Inspection on 28/06/05 for The Willows

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

The Willows 21/09/09

The Willows 25/03/09

The Willows 24/07/08

The Willows 31/10/07

The Willows 11/05/07

The Willows 20/11/06

The Willows 09/05/06

The Willows 19/01/06

The Willows 11/11/04

The Willows 13/09/04

The Willows 03/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Willows 2 Tower Road Barbourne Worcester WR3 7AF Lead Inspector Andrew Spearing-Brown Draft -Unannounced 28 June 2005 10:45 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Willows Address 2 Tower Road, Barbourne, Worcester WR3 7AF 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) 01905 20658 01905 20658 Mr Tony Harborne and Mrs Vivien Anita Harborne Mrs Lynda Jennings Care Home 14 Category(ies) of OP Old Age (14) registration, with number PD(E) Physical disability over 65 (14) of places The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may also accommodate a maximum of 4 people over the age of 65 with a dementia illness 2. The Home may also accommodate one person over the age of 65 with a learning disability 3. The Home may also accommodate one named person who has needs which fall within the category MD ie mental disorder, excluding learing disability or dementia. Date of last inspection 11 November 2004 Brief Description of the Service: The Willows is a large, detached, adapted property situated in a residential area near to Barbourne Park. The home provides a residential care service for a total of 14 people over the age of 65 years who may also have a physical disability. The home may also accommodate a maximum of 4 people over the age of 65 years with a dementia illness and one person over the age of 65 years with a learning disability. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a four hour period from mid morning till early afternoon. The previous full inspection took place during November 2004. A letter of serious concern was written immediately following the last inspection due to a number of concerns regarding medication. The main focus of this inspection was therefore to assess the progress made in relation to the requirements from the last inspection. On the day of this inspection the registered manager was on duty, one of the registered providers was also present within the home. One carer, who was working as the cook, was consulted as were a small representative number of residents. Many areas of the home were seen including some bedrooms and all communal rooms. The care records of a small sample of residents were seen. Other documents seen included medication records, staff records and some policies and procedures. What the service does well: What has improved since the last inspection? Some improvement was noted in care plans. National Vocational Qualification (NVQ) training that had come to a stop due to difficulties with the training provider has recommenced with a new trainer. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 6 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. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were assessed in any detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at The Willows. EVIDENCE: The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Progress on providing up to date care plans has been made; however the lack of risk assessments and unsafe practice in medication administration leaves residents at potential risk. EVIDENCE: Individual plans of care are available and those seen showed that progress had been made to ensure that all aspects of heath, personal and social care needs of residents are identified and planned for. Care plans are reviewed on a monthly basis but in one case the plan did not take into account recent changes in care needs, which had occurred between the monthly update. Neither the resident nor their representative had signed their care plans. Care plans did not include any information regarding meaningful activities undertaken by residents. Risk assessments are not taking place regarding aspects of care. This included falls, pressure care and environmental issues. No nutritional screening is taking place. Photographs of residents to be used for means of identification are not available. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 10 One resident confirmed that GP visits take place in the privacy of her own bedroom. Immediate requirement notices were left in respect of a number of serious concerns regarding the administration and recording of medication. The controlled drugs book contained correction fluid on numerous occasions, medication within a cupboard and on a worktop was held unsecured and gaps were on the administration record sheets. A ‘fridge for the sole use of insulin contained a bottle of wine and other drinks and no temperature records were maintained for the ‘fridge. Some residents self administer medication no risk assessments are in place and medication was seen to be unsecured within bedrooms. Some staff who administer medication have not received appropriate training and some staff had not signed a sheet giving a specimen signatures. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 There was no written evidence that residents are able to take part in meaningful activities to enhance daily living and quality of life. EVIDENCE: The provision of activities is generally on a add hoc basis and not on any planned arrangement with the sole exception of a person who visits to lead a music and movement session. No records existed of any activity or who had taken part and therefore it was not possible to assess the suitability of these events. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, and 17 The home has a suitable complaints procedure with some evidence that residents feel any concerns or complaints would be listened to and acted upon. EVIDENCE: The complaints procedure contained clear timescales and information as to how to contact the Commission for Social Care Inspection. Neither the home nor the Commission have received any complaints since the last inspection. A member of staff consulted stated that she knew about the procedure furthermore one resident also stated that she was confident that she would be able to express any concerns with the manager should one ever arise. Residents were able to vote by means of postal votes at the recent general election The homes adult protection procedure was viewed briefly however it was noted that it contained contain telephone numbers for both the Commission and Adult Protection Coordinator employed by Worcestershire Social Services. This policy will be assessed further during a future inspection. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, and 24 There has been no noticeable change to the décor and furniture over the past six months however the appearance of the home continues to create a comfortable and homely environment for residents EVIDENCE: This inspection took place during a very warm period of weather; therefore areas such as lighting and heating were not accessed. It was noted that the home was clean and had no unpleasant odours. The communal lounge and smaller lounge as well as communal facilities are well maintained, well furnished and homely in appearance. The entrance hall also provides a pleasant sitting area. The dining room is bright and suitable for purpose, it was well laid out for the forthcoming mid day meal. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 14 A stair lift is fitted to give access to the first floor of the building. The gardens to the rear of the home, although only seen from inside, appeared well maintained. The garden could be accessed by anybody with limited mobility or using a wheelchair. Several residents’ bedrooms were viewed. All those seen demonstrated that residents are able to bring personal belongings into the home with them. One resident was particularly pleased with her bedroom and en-suite facilities. No environmental risk assessments are in place, these need to be undertaken without undue delay. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 Procedures for the recruitment of staff are not sufficiently robust to ensure the protection of residents. The level of staff at certain times is not acceptable and leaves residents at risk. EVIDENCE: There are a number of staff vacancies mainly at nights and weekend evenings. The continuing none compliance in providing a staff rota results in difficulties while auditing the level of staff on duty. Staff are required to complete a weekly time sheet and these were used to establish the staffing provided over a one week period. As these are not completed by all those working within the home it appeared that at times nobody was working within the home. No gender policy was available. On the day of this inspection one carer had to cook the lunch. Therefore only one carer was left to meet the personal care needs of 14 residents once the other carer started her cooking role. The manager and registered provider were on site. There should be suitable numbers of carers available at all times. The staff files for two newer members of staff were viewed these indicated that the registered persons had not undertaken all the necessary recruitment checks to ensure the protection of residents. One file contained only one reference and this was dated after the employee had started work. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 16 One member of care staff currently holds an NVQ level 2 qualification while another eight members of staff are about to recommence or embark on this training. Staff were described as ‘kind and caring’ by a resident. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 and 38 The lack of servicing records, training records and risk assessments does not promote the safeguarding the health, safety and welfare of residents and staff and therefore places these persons at risk. EVIDENCE: No certificates or other documentation was available to indicate that gas equipment and appliances and the hoists over the baths had been serviced in line with relevant regulations. An immediate requirement notice was issued stating that a copy of these items needs to be obtained and forwarded to the Commission. Mandatory training has not taken place for all members of staff in relation to moving and handling and basic food hygiene. No formal supervision of care staff takes place in line with the relevant standard. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 18 Risk assessments of the building, environment and equipment have not been carried out. Financial and business plans were not sought on this occasion. No quality assurance programmes are in place and since residents choose to discontinue their meetings no methods of seeking residents views is in place; no satisfaction questionnaires have been circulated. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 2 3 x x x STAFFING Standard No Score 27 1 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x 1 x x 1 x 1 The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Requirement A service users’ guide, that includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service users. (This standard was not assessed as part of the inspection carried out on 28th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 2. 2 5 The service users’ contract (statement of terms and conditions) must be amended so that it includes all of the information detailed in Standard 2.2 of the National Minimum Standards. (This standard was not assessed as part of the inspection carried out on 28th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 21 Timescale for action 30/06/05 31/05/05 3. 7 15 Service user plans must be recorded in a style accessible to the service user, agreed and signed by the service user wherever capable and/or representative (if any) and reviewed by care staff at the home at least once a month. (Previous timescale of 31/05/05 not met). 31/08/05 4. 7 15 16 (2) (n) Daily records must demonstrate how residents have spent their day including activities that they have taken part in. Service users must be assessed in regard to their risk of falling and the outcome included in their plan of care with details of appropriate interventions. (Previous timescale of immediate and on going not met). 31/08/05 5. 7 15 immediate and on going 6. 8 15 (2) (b) 17 (1) (a) Schedule 3 (p) The registered manager must ensure that risk assessments in relation to pressure care prevention are carried out. (Previous timescale of immediate and on going not met). The registered manager must ensure that service users’ care plans contain information regarding nutritional care needs. (Previous timescale of immediate and on going not met). immediate and on going 7. 8 17 (1) (a) Schedule 3 (o) immediate and on going The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 22 8. 9 13 (2) The registered manager must ensure that Medication Administration Record (MAR) sheets are signed after medication has been administered to service users. The reason for any nonadministration of prescribed medication to service users must be clearly entered onto the MAR sheets. (Previous timescale of immediate and on going not met). immediate and on going 9. 9 13 (2) The registered manager must ensure that medication is held securley at all times. immediate and on going 10. 9 13 (2) 17 (1) (a) Schedule 3 (i) The registered manager must ensure that the practice of using correction fluid within the controlled drugs register ceases. The registered manager must ensure that the fridge used to store insulin is only used for medical items which need to be kept refrigerated. The registered manager must ensure that temperature records are taken and retained regarding the fridge used for medical items The registered manager must ensure that a record is kept of meaninful and purposeful activities which take place within the home. immediate and on going 11. 9 13 (2) immediate and on going 12. 9 13 (2) immediate and on going 13. 12 16 (2) (n) 31/08/05 The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 23 14. 19 13 (4) The registered manager must ensure that environmental risk assessments are carried out and available for future inspections. 31/07/05 15. 26 13 16 A risk assessment must be carried out regarding the handling of soiled linen, the disinfection of commode pans etc. and a sluicing facility provided, if necessary. (Previous timescale of 31/05/05 not met). 31/07/05 16. 27 17 (2) Schedule 4 (7) A copy of the duty roster of all the persons working at the home (including their names and designations), that is dated and a record of whether the roster was actually worked, must be maintained, in accordance Regulation 17 and Schedule 4. (Previous timescale of immediate and on going not met). immediate and on going 17. 27 18 (1) The registered manager must ensure that all times suitable and sufficent staff are on duty to ensure the heath and wellbeing of residents. immediate and on going 18. 29 19 Recruitment procedures must be immediate developed in accordance with the and on requirements of Regulation 19, going Schedule 2 and Standard 29. (Previous timescale of immediate and on going not met). The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 24 19. 30 18 All staff must have individual training and development assessments and profiles. (Previous timescale of 30/06/05 not expired - therefore this requirement will be assessed as part of a future inspection). 31/08/05 20. 33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 30/06/05 not expired - therefore this requirement will be assessed as part of a future inspection). 31/08/05 21. 36 18 (2) Care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. (Previous timescale of 30/06/05 not expired - therefore this requirement will be assessed as part of a future inspection). 31/08/05 22. 36 26 The person carrying out the 31/07/05 monthly visit on behalf of the registered provider must prepare a written report on the conduct of the care home and supply copies to the Commission, the registered manager and the registered provider in accordance with the requirements of Regulation 26. (Previous timescale of 31/05/05 not met). The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 25 23. 37 17 All the records required by regulation must be fully and accurately maintained within the home in accordance with Regulation 17 and Schedules 1, 2, 3 and 4 (Previous timescale of 30/06/05 not expired - therefore this requirement will be assessed as part of a future inspection). 30/06/05 24. 38 13 18 All staff must be provided with updated training on moving and handling, food hygiene, fire safety and infection control. (Previous timescale of 31/05/05 not met). 31/08/05 25. 38 13 Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3. (Previous timescale of 31/05/05 not met). 31/08/05 26. 38 13 Evidence must be provided to demonstrate the home’s compliance with all of the relevant legislation referred to in Standard 38.4. (Previous timescale of 31/05/05 not met). The Fire Risk Assessment must be reviewed at regular and frequent intervals, signed and dated. (This standard was not assessed as part of the inspection carried out on 28th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). E52 S18692 The Willows V236066 280605.doc 31/07/05 27. 38 13 30/04/05 The Willows Version 1.40 Page 26 28. 38 13 The registered provider must be able to demonstrate that all gas appliances and equipment are serviced as necessary. 05/07/05 29. 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 12 Good Practice Recommendations Service users interests should be recorded in their care plans with guidance for staff on the ways in which the service users will be given opportunities for stimulation through leisure and recreational activities in and outside the home, with particular consideration being given to people with dementia and other cognitive impairments. (Not assessed on this occasion) 2. 13 Relatives, friends and representatives of service users should be given written information about the home’s policy on maintaining relatives and friends’ involvement with service users at the time of an admission to the home. This information should be included in the service users’ guide (Not assessed on this occasion) 3. 14 Information on the service users’ right of access to their personal records, in accordance with the Data Protection Act 1998, and how this is facilitated for them should be included in the service users’ guide. (Not assessed on this occasion) 4. 18 A policy and procedure should be introduced to ensure that physical and/or verbal aggression by service users is understood and dealt with appropriately and that physical intervention (restraint) is used only as a last resort and in E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 27 The Willows accordance with Department of Health guidance. 5. 18 (Not assessed on this occasion) The home’s policies and practices regarding service users’ money and affairs should ensure service users’ access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and advice on personal insurance, and preclude staff involvement in assisting in the making of or benefiting from service users’ financial wills. (Not assessed on this occasion) A detailed cleaning schedule for all parts of the home, including the kitchen, should be provided. (Not assessed on this occasion) 7. 28 Arrangements should be made for staff to receive training which will enable a minimum of 50 of the care staff to attain a qualification at NVQ Level 2 or equivalent by 2005 The job description of the registered manager should be reviewed in order to ensure that it includes all of the duties and responsibilities that are commensurate with her position and status within the home. (Not assessed on this occasion) The results of service users surveys should be published and made available to current and prospective users, their representatives and other interested parties, including the CSCI. Feedback should be actively sought from service users about services provided through, e.g. anonymous user satisfaction questionnaires and individual and group discussion, as well as evidence from records and life plans; and this informs all planning and reviews The views of family and friends and of stakeholders in the community (e.g. GPs, chiropodist, voluntary organisation staff) should be sought on how the home is achieving goals for service users. A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 28 6. 26 8. 31 9. 33 10. 33 11. 33 12. 34 The Willows 13. 37 A statement to the effect that the service users have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records, should be included in the service users’ guide. (Not assessed on this occasion) 14. The Willows E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 29 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road, Worcester WR3 7NW 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 E52 S18692 The Willows V236066 280605.doc Version 1.40 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!