Inspection on 02/04/08 for The Willows Care Centre

This inspection was carried out on 2nd April 2008.

CSCI found this care home to be providing an Adequate service.

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 12/10/07

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 Mrs Carole Burgess Unannounced Inspection 2nd April 2008 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.V361740.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.V361740.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.V361740.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. 12th October 2007 Date of last inspection Brief Description of the Service: The Willows Care Centre is a purpose built home situated in the centre of Shepshed. It can provide care for up to sixty older people with a range of needs including physical disabilities. A registered nurse is on duty in the home at all times. Accommodation is provided on two floors accessible by a passenger lift. There is a large sitting/dining room and activities room on the ground floor and a number of smaller sitting rooms on both the ground and first floor. There are a small number of double rooms and some rooms have en suite facilities. There are specialised bathing facilities, with aids and adaptations fitted throughout the home. The home is set in its own gardens with seating available for general use. 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 Statement of Purpose, Service Users Guide & Inspection Report are available on request (these provide information on how the home is organised and what services they provide). The Statement of Purpose and Residents’ Guide are provided for all new residents. A copy of the Commission of Social Care Inspection report is available and is displayed in the foyer of the home. At the time of the inspection the weekly fees were £388 to £875 depending on care needs. There are additional costs for individual expenditure such as hairdressing, newspapers etc. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. The site visit was unannounced and took place over seven hours. The inspection was a key inspection and reviewed the progress made in meeting the requirements and recommendation following the last inspection in October 2007, when the home was rated 0 stars. The Inspector selected three residents and tracked the care they received through a review of their records, discussion with them (where possible), other residents, relatives, the care staff, and observation of care practices. The Inspector spoke with staff members regarding training and support. Planning for the Inspection included assessing notifications of significant events sent to the CSCI by the home. The Registered Provider (a person registered with the CSCI), and other staff spoken with were constructive and helpful during the inspection. What the service does well: Interventions for potential healthcare emergencies were well documented in the care plans. Staff were observed to interact well with residents. The home was clean, pleasant and homely. A variety of activities were on offer should residents choose to join in. A wholesome and appealing diet was on offer and all but one resident spoken with said that the food was very good. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Requirements: (what the home must do to improve the service) Information gained from the initial assessments of residents’ needs must be implemented incorporated into the plan of care and implemented to ensure that these needs are fully met. Care practices must be developed to ensure that residents 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. Staff must receive training in mandatory areas to ensure that all staff have the required knowledge and skills to meet residents’ needs. Management must communicate a clear sense of direction and leadership, which staff understand so that the aims and purpose of the home are met. The responsible person must address staff practices that do not meet with their policies and procedure and may put service users at potential risk. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 7 Recommendations: (what the home should do to improve the service). Needs assessment should contain more information about residents’ social interest, hobbies, religious and cultural needs to provide a more rounded, person centred approach to care planning. There should be a list of ‘homely’ remedies permitted by a GP to ensure that residents only receive approved medicines. Staff should be mindful that residents’ dignity is maintained during mealtimes, particularly by helping to feed residents in an unobtrusive manner. Staff should ensure individual choices and needs are actively supported so that residents are able to retain their independence. The presentation of soft diets should be agreed with the resident and any preferences should be documented in the residents care plan. All complaints should be promptly dealt with, whether verbal or written. Residents and/or relatives should be kept fully informed of actions and outcomes. Advocacy advice should be made available. Sufficient cleaning staff should be available to complete designated tasks, such as shampooing carpets, to ensure the control of infection. Management should ensure that staff disagreements are swiftly resolved and not allowed to affect residents’ care. The small amount of damage to the cupboard in the room identified to the manager should be repaired as soon as possible to ensure that the resident remains in a safe environment. Quality Questionnaires should be collated and actioned and written feedback provided in the Statement of Purpose and Service Users Guide to show that comments from residents and others help to improve the service. 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.V361740.R01.S.doc Version 5.2 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 DS0000001935.V361740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with good information about the home, and have their health, welfare and social care needs assessed, so that staff have sufficient information to enable them to meet the resident’s needs once they move into the home. EVIDENCE: The home provides prospective residents and their relatives with a Statement of Purpose and Service Users Guide (both give information about the home) to help them decide if the home is the right one for them. A copy of the Service The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 10 Users Guide is provided for residents in their own room, but was not available in some of the rooms that were checked during the inspection. The Statement Of Purpose and Service Users Guide is currently being updated, but the providers should be mindful to update contact details of the CSCI and not to include the name of the manager as the Registered Manager until this process has been fully approved by the CSCI. Copies of residents’ contracts are kept in the home in a separate file and residents, or their relatives, are provided with a copy. The three residents’ care plans reviewed contained a pre-admission assessment to show that the home could meet their specific health, welfare, and social care needs. It included personal details, relative and GP contact numbers, a past and present medical history, current health care requirements and medications. The pre-assessment could be more detailed in respect of personal preferences, social interests and hobbies to ensure that the home could meet all of a prospective resident’s needs and provide a more person centred approach. The home does not provide intermediate care. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although detailed, care plans lacked clarity, resulting in some aspects of residents’ health, personal and/or social care needs being missed or overlooked. EVIDENCE: Residents’ care plans provide nurses and carers with detailed information about the health and personal care needs of the residents. However, due to the complexity of the care plans important information is sometimes overlooked: for example, a resident who had a detailed nutritional assessment and was assessed as high risk and had been regularly weighed, had not received a food supplement which had been identified in the initial plan of The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 12 care; also personal care records, kept in residents’ rooms, to show that care such as assistance with washing, had not always been completed. Therefore it was difficult to assess if essential, basic care had been provided. In addition, there was little information about residents’ personal preference and how these would be met. Two residents said that they would like more baths/showers. They both said they were assisted to bathe/shower once a week but would like this to happen at least twice a week. Both residents said that prior to admission they were used to bathing or showering daily. This was not reflected in their plan of care. However, the care plans relating to health and medical issues were detailed and provided clear guidance for staff to address specific areas of concern such as the management and observation of residents prescribed digitalis (a medication to manage heart conditions), and how to monitor and manage symptoms of stroke to ensure a prompt response should concerns arise. Contact with healthcare professionals such as GP’s, District Nurses, hospitals and Podiatrists were recorded to ensure that healthcare needs and treatments were addressed. Care plans had been signed by the resident and/or their representatives to show that residents and/or their relatives were involved in and agreed with their personal plan of care. A visitor said that s/he had been consulted about the plan of care for their relative and that s/he attended the review meetings. The senior manager and home manager acknowledged that care plans required improvement to give clearer information for staff. They have started to revise all residents care plans. This will provide a greater focus away from a taskorientated approach to more person centred care for the residents. Medication policies and procedures were satisfactory. Only nurses and senior carers, who are trained to do so, administer medication. This ensures that residents receive their medication safely and as prescribed. It was noted that a resident had been provided with ‘over–the–counter’ eye drops by a relative, as recommended by the visiting optician. These and any other ‘homely’ remedies should be discussed with and agreed by the residents GP, with appropriate records maintained to ensure the safety of the resident. Observation during the inspection showed that staff had a good awareness of how to protect residents privacy and dignity. However, one member of staff was seen to be standing up feeding a resident at lunchtime rather than sitting unobtrusively at their side. Nevertheless, staff spoke to residents and visitors in a respectful, friendly, quiet and helpful way. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 13 A visiting GP said that general care was satisfactory and staff made appropriate referrals to the local health centre on behalf of residents. However, he felt that residents should have end of life care plans, discussed and agreed with the GP and relatives to stop unnecessary interventions and hospital admissions, and allow residents to remain in the home during the final days of their lives if this was their wish. The manager said that she was implementing new procedures and care plans using the Gold Standard Framework to ensure improved end of life care for residents. Five residents, and a relative, spoken with during the inspection said that staff were generally caring, but there were times when they felt rushed, such as when being helped to wash and dress in the morning; that staff were not always conscientious in completing care charts to show that care had been given; and a number of comments indicated that staff’s personal disagreements spilt over, affecting the care of the residents. This is unacceptable and must be addressed by management. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff work to ensure that residents experience a safe, stimulating and homely life style. However, more effort should be made to ensure the prevision of individualised care, which recognises and supports personal preferences. EVIDENCE: There is a full-time activities organiser who offers a programme of activities such as craft sessions, movement to music, one-to-one time, trips out, hand and nail care, foot spa sessions and general entertainment. There is a notice board in the foyer that shows all the activities on offer, both in written and pictorial format, so that residents can choose what they would like to do. Information regarding residents’ past and present hobbies and social activity preferences and activities are recorded in their plan of care but these could be improved to provide a more rounded picture of what activities residents The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 15 preferred, and responded to, especially for those residents with a degree of memory loss. Residents said that they were able to have visitors at any time and a number of people came to visit during the course of the inspection. Staff support residents with making choices in their everyday life. All residents spoken with said they got up and went to bed when they wished, were able to choose what they wanted for their meals and take breakfast when they wished, and were well supported by caring staff. However, one resident said that s/he had, on a number of occasions, asked about batteries for a wristwatch and electric toothbrush, but was still waiting. S/he also said that s/he did not like the jogging trousers that s/he had on and was used to something smarter. This was discussed with the manager so that these issues would be addressed. Such details are important to residents and attention to them can either add or detract from the quality of life that they are entitled to enjoy. All meals were prepared in the home’s kitchen by the chef. A cooked breakfast was available every day if required. There were choices at all main meal times. Drinks, snacks and fruit were available throughout the day. Special diets such as diabetic and soft diets were catered for. Residents were weighed on admission, and regularly thereafter as necessary, and had a nutritional assessment in their care plan to ensure that their dietary needs were met (also see Health & Personal Care). The food provided for lunch looked nutritious, well presented and residents who required help with feeding were given this in an unhurried manner. However, very soft diets were mixed together and looked brown and unappetising. Unless this is the preference of the resident (which should be recorded in their care plan) food whenever possible should be kept separate on the plate so that the meal looks as normal and appetising as possible. Although one resident said that the food was poor all other residents spoken with said the food was very good and that choice and personal preferences were catered for. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints could be improved but the home’s policies and procedures do protect residents from abuse. EVIDENCE: The CSCI has not received any formal complaints about the service since the last inspection but are aware of a number of concerns and complaints made to the manager and social services about the standard of care for some residents in the home. This is being closely monitored to ensure that these concerns are addressed, standards improve and satisfactory outcomes are achieved. Residents’ and staff comments showed that people feel that they could discuss concerns with the manager and staff. However, a relative said that appropriate feedback was not always provided to ensure that they were satisfied with the outcome after a concern had been being raised. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 17 Information regarding advocacy services was not available. It is recommended that this should be made available in the main foyer area for residents and relatives who may require independent support and advice. The home’s complaints process reflects the local agreed procedures for Safeguarding Adults ‘No Secrets’ policies. Staff were able to show that they were aware of the correct procedures to follow to ensure the safety of the residents. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of accommodation is clean and provides residents with a pleasant and homely environment. EVIDENCE: The home was clean, and warm and maintained with adaptations to suit residents’ specific needs. It is decorated and furnished to a good standard that creates a comfortable environment for the residents. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 19 Some residents’ rooms have en-suite facilities, all have a ‘nurse call’, and the rooms inspected were clean. Residents were able to bring items of their own furniture and possessions with them to personalise their rooms. Residents’ rooms were well personalised, which made them look homely and comfortable. There are sufficient additional lavatories, bathing and assisted bathing facilities. The manager said that there was a continuing programme to deal with all maintenance and refurbishment issues and there is a maintenance person to ensure that day-to-day repairs etc are quickly dealt with. Two cleaners were employed, each cleaning one floor of the home. A comment was made that sometimes there was only one cleaner on duty; it was then difficult to maintain standards and sometimes thing were left, such as shampooing carpets. The manager should closely monitor this, to ensure that the required standards are maintained at all times, so that residents are protected from unnecessary infections. Residents commented that the home was kept clean and tidy. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 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. 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 this service. Staff at the home are trained and sufficient in number to meet the current residents’ needs. EVIDENCE: The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 21 There were 43 residents at the time of the inspection, 13 for whom required nursing care. Staffing levels, at the point of inspection, were in line with those suggested by the Department of Health Residential Forum Guidelines and were sufficient to meet the current residents’ needs. During the day there were eight staff, including ancillary staff such as administrative staff, cooks and cleaners, and at night there were four staff: there was always a trained nurse on duty. Although the home has had some staffing problems staff, residents and a relative said that there usually seemed sufficient staff on duty now. Three staff files were checked during the inspection and showed that there was a satisfactory recruitment process to ensure that residents are well protected. New staff carry out an induction programme and a nurse who was new to the home said that she had commenced an induction programme and was well supported by management. Not all staff had received all of the mandatory training, but the manager had a training matrix to ensure all staff training needs were identified and updated and additional updates were in progress. All staff will undertake training in specific areas such as fire training, first aid, moving and handling, food safety, infection control, and safeguarding adults. The manager said that nine or more of the care staff had completed National Vocational Qualification (NVQ) in Care, Level 2/3 and that a number of other care staff were undertaking or just completing NVQ’s. This and the training matrix should ensure that staff have the necessary skills to give safe care to the residents. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager, who is fairly new in post, provides an adequate standard of leadership for staff but needs to build upon all of the work in progress to improve service provision, especially in relation to ensuring clear lines of responsibility and accountability. EVIDENCE: The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 23 The Providers have appointed a new manager and deputy manager who work in a supervisory and management role in addition to nursing and care staff numbers. An operations manager is currently supporting the service. The new manager is in the process of applying for registration with the CSCI, which ensures that she has the necessary skills and is ‘fit’ to manage a care home. The information provided to the Commission prior to the visit stated that staff and residents meetings are held on a regular basis and regular audits take place to monitor the quality of the service. The manager said that specific quality questionnaires had started to be sent to residents and relatives and these would be collated at a later date. Information received should be collated, actioned and written feedback provided in the Statement of Purpose and Service Users Guide to show how comments from residents and others have helped to improve the service. Staff have not been regularly supervised by the managers and senior nurses in performing their nursing and care tasks. The current manager is in the process of ensuring that all staff receive annual appraisals and supervision (a regular review of staff’s personal and training needs in relation to their work). The implementation of the training matrix, and regular, recorded supervision, should ensure that staff have their training needs identified and that they have the necessary skills to provide a good service for the residents. Health and Safety Policy and Procedures, such as regular recorded fire drills, fire alarm tests and regular equipment maintenance had been completed and showed that the manager was mindful of her responsibilities to make sure that residents live in a safe environment. However, during the tour of the home it was noted that a cupboard in a resident’s room was damaged and could potentially put the resident at risk. This was identified to the manager to ensure that it would be repaired. Residents’ finances, although pooled, appear to be appropriately managed and there was a system in place for two members of staff to check and sign to confirm that all was in order. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 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 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Information gained within the initial assessments of residents’ needs must be utilised within the plan of care to ensure that their needs are fully met. (This is an outstanding requirement from 12/12/07 but the revision of care plans to address this is in progress) 2. OP10 12(2,3) Practices must be developed to ensure that residents 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. (This is an outstanding requirement from 12/12/07 but the revision of care plans to address this is in progress) 3. OP30 18(1,c,i) Staff must receive training in mandatory areas to ensure that all staff have the required knowledge and skills to meet DS0000001935.V361740.R01.S.doc Timescale for action 02/06/08 02/06/08 02/06/08 The Willows Care Centre Version 5.2 Page 26 residents’ needs. (This is an outstanding requirement from 12/01/08 but the revision of staff training is in progress) 4. OP32 24 The responsible person must ensure that management communicates a clear sense of direction and leadership, which staff and residents understand and are able to relate to the aims and purpose of the home. The responsible person must address staff practices that do not meet with their policies and procedure and may put service users at potential risk. (This is an outstanding requirement from 09/11/09 but the revision of lines of accountability are in progress) 02/05/08 5. OP38 12(1,a, b) (13,4,c) 02/06/08 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 OP3 Good Practice Recommendations It is recommended that the needs assessment should contain more information about residents’ social interest, hobbies, religious and cultural needs to provide a more rounded, person centred approach to care planning. It is recommended that there should be a list of ‘homely’ remedies approved by a GP. It is recommended that staff ensure that residents’ dignity is maintained during mealtimes, particularly by helping to feed residents in an unobtrusive manner. DS0000001935.V361740.R01.S.doc Version 5.2 Page 27 2. 3. OP9 OP10 The Willows Care Centre 4. OP14 5. 6. 7. 8. 9. OP15 OP16 OP26 OP36 OP38 10. OP38 It is recommended that staff ensure individual choices and needs are actively supported so that residents are able to retain their independence – for example, by replacing batteries in watches and electric toothbrushes, and by ensuring that residents wear their preferred type of clothing. It is recommended that the presentation of soft diets be agreed with residents and any preferences are documented in the residents care plan. It is recommended that all complaints are promptly dealt with, and that advocacy advice is made available for residents. It is recommended that there are sufficient cleaners at all times to complete designated tasks, such as shampooing carpets, to ensure the control of infection. It is recommended that management ensure that staff disagreements are swiftly resolved and not allowed to affect residents’ care. It is recommended that the small amount of damage to the cupboard in the room identified be repaired as soon as possible to ensure that the resident remains in a safe environment. It is recommended that Quality Questionnaires are collated and actioned and written feedback provided in the Statement of Purpose and Service Users Guide to show that comments from residents and others help to improve the service. The Willows Care Centre DS0000001935.V361740.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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