Inspection on 06/06/06 for The Willows

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Willows 04/09/07

The Willows 21/11/05

The Willows 16/06/05

The Willows 03/12/04

The Willows 21/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Willows 74 Station Street Rippingale Lincs PE10 0SX Lead Inspector Sue Hayward Key Unannounced Inspection 6th June 2006 13:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Willows DS0000002467.V298871.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 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 DS0000002467.V298871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 74 Station Street Rippingale Lincs PE10 0SX 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) 01778 440773 willripp2@aol.com Mrs Ellen Floyd Mr Anthony Paul Floyd Mrs Ellen Floyd Mr Anthony Paul Floyd Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (27) of places The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: The Willows is situated in the village of Rippingale, six miles north of the town of Bourne. The village has a pub, shop/post office, church, GP surgery and a village hall. It is within easy reach of Bourne, which has a wide range of shops and amenities. The home is registered for 31 older people including up to 4 with dementia. The original house has been extended and accommodation is provided on two floors. Stairs or a passenger lift can reach bedrooms on the first floor. There are a variety of communal areas including three lounges, a reading room, a sun lounge and two dining areas, one of which has a bar. There are 19 single bedrooms, two of these having en-suite facilities and three twin bedrooms with en-suite facilities. The gardens are spacious and enclosed. The rear of the property is laid to flower beds and lawns, with a furnished patio area. There is a raised pond, a summerhouse and a barbeque area. The property also has a driveway and car parking area. There is an adjacent building containing offices, a laundry and a large room used as a training venue. The home has achieved and maintained the Investors in People award. The owner/managers live in a house within the grounds. Information provided prior to the inspection on 05/05/06 indicated that the current range of fees is £335 - £415. Hairdressing, newspapers, drinks from the homes bar and items from the homes “shop” are charged separately. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken by one inspector and formed part of a key inspection. It started at 13:20 and lasted four hours. Information already held on file was used to plan the visit and produce this report. This included the pre-inspection questionnaire, records of any incidents that had been notified to the CSCI since the last inspection and correspondence and checking the records that the CSCI keeps in relation to the service history. Have your say questionnaires had been returned to the CSCI from thirteen people, which included comments from some residents and some relatives. A community nurse who was visiting at the time also participated in the inspection. The site visit focussed on key standards and checking whether requirements and recommendations issued at the previous inspection had been addressed. A partial tour of the home was made. This included checking a sample of residents’ bedrooms and bathrooms as well as communal areas of the home, the kitchen and laundry. “Case tracking” was the main method used. This involved checking the care records of three residents with a range of needs and discussion with two of them. One other resident was spoken to on a general basis as in view of their needs they were unable to answer specific questions. Three staff members were spoken with as was the deputy manager who was present throughout the site visit. Observations were also made of staff undertaking aspects of their work including part of the drug administration procedure and a mealtime. The owner/manager, Mrs Floyd was seen briefly at the end of the visit and general feedback was given. A subsequent telephone call was made to her on 14/06/06 for additional information in order to conclude the inspection. What the service does well: There is a consistent staff team providing care for residents in a comfortably furnished home which is generally well maintained. There is an on-going training programme in place for staff to ensure that they have the necessary knowledge and skills to provide residents with the care they need. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 6 Residents commented positively about the care and accommodation that is provided. Staff were referred to in terms of being “good and kind” and residents made comments, which indicated that they felt safe, and knew who to go to if they had a problem. Residents have choices as to how they lead their lives in the home. Staff are committed to providing good care for residents. What has improved since the last inspection? 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 DS0000002467.V298871.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Willows DS0000002467.V298871.R01.S.doc Version 5.2 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 the following standard(s): 1 & 3 Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The systems in place for the introduction and assessment of resident’s to the home ensure care needs are identified and met. Written information about the home is made available to residents and their representatives. EVIDENCE: All records checked demonstrated that the needs of residents had been properly assessed and planned for. A resident recently admitted to the home commented that she had been able to visit and look around prior to admission. Staff comments indicated they knew the admission procedure, which is generally undertaken by the owner/manager who visits prospective residents either in their own home or in hospital. Information about any resident due to be admitted is given to staff at shift handover times or verbally by the person in charge. Assessment information, care plans and records are available for staff to consult. Records checked also demonstrated that information from The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 9 other care professionals had been obtained as appropriate such as social workers. Comments from staff demonstrated that they had a good knowledge of the needs of residents and how to meet them. Residents confirmed that they received the help and support they needed. The pre-inspection questionnaire confirmed there had been no changes to the homes statement of purpose and that information could be provided in a range of formats if requested. Resident’s records indicated that residents had been given a “welcome pack” which provides information about the home. The majority of surveys completed by residents and relatives indicated that they received sufficient information about the home before moving in, one could not remember, two said their relatives had assisted and one made the comment that “Not really, I was told it was a good home – my son would know”. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans contain sufficient information to ensure residents’ health and care needs are met and demonstrate the involvement and agreement of residents or their relatives with them. There are satisfactory storage arrangements for medication. The owner/manager has agreed to further review the procedure for recording when medicines have been administered in order to further safeguard residents. Residents’ privacy and dignity is promoted. EVIDENCE: The sample of three residents files case tracked all contained assessment information, care plans and risk assessments. Care plans identified the needs of residents and how to meet them and they contained signatures of residents or their relatives to denote their involvement. They are available for staff to The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 11 refer to and contained signatures demonstrating that staff reviewed care plans on a monthly basis. A community nurse was visiting a number of residents on the day of the site visit. She commented positively about the care that staff provide to residents at the home. She felt that communication between the community nurses, local G.P practice and the home was good and that staff responded well to any advice given in relation to the health needs of residents. For example, in ensuring that residents’ skin was well looked after in order to prevent pressure sores. There are weekly visits from a local G.P who can also be called out if needed. Records of residents being case tracked demonstrated the involvement of other health professionals such as chiropodists and psychiatric services when needed. Every survey completed indicated that residents “always” received the medical support they needed. Part of the lunchtime medication round was checked. Good attention was paid by the person administering medications to ensure the safety of the medicine trolley, medication records were thoroughly checked and the staff member offered appropriate assistance to residents who needed help with taking medication. The medication policy has been reviewed since the last inspection however it was noticed that medication is signed for prior to residents taking medication. This practice needs to be reviewed to ensure no alterations to the record are needed should a resident refuse medication. This matter was discussed with Mrs Floyd. It was acknowledged that this procedure was in place to ensure that staff checked every medicine had been dispensed but agreed to the practice would be reviewed to ensure there was no alterations needed to the record should residents refuse their medication. Medicines are being stored safely. There is a homely remedies protocol in place, which has been agreed by residents G.P’s. If assessed as able, residents can choose to take responsibility for administering their own medication however none of the current residents do so. Staff who administer medication do so only after they have been trained and assessed as competent. Residents made comments that indicated their privacy and dignity is respected at the home. Staff were observed to knock on bedroom doors before entering and it was noticed that one staff member quietly informed another staff member not to enter a resident’s room as she was carrying out a personal care task. Staff had a good knowledge of the needs of residents and a good rapport was noticed with residents. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The activities and leisure interests offered have improved since the last inspection. The meals provided are well balanced and take into account residents personal preferences and special dietary requirements. Visitors are made welcome and residents have as far as possible choices as to how they lead their lives. EVIDENCE: Comments from residents seen on the day of the site visit were positive about the social, cultural and recreational interests that the service provides. At the time of the inspection an entertainer was visiting the home at which a group of residents were attending. Comments from residents indicated that they have a choice as to what they participate in. Surveys completed included comments such as “ I like to sit and listen and sing to the music” and “I go to most of the activities and entertainment” and one that there were always activities arranged by the home that the resident could take part in however they “usually chose not to”. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 13 Other comments from the surveys received indicated that residents have the opportunity to take part in quizzes and games such as dominoes. Records checked corroborated these comments. Staff confirmed that Church services are held in the home from different denominations and residents can attend services held in the local community if they wish. A staff member commented that her national Vocational Qualification award had included training about different religions and antidiscriminatory practice. The pre-inspection questionnaire which had been completed by Mrs Floyd indicated that Equality and diversity training is planned Comments from residents seen on the day of the visit confirmed that they have choices as to how they lead their lives in the home such as times they get up and go to bed. The community nurse who was visiting said that she was always made to feel welcome at the home and had been offered lunch on the occasions when she had visited at that time. Residents said that they were able to have visitors when they wished and visitors were observed to come and go during the site visit and have a good rapport with staff. The lunchtime meal was in the process of being served at the start of the visit. It was noticed that staff were available and were assisting residents who needed help to eat their meal appropriately and in a manner, which respected their dignity. There is a choice of breakfast and tea options. The main meal is a set meal however individual personal preferences are incorporated into this. The community nurse confirmed that staff are aware of the importance of good nutrition to resident’s health and also said that she had mentioned to the staff that a resident with a poor appetite had said the only thing she had an appetite for was tinned tomatoes. She had noticed that this was provided for the resident for her lunch. Staff are aware of the individual food preferences of residents and of any special dietary requirements. They confirmed that basic food hygiene training is incorporated as part of their training and records checked confirmed this. Comments from residents and from the completed surveys were generally positive about the meals for example “cooking is very good”, “some things I don’t like but I am given something else”. Discussion with Mrs Floyd after the site visit indicated that a choice of two main meals had been offered in the past however this had not been successful therefore individual preferences were catered for on a daily basis. Mrs Floyd confirmed that since the site visit a record was being kept which noted any alternatives provided to the main meal to demonstrate the range of choice available to residents. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are satisfactory procedures in place to ensure residents are as far as possible, protected. EVIDENCE: Information provided prior to the site visit indicated there are procedures for staff to follow should there be any complaints or adult protection issues raised although none had been. Neither has the CSCI been notified of any concerns. The complaints procedure is on display in the dining room and copies of this and adult protection procedures are available in the main office and staff room. Questionnaires returned prior to the inspection indicated that neither residents nor relatives had had cause to raise concerns but would know how to should the need arise. For example, the following comment was made, “I would voice it to Ellen and my daughter would know the next stage to go to if I wasn’t happy” and “never had need to complain in the 11 years that mother has lived at the Willows”. Comments from residents spoken to at the time of the visit indicated that they knew who was in charge and felt able to talk to staff about any problems. Staff were aware of the procedure for reporting concerns and adult protection issues and the forms abuse could take. A staff member confirmed that adult abuse training had been covered as part of National Vocational Qualification (NVQ) award. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A clean, tidy and generally well-maintained environment is provided for residents where they are enabled to personalise their own rooms. This helps to ensure residents live in a safe and comfortable environment. EVIDENCE: Those areas of the home seen on this occasion included a sample of bathrooms and toilets, three residents bedrooms, lounges, dining room, kitchen and laundry. All areas were clean and tidy and smelt fresh. Residents said that they found their rooms to be comfortable and it was noticed that there was equipment in place to ensure the safety of residents, for example one bedroom checked had had a special mattress provided and bed guards were in use with covers to ensure residents safety and welfare. Radiators are guarded and there is a call bell system in place. The call system was tested and staff answered the call promptly. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 16 Equipment was seen to assist residents who have mobility needs such as hoists and a specialist bath. The pre-inspection questionnaire demonstrated that equipment such as hoist, wheelchairs and the passenger lift had been serviced within the past six months. Stocks of gloves and aprons were available for staff to use to ensure good hygiene and infection control procedures. A fire safety officer last visited the home on 15/11/04 to check the fire risk assessment, which was satisfactory. Staff comments indicated that any necessary maintenance matters are dealt with promptly. Residents made comments, which indicated that they found their rooms comfortable and had been able to make them more homely with their own personal items. Questionnaires received indicated that the environment of the home was fresh and clean and two additional comments were made, “it is very well kept” and “I’ve not seen it dirty”. There are well established and maintained gardens. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 17 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is being well staffed to meet the current needs of residents. There is a consistent staff team who receive training to ensure they have the skills and knowledge to provide residents with appropriate care. The recruitment procedure ensures as far as possible that residents are protected. EVIDENCE: Comments from residents and observations made on the day of the visit indicated that the home is being well staffed to meet the current needs of residents. Questionnaires completed and forwarded prior to the inspection indicated that residents received the support they needed and staff were “always” or “usually” available when needed. Staff were described in terms of being “good”, “kind”, “friendly”, “thoughtful”, “caring”, “I can always call on them if I need them” and “They’ve never let me down in anyway”. Staff comments were that staffing levels in the home enabled them to provide residents with the level of care needed. Staff rotas seen and sent with the pre-inspection information confirmed that there is always a minimum of 5 -7 staff in the mornings, 3-4 staff in the afternoons and 2 wakeful night staff. Discussion with staff confirmed these levels. In addition they said there are 2 cleaners and a cook. Since the last inspection specific time has been allotted The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 18 for specific staff to spend with residents developing social and recreational activities. Staff discussion and training records confirmed that there is a training programme in place which includes training and updates in relation to some matters such as fire training and moving and handling and training which is tailored to meet the needs of some residents such as dementia care. Preinspection questionnaire information demonstrated that there is a range of future training planned to include for example food hygiene training, equality, diversity and rights and dementia care. There are 18 staff that have obtained National Vocational Qualification (NVQ) awards Level II or above which exceeds national minimum standards. Pre-inspection information demonstrated that there is a consistent staff team with only one staff member leaving since the last inspection. A staff member spoken to confirmed that she had participated in a TOPPS induction course and had worked in the home in a purely observatory capacity for two weeks alongside staff. There is a thorough recruitment procedure in operation. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 19 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is being well managed and led by owners who have daily input into it. The quality and monitoring systems of the home have improved to enable the views of residents to be obtained about the quality of the service and how it can be developed. Residents’ health and safety is promoted and there are satisfactory processes in place to ensure that residents’ financial interests are safeguarded. EVIDENCE: There are satisfactory management arrangements in place, which consist of daily input from the owners, one who is responsible for the overall running and The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 20 management of the care side of the business, who is supported by a deputy manager. It was clear from comments that residents and relatives made, that they felt able to raise any issues with the manager or staff and knew who was in charge. Staff felt valued and supported in their work. There is a supervision and appraisal system in place and staff meetings are regularly held. Records seen confirmed this. A staff member commented that she had had a thorough induction into the work and records of the induction procedure are in place. The home has a range of policies and procedures to protect residents and ensure their safety, which are accessible to staff. The sample of records seen that are required by law to be kept were available and up to date, for example records of the fire alarm system indicated weekly checks are made, monthly checks of the emergency lighting and 12 staff had attended a fire drill which was held on 27/04/06. Pre-inspection questionnaire information demonstrated that there are regular checks made on equipment such as the servicing of the lift, central heating system and electrical equipment in the home to ensure the health and safety of residents. Since the last inspection questionnaires have been used with residents to obtain their views about the service and a report compiled of the audit findings. Mainly positive comments were received about the care however one finding was that staff needed to improve areas relating to residents laundry. There was evidence in place, which indicated that this had been addressed with staff during a staff meeting. The pre-inspection questionnaire confirmed that Mrs Floyd does not have any current responsibilities for the financial affairs or personal allowances of residents. The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 21 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 The Willows DS0000002467.V298871.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 DS0000002467.V298871.R01.S.doc Version 5.2 Page 24 - 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!