Inspection on 12/10/07 for The Willows Care Centre

This inspection was carried out on 12th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Care Centre 10/07/09

The Willows Care Centre 01/04/09

The Willows Care Centre 02/04/08

The Willows Care Centre 03/10/06

The Willows Care Centre 14/10/05

The Willows Care Centre 04/04/05

The Willows Care Centre 29/10/04

The Willows Care Centre 04/05/04

The Willows Care Centre 03/02/04

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 Care Centre 14 The Lant Shepshed Loughborough Leicestershire LE12 9PD Lead Inspector Karmon Hawley Unannounced Inspection 12th October 2007 10:00 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 DS0000001935.V351916.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 Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Care Centre Address 14 The Lant Shepshed Loughborough Leicestershire LE12 9PD 01509 650559 01509 650362 thewillowsnh@schealthcare.co.uk 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) Exceler Healthcare Services Limited Vacant. Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (25), Physical disability of places over 65 years of age (25), Terminally ill over 65 years of age (25) The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers. No one falling within categories PD, PD(E) or TI(E) may be admitted to the home when 25 persons of these categories/combined categories are already accommodated within the home. 3rd October 2006 Date of last inspection Brief Description of the Service: The Willows Care Centre is a purpose built home situated in the centre of Shepshed and within walking distance of the local amenities. The home is set in its own gardens with seating available for general use. Accommodation is provided on two floors accessible by a passenger lift. There is a large lounge/dining room on the ground floor and a number of smaller sitting rooms on both the ground and first floor. The home offers specialised bathing facilities, and aids and adaptations are fitted throughout the home. The home is accessible by public transport and is close to a number of public amenities such as the local library, churches and the community centre. The range of fees and additional information required is made available on enquiry. Fees range from £331.00 to £750.00 per week A copy of the Commission of Social Care Inspection report is available and is displayed in the foyer of the home. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken by an inspector reviewing all the previous inspection records available, looking at information provided by the manager about The Willows Care Centre and by undertaking a visit to the service with the inspector using a method called “case tracking.” “Case tracking” involves identifying individual service users who currently live at the home and tracking the experience of the care and support they have received during the time they have lived there. The inspector also checked that information provided by the manager matched individual experiences of the service user living at the home by talking with them and observing the care received. A number of records were not available for inspection, therefore information provided by the service prior to the visit has been utilised in this report as evidence. The service was short staffed on the day of the visit, which also had an affect on the findings detailed in the report. What the service does well: What has improved since the last inspection? What they could do better: Information gained within the initial assessments of service users needs must be utilised within the plan of care to ensure that their needs are fully met and service users are protected. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 6 When a service user experiences complex needs, plans of care and risk management plans must be in place to ensure that their needs are fully met and they are protected. All medications including creams must be signed for on the prescription sheets and stored in the appropriate manner. Practices must be developed to ensure that service users are enabled to make decisions with respect to their care and have their wishes and feelings taken into account to ensure that their dignity and rights are maintained. Systems must be in place to ensure that adequate staff are available and the skill mix is taken into consideration to ensure service users needs are met. Staff must receive training in compulsory areas to ensure that all staff have the required knowledge and skills to meet service users needs. Records must be available for inspection to demonstrate that the service can be monitored and it is working in line with the regulations, thus ensuring that service users health, safety and wellbeing are paramount and the service can be monitored appropriately. The responsible person must address staff practices that do not meet with their policies and procedure and may put service users at potential risk. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Willows Care Centre DS0000001935.V351916.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 Care Centre DS0000001935.V351916.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users know that their needs will be assessed before they move into the home and that the staff can meet these. The service does not offer intermediate care. EVIDENCE: Appropriately trained staff visit prospective service users in the community to carry out a preadmission assessment to ensure that the service is able to meet their needs. There was evidence of assessments taking place within those service users files seen. Prospective service users and their family may also visit the home and spend time there to see how the home is run before they make a decision to move in. One service user spoken with discussed how their relative had visited the home and had looked around before they moved in. Also available for new service users is an information booklet that outlines the facilities on offer both within the home and the local community. The service does not offer intermediate care. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users health and personal needs are not fully met due to the lack of care planning and staff availability. Service users are placed at a degree of risk due to the lack of risk assessments in place. Although service users feel that staff are respectful, development of understanding the need to maintain service users dignity and choices would enhance this. EVIDENCE: Service users undergo various assessments such as the activities of daily living, manual handling and nutritional needs. Information gained forms the plan of care. Plans of care were personalised and reflected service users preferences. A number of care plans where a service user had complex needs were in depth and covered all aspects of the care and support required. However on observing a recently admitted service user’s case file a thorough risk assessment for the use of bedrails and entrapment was not in place. Neither was a plan of care or risk assessment for diabetes mellitus to ensure their needs were met and they were protected. For another service user with diabetes mellitus a plan of care was in place that identified the risks of The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 10 hyperglycaemia (high blood sugar) and hypoglycaemia (low blood sugar) however it did not outline the emergency action that should be taken should this occur, or cover the specialist care one may require such as foot and nail care. Where a service user had been assessed as being at risk of choking, risk assessments were in place, however they did not outline the emergency action that staff must take should choking occur. One service user had been identified as being at risk of developing pressure sores in their assessment, however this information had not been utilised and no care plan in regard to management of this had been put into place to prevent pressure areas breaking down. Where plans of care identified that service users experienced pain and discomfort, brief plans of care with regard to administering pain relief were in place, however these did not cover other support that may be offered such as reassurance and assisting the service user to find a more comfortable position. Daily records were maintained which contained significant information, however within one plan it had been noted that a service user had swollen legs and a doctors visit was needed, however there was no evidence of follow up action taking place. staff spoken with were able to discuss service users needs and the support they required, however felt that they had not been able to offer quality care due to time restraints and staffing levels. Service users spoken with stated that staff were very kind and caring and their needs were met. There was evidence within service users files to show that they have access to services such as the doctor, district nurse, dentist, optician and other specialist services as required to ensure that their health care needs are met. On the day of the visit the in house ophthalmologist was visiting service users. During the brief tour of the home specialist equipment such as hoists, mattresses and cushions were in place. One service user discussed how comfortable their specialist chair was. Two service users spoken with said that they could see the doctor at any time they needed and one confirmed that they had seen the optician that morning. The lunchtime medication round was observed, demonstrating that staff follow the homes policies and procedures. Six members of staff have received training in the safe administration of medication and one member of staff spoken with confirmed this. The medication sheets were checked which showed that medication is signed into the building and all hand written entries are signed by two members of staff to show that these have been checked as correct. The requirement set at the previous inspection with regard to signing for prescription creams had not been met, this was discussed with the senior carer who explained that they were liaising with the pharmacy as some of the creams on the prescription were no longer in use. A strategy to ensure that medication records are always signed was discussed and the senior carer stated that they would implement this to ensure that the requirement would be met. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 11 Service users spoken with all spoke very highly of staff and stated that they felt that staff were respectful at all times. Within plans of care reference was made to ensuring that service users privacy and dignity was maintained at all times. Staff were observed to treat service users in a respectful manner however whilst the inspector was talking with a service user they were handed a beaker of tea by a staff member. The service user questioned what it was, to be informed that it was a beaker of tea, the service user then asked why they had been given it in a beaker as they normally had a cup. The staff member said that this was because the service user was not sat at a table and they may spill their drink, it was then suggested by the inspector that maybe we could move to a table so that the service user could have their usual cup. This practice affects service users dignity and reduces the opportunities for them to express choices in their every day life. The Willows Care Centre DS0000001935.V351916.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled to maintain contacts with their family and friends and use facilities in the local community if they wish. The menu offers service users a wholesome and appealing diet where choices are available. EVIDENCE: An activities coordinator is employed who offers activities such as bingo, trips out, hand and nail care, foot spa sessions and general entertainment on both a group and individual basis. Service user spoken with said, “I enjoy the activities and the trips out,” “I am knitting scarves at the moment for the old people,” and “I enjoy joining in the activities and the songs of praise” There is a notice board in the main entrance that shows all the activities on offer so that service users know when these are. To enable service users to maintain their faith, various clergy visit the home from the local community. There are no restrictions imposed upon visiting and visitors were seen to come and go throughout the day. Two visitors were spoken with who said that staff were very approachable and made them feel welcome at all times. One service user said, “I enjoy having visitors and I can see them in private if I wish,” and another said, “I have regular visitors and I often go out with them.” The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 13 Service users spoken with stated that they felt that their individual needs and choices were respected and they offered the following comments, “staff are goodness themselves, it is a wonderful place,” “I am settled and happy here,” “the staff are gems, I get on really well with them” and “ I am very happy here, settled and well looked after. Staff are very caring and we have a laugh.” Staff were able to discuss service users individual needs and how they support them in meeting these. A wholesome and appealing menu is on offer where choices are available at each meal. Specialist diets such as diabetic and liquidised are accommodated. One service user spoken with confirmed that they have a diabetic diet. During the lunch time meal service users were seen to have several choices available to them. Service users spoken with said, “the food is very good here and I get plenty to eat,” “the food is lovely, I can have anything I want,” and “ I have many ‘fads’ which the kitchen staff know about, they work around this and I am happy with what I have.” The Willows Care Centre DS0000001935.V351916.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and relevant others feel that staff listen to them and if they express any concerns these will be addressed. Further documentary evidence would demonstrate that service users are fully protected from abuse. EVIDENCE: The information received by the Commission outlined how complaints are dealt with and stated that 15 complaints had been received, 4 of which were upheld. Further information about complaints received was inaccessible as these were locked in the operational managers office. Staff spoken with were able to explain how they would deal with a complaint should one be received. All service users and the relatives spoken with spoke highly of the staff team and no complaints were expressed. The information sent to the Commission prior to the visit stated that all staff have the relevant pre-employment checks in place, however information with regards to staff Criminal Record Bureau checks was unavailable; therefore the inspector was unable to fully evidence if all staff employed have these in place. The information received by the Commission prior to the visit also stated that two referrals to the safeguarding adults team had been made, again information with regards to this was inaccessible. Staff spoken with were able to discuss the issues with regards to ensuring service users are protected, 27 members of staff have attended training in safeguarding adults and there was evidence available to show that further training had been arranged. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 15 The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable environment, which is homely and domestic in nature, however further understanding of infection control and the necessary procedures would enhance this and ensure service users are fully protected from infection. EVIDENCE: Routine maintenance continues to take place and the home was in a good state of repair. There are several seating areas around the home, which service users and relatives may access if they wish. A sensory garden has been developed for service users to enjoy. Domestic staff are employed to maintain the cleanliness of the home, all areas were clean and tidy with exception of the visitor and staff toilet. This became blocked, the cleaner was informed of this and a request to clean it made, however half an hour later this had not taken place, therefore this concern was relayed to the senior care staff member, who stated that they had also been The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 17 informed of the problem, it was requested that she asked the cleaner to deal with this problem; this was then actioned. No members of staff have undergone training in infection control, which is a concern due to the recent outbreaks of sickness that have occurred in the home. One relative spoken with said that the home was always kept clean and tidy. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although service users spoke highly of staff, they are not receiving a quality service and their needs are not fully met due to the staff availability and skill mix. Attention to staff training would ensure that all staff are fully trained and competent in their job roles. EVIDENCE: On the day of the visit the service was short staffed due to illness. The administrator said that the project manager had been contacted, however they were in a meeting; therefore a fax had been sent to inform them of the situation. There were three kitchen staff on duty and a breakfast assistant; one housekeeper, one registered nurse, one senior carer and three care assistants. Due to the lay out of the home three care assistants were working upstairs leaving one care assistant and the nurse downstairs. The nurse was busy attending to the administration of medication, the in-house optician visit and doctors visits, this subsequently left one care assistant to care for 17 high dependency service users. The off duty rota showed that staff had been short on several occasions and the duty rota did not accurately reflect the staff that were on duty that day. One member of staff who was off sick was still on the duty rota as being at work, also a staff member that was no longer employed had also been left on the duty rota, however this had been covered at a later date when the error was established. The registered nurse and the administrator stated that unfortunately there were seven members of staff off The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 19 on long-term sick leave and two off on the day of the visit, which was affecting the staffing levels on that day. They said that attempts were being made to recruit new members of staff. Relatives spoken with confirmed that they had been informed of this, but felt that is was weeks ago and it had not happen yet. Staff spoken with expressed that they were very busy and having to prioritorise care delivery, however one member of staff felt extremely distressed as they did not feel that they could offer a quality service. It was suggested by a member of staff that the staff team were feeling extremely tired due to the work load at present and staff covering more shifts than usual. It was also stated that there were concerns as staff were not able to follow company procedures such as not using the hoist alone, however staffing levels had prevented them from maintaining these practices, thus affecting the health and safety of both staff and service users. Staff were observed to be extremely busy which affected the quality of care service users received. The last service user came down for breakfast at eleven o clock, lunch being at one o’clock, there were 10 service users sitting at the breakfast tables at eleven and the majority of these remained there until lunch time. One service user was observed to fall out of their wheelchair; there were no care staff available. The inspector brought this incident to the attention of the breakfast assistant who informed the kitchen staff. A member of the kitchen staff called the care staff who attended to the service user, however one member of the kitchen staff assisted in this procedure which leaves a potential risk of cross infection occurring. One service user was seen to be lying in bed with their legs hanging over the bedrails for several hours; this could result in problems with circulation and skin integrity. Service users spoken with said they were looked after but there were not enough staff and they were very busy. To ensure new members of staff are aware of their roles and responsibilities they undergo an induction on commencement of their employment, due to staff files being unavailable this was unable to be fully evidenced. The information provided prior to the visit stated that 49 of staff had undergone the National Vocational Qualification in care (a nationally recognised work and theory based qualification) The information received by the Commission prior to the visit stated that all staff had undergone the required checks prior to employment, however staff records were not available for inspection. The administrator stated that these were locked in the operational managers office, thus the inspector was unable to fully evidence that service users were fully protected by the services recruitment policies and procedures. Staff personnel files and individual training records were not available for inspection, however a staff training matrix was displayed in the main entrance. The matrix demonstrated that whilst staff are working towards attending compulsory training there were deficits in the following areas: fire safety, health and safety, infection control and manual handling. There were notices on the training board that showed that further training in manual handling and The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 20 safeguarding adults had been arranged. Staff spoken with stated that the training on offer is improving. Service users spoken with all felt that staff were well trained to care for their needs. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. As vital records that must be available for inspection were not accessible there are concerns about the current systems of management for the service. Service users are placed at risk due to the lack of systems in place to deal with staff shortages, resulting in staff working alone and unable to follow the service’s policies and procedures. EVIDENCE: An operations manager is currently supporting the service until the new acting manager commences work. The notice board in the main entrance states when the acting manager is due to commence employment, to ensure that service users and relatives are aware of this. Not all staff spoken with currently felt supported by the management structure in place and they were looking forward to the new acting manager starting employment. No concerns were expressed from service users or relatives about the management of the home. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 22 The information provided to the Commission prior to the visit stated that staff and service user meetings are held on a regular basis and regular audits take place to monitor the quality of the service, however information with regard to quality assurance was not available as again this was locked in the operational managers office. Service users may have money kept in safe keeping in the administrators office should they wish. Four accounts were checked, all corresponded with the accounting sheet and receipts were available for transactions. Within one plan of care observed the financial arrangements for the service user were documented. One service user spoken with said that they can access their money when they want. The administrator confirmed this and stated that if any money was needed for a weekend this was usually prearranged. The information received by the Commission prior to the visit showed that routine maintenance and servicing such as the gas and electrics were taking place. The inspector requested to see the hoist certificate on the day of the visit, however this was unavailable. Only 15 members of staff out of 44 have received training in health and safety. The health, safety and welfare of service users was affected due to the staffing levels in the home on the day of the visit. Service users were left unsupervised for long periods of time and staff stated that they were unable to maintain the health and safety procedures for the use of the hoist. The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 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 2 3 X X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X 1 1 The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Information gained within the initial assessments of service users needs must be utilised within the plan of care to ensure that their needs are fully met and service users are protected. When a service user experiences complex needs, plans of care and risk management plans must be in place to ensure that their needs are fully met and they are protected. All medications including creams must be signed for on the prescription sheets and stored in the appropriate manner. This is an outstanding requirement from 31/12/06 and must be addressed. Practices must be developed to ensure that service users are enabled to make decisions with respect to their care and have their wishes and feelings taken into account to ensure that their dignity and rights are maintained. Systems must be in place to ensure that adequate staff are DS0000001935.V351916.R01.S.doc Timescale for action 12/12/07 2 OP7 13(4,c) 12/12/07 3 OP9 13 (2) 12/12/07 4 OP10 12(2,3) 12/11/07 5 OP27 18(1,a) 09/11/07 The Willows Care Centre Version 5.2 Page 25 6 OP30 18(1,c,i) 7 OP37 17 (3,b) 8 OP38 12(1,a,b) (13,4,c) available and the skill mix is taken into consideration to ensure service users needs are met. Staff must receive training in compulsory areas to ensure that all staff have the required knowledge and skills to meet service users needs. Records must be available for inspection to demonstrate that the service can be monitored and it is working in line with the regulations, thus ensuring that service users health, safety and wellbeing are paramount and the service can be monitored appropriately. The responsible person must address staff practices that do not meet with their policies and procedure and may put service users at potential risk. 12/01/08 09/11/09 09/11/09 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 Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows Care Centre DS0000001935.V351916.R01.S.doc Version 5.2 Page 27 - 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!