/06 31/07/06 31/08/06 31/05/06 31/07/06 31/07/06 30/06/06 31/05/06 30/06/06 Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willows, The DS0000033630.V291518.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham 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. 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