Inspection on 12/01/06 for The Willows Care Centre

This inspection was carried out on 12th January 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 Care Centre 16/01/08

The Willows Care Centre 04/07/06

The Willows Care Centre 17/11/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Willows Care Centre Heathercroft Great Linford Milton Keynes Buckinghamshire MK14 5EG Lead Inspector Mrs Caroline Roberts Announced Inspection 12th January 2006 09:30 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 Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 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 Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Willows Care Centre Address Heathercroft Great Linford Milton Keynes Buckinghamshire MK14 5EG 01908 679505 01908 395232 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) Excel Care Holdings plc Ms Jacqueline Ann Blease Care Home 116 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (43) of places The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 (four) Step-up beds on the nursing unit The person(s) registered must satisfy themselves that the home can meet the care needs of any person admitted prior to said person`s admission. That the home is registered to provide Nursing Care for 30 (thirty) service users. 17th November 2005 2. Date of last inspection Brief Description of the Service: The Willows care home is a residential home with nursing that is registered to accommodate 116 residents over the age of 65 years. Categories of registration include: Dementia care 43 Frail elderly 43 Nursing 30 The home is situated in the Great Linford area of Milton Keynes close to shops and transport links to the city centre. The building is set over three floors and has three shaft lifts to enable resident’s access to upper floors. All rooms are single with ensuite facilities; the home has ample communal space. CCTV is provided in the entrance area. Ample car parking facilities are available. Excelcare runs the home and the responsible individual is Mrs Diane Jay. The home has two managers Ms Jackie Blease registered general manager, and Mrs Tracey Davies care manager. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Each care home that is registered with the Commission for Social Care Inspection, receives one announced and one unannounced inspection each year and further additional visits as necessary. All inspections, both announced and unannounced are followed by a written report, which eventually become public documents. It is a requirement that inspection reports are made available within the home. This inspection was announced and took place on the 12th January 2006. The inspectors present were Mrs Caroline Roberts (Lead Inspector) and Mr Guy Horwood. This inspection consisted of meeting with Residents and staff, viewing records and documents pertaining to the provision of care and the running of the home. The Inspectors found staff polite, helpful and welcoming, and would like to thank them for their co-operation and assistance throughout the course of the inspection. The inspectors met and discussed the inspection findings with the managers and regional manager before leaving. What the service does well: The home has a detailed “welcome and information pack” for prospective new residents, and this enables people to make informed decisions about the possibility of going into the home. The building is well maintained, and is attractively presented. The maintenance team and housekeepers work hard to keep the premises clean and well decorated. There were no offensive smells anywhere in the building. The general manager ensures that the inspector is kept informed of any significant changes in the home; and events, incidents and complaints. All residents have an individual plan of care, which supports staff to implement appropriate care in a manner preferred by the resident. Personal care is implemented in a manner that ensures the privacy and dignity of residents is maintained. Staff have a clear understanding of individual residents needs, receiving additional training and support as needed to fulfil their roles. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 6 The staff team are dedicated and committed to providing a professional service. 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 Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 8 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 Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 9 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): 3,4,6 The admission process is well managed with residents and their representatives being provided with clear information regarding the home and ability to make pre-admission visits. EVIDENCE: The registered manager’s undertake a full care needs assessment for each prospective resident prior to offering a place at the home. The assessment covers all aspects of care needs including personal, emotional and social needs. Assessments seen for three residents who had recently been admitted to the home were good and contained details of the resident’s past medical history, medication and history of falls. Relatives are encouraged to participate in the assessment process and relevant information from the care managers and health professionals is included in the completed report. The full care assessment forms the basis for the individual care plans. The registered general manager has experience in providing care for people over 65 years and those over 65 with dementia. Ms Blease holds the The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 10 Registered Managers Award. The registered nurse manager has many years experience of providing nursing to people over 65 years and is hoping to commence her registered Managers award within the next couple of months. The home has a stable workforce with new staff being recruited to ensure the needs of the increasing number of residents can be met. Staff at the home receive training in all aspects of care as well as the mandatory training. The home is registered for four step up beds; this provision has not yet been established and will be monitored at the next inspection. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 11 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 People, who use this service can expect to be treated with respect, have their needs identified in their care plan and met. Medication is not handled in a safe and responsible manner throughout the home, with some staff failing to adhere to policies and guidelines for the safe handling, administration and disposal of medicines. Through staff actions or omissions in relation to medication, residents may be placed at risk of harm. EVIDENCE: Care plans were sampled for five residents from the nursing unit. Preadmission assessments are followed up with detailed nursing assessments on admission. Care plans are developed from these assessments, these incorporate plans for personal hygiene, mobility, skin integrity and pressure area care, medication, nutrition, breathing, continence, elimination, pain and sleeping. They are backed up by weight charts (monthly weights) and nutritional risk assessments; falls risk assessments; epilepsy/diabetic control charts; wound care (with body maps), and other plans as indicated. Three care plans were viewed from the frail elderly group the plans were good and provided clear information for staff on the care needs of the residents and The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 12 the actions required to meet those needs. Risk assessments, including assessments for mobility, nutrition and pressure areas were contained in the care plans. The documents showed evidence of monthly review. Residents being cared for in bed had turning charts in place, no evidence of fluid balance charts being used was seen by the inspectors. Care plans indicated that advice was sought from GP’s and other health care professionals as required by residents. Daily reports are written at the end of each shift by the nurse on duty, it is recommended that the daily report be completed by the care staff who have given personal care, and that they are then countersigned by the nurse on duty – who can add extra nursing information. It is also recommended that a separate sheet is introduced to the care plan to record details of any advice/visit from a Health care professional such as Physiotherapist, community Psychiatric Nurse, Chiropodist or hospital clinics, this would also include directions given by doctors, and changes in medication. This information should be retained within the care plan. The receipt, storage, recording and handling of medicines was inspected on two units within the home – one unit providing personal care only, and one providing care with nursing. Both units possessed lockable storage rooms for medicines. These rooms were warm and it is recommended that the temperature should be monitored to ensure medicines are stored at the appropriate temperature. The unit providing personal care had suitable storage to manage the amount of medication held, (2 lockable trolleys, a lockable cabinet and a wall mounted secure cabinet for controlled drugs). The nursing unit possessed only one trolley and a secure cabinet for the storage of controlled drugs. Stock medication was held in plastic boxes on the floor of the medicines storeroom, and the medication trolley was crowded and difficult to access without first taking out other medication containers. Medication received onto the nursing unit is recorded and stored by a nonnurse member of care staff. All other recording and administration of medicines is performed by qualified nurses. Medication stored in the fridge included insulin and eye drops. On the nursing unit staff had failed to consistently record the date of opening on eye drops with a short “use by” shelf life. Medication Administration Records, (MAR), were viewed. Mar charts viewed on the residential unit were up to date, complete and well maintained. On the nursing unit, however, MAR charts contained unexplained gaps and were The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 13 poorly maintained. On both units MAR charts were found to contain handwritten directions and changes to printed prescriptions, which had been entered by members of staff. Upon requesting evidence to support the changes made to these charts, (e.g., copies of original prescriptions), none could be provided. Staff members responsible for handwritten entries had not signed where they had made changes. On the nursing unit a medication cassette was found to contain medicines that had been signed as given on the corresponding MAR. Upon questioning the nurse responsible for one of these incidents, no explanation could be offered to justify these findings. A similar episode where an agency nurse had been responsible for signing medicines as given but not to have actually given the medicines had been noted by a nurse, yet no investigation or remedial action into this had been undertaken. Medication practices and records on the residential unit were said to be audited by senior care staff on a regular basis, however this was not the case on the nursing unit. On the residential unit wasted medication is stored in a labelled envelope until collection by the pharmacist. On the nursing unit the Clinical Manager stated that wasted meds are disposed of down drains. This practice does not follow good practice guidelines and current legislation, and the manager was directed to contact the local pharmacy to acquire a suitable receptacle for the disposal of medicines. The manager contacted the pharmacy promptly to obtain a suitable waste bin for medicines. Medication practices on the residential unit were assessed as mostly sound with good record keeping, handling and administration apparent, and staff able to demonstrate a sound knowledge of their responsibilities and accountability. Medication practices conducted by trained nurses on the nursing unit were assessed as poor, a risk to the well being of residents, and not befitting what is expected of trained nurses. Trained nurses working on the nursing unit would do well to take note of the practice conducted by their non-nurse colleagues on the residential unit in order to reflect on their professional accountability and practice in relation to the handling of medicines. Staff were observed knocking on doors before entering rooms. Residents were assisted with their meals sensitively and conversation between residents and staff was relevant and caring. Staff responded to any request for help promptly and willingly. Residents and a relative stated that care staff treat residents with respect, and are careful to retain their dignity. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 14 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, People who use this service can expect to be given choice about the way they spend their time and be encouraged to maintain contact with family, friends and the community if they wish. They can also expect to have a well balanced diet. EVIDENCE: Throughout the day residents were observed in all areas of the home and staff were overheard asking people which room they wanted to go to. The home has it’s own cinema room which once fully equipped and operational will no doubt be a popular area within the home. Each floor of the home has activity co-ordinator hours allocated; recruitment for the vacant hours is ongoing. One activity co-ordinator was observed providing a small group activity on the dementia care group. Family and visitors are welcome at any time and during the day were observed in the lounges and resident’s bedrooms at the choice of the resident they were visiting. Details of the next of kin and contact numbers were recorded in the all the files seen. The menu’s supplied with the pre-inspection questionnaire looked varied and well balanced. The main meal of the day offered a choice of two dishes. The The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 15 meal served on the day of inspection was appetising and hot. The chef confirmed that fresh fruit and vegetables are used. Freshly baked cakes are offered at teatime each day. All of the residents spoken with talked about the good quality of the food. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 16 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 The home has a satisfactory complaints procedure, which is accessible for anyone entering the home. It is apparent that complaints are listened to and acted upon within agreed time frames. Staff showed good understanding of the prevention of adult abuse, and adult protection protocol. EVIDENCE: The home has a complaints policy that is accessible to residents and visitors. One visitor said they would go directly to the manager if they had any concerns and they named the manager. The complaints log was seen and contained details of three complaints received. One complaint dated 07/12/05 referred to a lack of staff on the nursing floor, and only having one hoist. At the time this complaint was made the home only had 12 residents in occupancy on the nursing floor with one hoist. A response from the organisation stated that as the numbers increase extra staff would be provided as will an additional hoist. It was very disappointing to note that on the day of inspection the nursing group still only had one hoist and the staffing levels remained unchanged despite occupancy of twenty residents. An immediate requirement was served (please refer to standard 27). An additional hoist had been ordered and the home was awaiting delivery, the regional manager made arrangements for one to be obtained from another home to be used until delivery of the new hoist, this was done immediately. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 17 The other two complaints received both had letters back to the complainants; no other information was available in the form of an investigation. The Commission received one written complaint prior to the inspection, during the inspection this was discussed with the Regional Manager who agreed to meet the complainants and investigate the complaint fully. The training records of the staff seen contained evidence that Protection of Vulnerable Adults (POVA) training had been done and more projected dates were available to ensure all staff undertake this training. Ancillary staff are invited to any training-taking place at the home, the laundry assistant confirmed this to the inspectors. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 18 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 The home is attractively presented and well maintained, providing a good venue for residents to live in. Suitable equipment is in place to enable residents to access different areas, and to promote their well being. Furniture and fittings are of a good standard, and good laundry facilities ensure that resident’s clothes are cared for properly. EVIDENCE: The home is situated in a suitably quiet area, and as a purpose built unit, has been designed to meet the needs of older people. The home has two large passenger lifts for easy access to all floors, and corridors are wide, and easy for people in wheelchairs to use. All of the bedrooms are for single use, and have en-suite facilities. Each bedroom has a locked drawer for any personal items, and doors can be locked if requested. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 19 Each group has a bathroom, which is fitted with disabled bathing facilities and grab rails. All six groups have a lounge/diner, and these had comfortable armchairs, and tables and chairs for mealtimes. They were laid out in a style, which looked, informal, and allowed for different grouping of residents. There is a large conservatory on the ground floor and the cinema room. The home has a large laundry room on the ground floor; dirty clothing is put into linen sacks and sent to the laundry, a large amount of black plastic bags were also being used as a temporary measure as a number of linen sacks were awaiting delivery. Soiled items are put in red alginate bags, and these are washed on sluice programmes before normal washes on the machines. A laundry person is employed each day, and the laundry was very tidy and organised. The home was generally clean, which is a credit to the housekeeping staff. It was noticed that the windows to the home were still covered in building dust and prevented residents from enjoying the view of the gardens; a requirement is served that all of the windows be cleaned inside and out. It was also noted that in some of the lounge/dining areas paint splashes are still evident on the tiled floors the manager agreed to arrange for the maintenance team to undertake the task of cleaning this immediately. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 20 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 Staffing arrangements provide for a suitable mixture of qualified nurses, care staff, administrative staff, domestic, catering, activities and maintenance staff. Staffing levels on the frail elderly and dementia care group appeared satisfactory for the level of need. Staffing levels on the nursing group need to be kept under review to ensure that residents needs can be fully met. There is a good rapport between staff, with most respecting and recognising each other’s roles and responsibilities. Residents are protected by the homes recruitment policies and procedures. EVIDENCE: There is a recorded staff rota displaying which staff are on duty throughout the day and night. There is always a senior on each group and a nurse on the nursing unit. Staffing levels are currently: Four staff throughout the waking day on the dementia care group. Four staff in the morning and three in the afternoon on the frail elderly Four staff on the nursing group, 1 nurse and 3 carers. The above information was ascertained from the duty rotas and discussions with care staff. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 21 Nursing group At 10.45 am one resident was still waiting to be assisted with getting up, this resident informed the inspectors that she had not yet had her breakfast and was eager to be helped up. This information was passed on to the senior of the group who said that they were waiting for the hoist as it was still in use and they were busy, the nurse manager was then informed who went to see the resident. Another resident said that call bells were not always answered promptly because the staff were so busy. Staff were busy performing personal hygiene and daily living tasks with residents, no other interaction was noted during the inspection by staff with residents. Throughout the duration of the inspection the staff on the nursing group were busy, it appeared to the inspectors that the staff on this group lacked guidance and direction and would benefit from a more direct leadership. An immediate requirement was served that throughout the waking day the staffing on the nursing group should be a 1 nurse and 4 care staff. This was acted on immediately by the home. A requirement is served that the nurse manager needs to take a more active role on the nursing group to promote, cascade and monitor practice. Observations of the frail elderly and dementia care groups showed an organised team of carers who were clearly able to answer all questions posed. All residents looked well cared for, and interaction between carers and residents was noted on all visits to these groups. Four staff files were viewed during the inspection and included the documentation required to ensure that the homes recruitment procedures are sufficient to protect residents. They also contained evidence of induction training and certificates of training courses attended. The manager has not yet developed individual training plans for all staff to ensure they receive necessary training. However, this was discussed and the manager hopes to collate a spreadsheet, which will list all mandatory training and highlight renewal dates. This will be further assessed at the next inspection. Staff spoken with confirmed they have received training in Moving and Handling, Health and Safety, First Aid, Medication and Fire prevention. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 22 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 People who use this service can expect that the management of the home is positive and open. Residents are able to voice their opinions about the home, and their records are stored confidentially. EVIDENCE: Both of the managers are available to staff and residents alike on a daily basis. They are committed to improving care. Improvements in care planning have been ongoing and an audit of the care takes place regularly with the key worker. The clinical manager is responsible for the nursing unit, which did not appear to be functioning at the same level as the other units in the home. The inspectors are aware that the clinical manager has been undertaking a lot of assessments and that this position is relatively new to her however, she need The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 23 to focus her time into providing this unit with direct leadership and management. The Organisation has recently implemented an audit process, which yet has to be conducted at this home. Managers from this region operate out of hour’s audits, evidence of which was seen by the inspectors. Relative and resident satisfaction questionnaires are sent out twice yearly. The home does not manage any of the resident’s finances. The general manager readily produced all records and policies requested for inspection. Staff files were kept locked up but policies and procedures were available for staff to access. The kitchen was clean and tidy. Records were kept of temperatures of refrigeration and freezers and these showed they were within the safe range for food storage. Food stored was labelled and dated. All chemicals in the kitchen area were stored correctly according to COSHH guidelines. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 24 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 x x 3 3 x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 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 2 17 x 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 25 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. 1 Standard OP27 Regulation 18(1) Requirement An immediate requirement was served on the day of inspection that staffing levels on the nursing group are increased by one carer throughout the waking day. It is required that the nurse manager base herself on the nursing unit, to ensure that practices are improved and that the staff benefit from direct leadership and guidance. The regional manager, who in turn should update the inspector, should review this period of direct leadership after one month. All of the windows inside and out should be cleaned. The unit providing nursing care is to be provided with storage facilities for medicines equivalent to the non-nursing unit inspected. Where staff enter hand written instructions as to the administration of medicines in a MAR sheet, a copy of the original prescription must be held with DS0000065320.V268599.R01.S.doc Timescale for action 13/01/06 2 OP31 10(1), 12(1), 18(1) 31/01/06 3 4 OP19 OP9 23(2) 13(2) 01/03/06 01/04/06 5 OP9 13(2) 01/04/06 The Willows Care Centre Version 5.0 Page 26 6 OP9 13(3) 7 OP9 13(3) the MAR sheet as evidence of the transcribed instructions. The Clinical Manager is to 01/03/06 conduct weekly medication audits on the nursing unit in order to monitor, support and supervise the medication practices of nursing staff. For reasons of consistency and 01/03/06 accountability, qualified nurses must be responsible for the receipt, recording, handling, storage, administration and disposal of medicines on the nursing unit. 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 OP9 Good Practice Recommendations The temperature in medication store rooms should be monitored to ensure medicines are stored within their defined temperature ranges. The Willows Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Care Centre DS0000065320.V268599.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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