Inspection on 25/10/06 for The Willows Intermediate Care Service

This inspection was carried out on 25th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Intermediate Care... 28/12/05

The Willows Intermediate Care... 22/09/05

The Willows Intermediate Care... 23/03/05

The Willows Intermediate Care... 13/01/05

The Willows Intermediate Care... 08/03/04

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Willows Intermediate Care Service Ambergate Road Beechdale Estate Nottingham NG8 3GD Lead Inspector Rob Cooper Key Unannounced Inspection 25th October 2006 10:00 X10029.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 Intermediate Care Service DS0000037311.V317304.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 and Care Homes for Adults 18 – 65*. 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 Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Intermediate Care Service Address Ambergate Road Beechdale Estate Nottingham NG8 3GD 0115 9293861 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) Nottingham City Council Mr Stephen Upton Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Willows Intermediate Care Service is registered to provide personal care for male and female service users whose primary care needs fall within the following categories:Old age not falling within any other category (OP) over 50 years of age The maximum number of persons to be accommodated in The Willows Intermediate Care Service is 16 28th December 2005 2. Date of last inspection Brief Description of the Service: The Willows Resource Centre is a multifunctional complex situated in a residential area that has a high proportion of elderly residents. The complex is very close to a range of community facilities including a church, shops and a community centre. The complex offers a range of facilities to people aged fifty years and over. The Willows residential unit provides Intermediate care for up to sixteen people. It is owned by Nottinghamshire City Council Social Services and is run in partnership with Nottingham Health Authority. The residential unit is a single storey building with sixteen single bedrooms, none of which meet the National Minimum Standards size requirements. All bedrooms are well decorated and comfortably furnished. None of the bedrooms have en-suite facilities but there are sufficient toilets and bathrooms, conveniently located throughout the building. There is an inner courtyard garden, which has been well maintained and is accessible by all residents. Nottingham City Council are considering converting some beds from Intermediate care into assessment beds – this would mean that residents would stay for a short term period, and be assessed as to whether they need residential care, or could return to their homes. Fees: The fees at the Willows are assessed on an individual basis, and differ according to circumstances. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection – so that no one at The Willows knew that the inspection was going to take place. The inspection took approximately three hours through the middle of the day with one Inspector present. The method used to carry out the inspection was to send out a questionnaire, which asked questions about the service, to gather statistics, such as how many residents there are, the numbers of staff etc. In addition ten questionnaires were sent out to residents of the Willows to gain their views. This was followed with a visit to the Willows, where a method called case tracking was used; this involved identifying three residents and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was achieved by a partial tour of the Willows, looking at the activities on offer, and talking to residents, relatives and staff. As a result three service users were spoken with about the service they are receiving, two relatives, and three members of staff were spoken with to get their views on how resident’s needs are being met. Seven resident questionnaires were returned prior to the inspection. Stephen Upton the Registered Manager was present during the inspection and provided the information that was requested. This was a good inspection, and there were many examples of good practice seen, and examples of good experiences for residents identified. What the service does well: Residents at the Willows are well assessed before they move in, and once they have arrived, there is a good in-house assessment of their needs. The Willows provides an Intermediate Care service, and this is well resourced and staffed by different care professionals. The care planning process, particularly in relation to reviewing goals and needs is particularly effective. The Willows has a good medication procedure, which is designed to help individuals realise their independence, while retaining a good level of safety through assessment and re-assessment of resident’s abilities. The residents at the Willows say that the staff respect their privacy & dignity, and are kind and caring. There is a good range of activities available to residents, with staff available in the day centre to help where needed. The residents say that the meals provided are very good, and there is often a homemade option on the menu, and when available home grown vegetables. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 6 There is a good staff training programme, designed to help staff develop, and to give them the essential skills they need to do their jobs. The Manager of the Willows is suitably experienced and qualified What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 123&6 The quality outcome in this area is excellent. This judgement has been made using the available evidence including a visit to this service, and meeting with residents. Prospective residents at the Willows have the information they need to make an informed choice about where to live. Each resident has a written contract/ statement of terms and conditions with the Willows No resident moves into the Willows without having had their needs assessed, and been assured that these will be met. Residents assessed and referred solely for intermediate care, are helped to maximise their independence and return home. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 9 EVIDENCE: The Willows’ welcome pack was seen, which includes the statement of purpose and service user guide. This is a comprehensive document, which is full of useful information about the service, and contains all of the essential information required buy Care Homes Regulations. A copy is available in every bedroom, and several examples were seen. Two residents were asked if they had a copy of the welcome pack, and both said they did. As part of the case tracking process three resident’s files were seen, each file had a copy of the contract/ terms and conditions of residence within it. The files also contained detailed assessments carried out by health and social care professionals. These assessments included copies of the Shared Nottinghamshire Assessment Process (A SNAP), which is the preferred assessment tool for older people in Nottinghamshire. There were also risk assessments, Occupational Therapists assessments, Physiotherapists assessments and Nursing assessments. In addition the Willows have recently introduced a new care/goal plan summary sheet, to record the weekly multi-disciplinary meeting where an individual’s assessment of need is reviewed. This new summary sheet is written in plain English, and is an attempt to communicate with residents about their care needs, without lots of confusing medical jargon. The Willows have a number of designated intermediate care beds, where an individual is admitted on a short term basis (usually about 4-6 weeks) so that they can regain their confidence and skills to enable them to return home (usually after a stay in hospital) The focus of their stay will probably be on issues of mobility, using the stairs, self help skills such as bathing, or cooking. The residents staying in the intermediate care beds will have access to health care professionals, and there are nurses, physiotherapists and occupational therapists available to assist them. Currently the City Council is considering changing some of these beds to assessment beds – that is for individuals to be assessed as to whether they can return home, or need to move into full time residential care. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 The quality outcome in this area is excellent. This judgement has been made using the available evidence including a visit to this service, and meeting with residents. Resident’s health, personal and social needs are set out in an individual plan of care at the Willows. Resident’s health care needs are fully met. Residents at the Willows are protected by the policies and procedures in place for dealing with medicines. Residents at the Willows feel they are treated with respect and their right to privacy is respected. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three resident’s files were seen as part of the case tracking process, these were found to have a very clear plan of care, with individual goals and needs identified. The care plans are being reviewed on a regular basis, and with the introduction of the new weekly review, they are exceeding the standards. Within the three files there were clear and comprehensive health care notes, relating to the individual’s health care needs. Two residents were asked about their health, and both said that they had no worries at all. If they needed a doctor the staff would arrange for one to call, and they could see the doctor in private if they wished. The nature of Intermediate care is that many residents will be actively encouraged to take responsibility for their own medication – as when they return home, they will have to do this for themselves. As a result many of the residents at the Willows self-medicate. The Willows has a system of assessing residents where by they are observed, and supported through two levels. Each resident who does self-medicate has a risk assessment, and does not do so until the staff are confident they are safe. Some residents in the residential unit do not self-medicate, and an inspection of the storage of medication and the administration records showed that the system for medication is secure and safe. Two residents were asked if they felt that their privacy and dignity was upheld at the Willows, and both said they thought it was. One resident said: “The staff are excellent, first class, they really try to help you, and they are ever so kind.” The second resident commented: “They always knock on the door, and they ask rather than tell us what to do, I think it’s really very good.” One resident responded in their questionnaire with: “Oh yes, an efficient and very happy staff. Always helpful.” Observations of staff interactions with residents during the inspection were very positive, staff were indeed seen to be knocking on doors before entering, and when speaking with residents staff were seen to be respectful and polite. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 The quality outcome in this area is excellent. This judgement has been made using the available evidence including a visit to this service, and meeting with residents. Residents find that the lifestyle experienced at the Willows matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Residents at the Willows maintain contact with their family, friends and representatives and the join in the local community as they wish. Residents are helped to exercise choice and control over their lives. Residents receive a wholesome appealing balanced diet in pleasing surroundings at times that are convenient to them. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 13 EVIDENCE: During the course of the inspection the Willows was found to be very busy, with a lot of resident activity taking place. There is a small day centre on site, which residents can attend if they wish, and to which a number of service users come from the local community. The atmosphere among the residents and service users in the day centre was very good, with a number of activities going on, and everyone seeming to be having a very good time. There is a reminiscence corner where residents and service users have brought photos from home, which have been copied – showing their younger selves working, or attending memorable events. The manager explained how this was very popular, and a useful tool when talking to residents about their past. In the centre of the Willows is a small courtyard area, and two residents (and the manager) very proudly told me about the vegetables that had been grown through the summer – home grown tomatoes for example had made their way into salads produced by the kitchen. The Willows has an open door policy for relatives, and during the inspection a number of relatives were coming and going. Two relatives were spoken with during the inspection, they both said that they felt welcomed by the staff, and were very happy with the care that their relative was receiving. Visits tended to happen in the afternoon, although neither was aware of any time restrictions in relation to visiting, and had never encountered a problem. Three residents were asked about choice, and all three said that there was plenty. The most obvious was to talk about meals, and all three said there was always a choice, with one adding: “And if you don’t like that, they will make you something else like cheese on toast, or a sandwich or something.” Records seen within the kitchen showed that choice was available at all meals, and the choices that people had made had been recorded. In relation to bed times, and getting up in the morning, all three residents said that they tended to go to bed when they wanted to, and got up more or less the same. One resident said that he liked going to the day centre, while another said she did not. Both of these choices were accepted by the staff, and none of the residents said that they felt pressured. On the day of the inspection the first choice for lunch was steak and onion pie, during an inspection of the kitchen the cook was seen preparing the pastry, and said that wherever possible they preferred to make homemade pies, rather than having shop bought or frozen, the cook also said that the vegetables grown by the residents were most welcome, and had all been used in meals prepared in the kitchen. The steak and onion pie looked very appetising, and later three residents said how nice it was, and how much they had enjoyed it. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality outcome in this area is good. This judgement has been made using the available evidence including a visit to this service, and meeting with residents. Residents and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon at the Willows. Residents at the Willows are protected from abuse. EVIDENCE: Since the last inspection the Willows have received three formal complaints, inspection of the complaints records showed that each complaint had been dealt with in line with the Willows’ complaints procedure, and in a timely manner, with the outcome recorded. Two residents were asked about complaints, both said that if they were not happy they would talk to Stephen (the manager), one resident said: “He will sort it out.” Which I understood to be her confidence in the fact that her complaint would be listened to and taken seriously. Every resident has a copy of the complaints procedure, which is in the welcome pack. One relative was asked about complaints, they said that they The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 15 had seen the complaints procedure, and while she couldn’t remember what it said, she would look at it again if she wanted/needed to complain. A review of the staff training records showed that training for every member of staff in safeguarding adults, and the protection of vulnerable adults is booked for the 15th November. Staff awareness of the issues involved in abuse, will make abusive behaviour less likely, and should it occur, staff will know how to respond appropriately. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 23 & 26 The quality outcome in this area is good. This judgement has been made using the available evidence including a visit to this service, and meeting with residents. Residents at the Willows live in a safe, well-maintained environment. Resident’s own rooms suit their needs. The Willows is clean, pleasant and hygienic. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 17 EVIDENCE: A partial tour of the Willows showed it to be spacious, with plenty of communal areas, with good sitting areas outside. The fixtures and fittings were found to be of a good quality, and the building was generally in a good state of repair. Two residents were asked about the building, and both said that they found it comfortable, and gave them everything they would want. The bedrooms at the Willows are a little on the small side, and do not have any en-suite facilities. They are however quite comfortable, and both residents who were asked said they like their bedrooms, and thought that they had everything they needed in their bedrooms, although one added he thought his bed room was quite small. The resident’s stay at the Willows tends to be short-term, and therefore the bedroom size while not ideal, is also not a major issue. The Willows was found to be clean, tidy and fresh. Staff were seen cleaning various parts of the Willows during the inspection, and two residents when asked said they thought it was clean. The two relatives who were spoken with also said that it was always clean and tidy, and if ever there was a spillage the staff would quickly clean it up. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 The quality outcome in this area is excellent. This judgement has been made using the available evidence including a visit to this service, and meeting with residents. The numbers and skill mix of staff at the Willows meets the residents’ needs. Residents at the Willows are in safe hands at all times. Residents are supported and protected by the Willow’s recruitment policy and practices. Staff at the Willows are trained and competent to do their job. EVIDENCE: The staffing rota for the willows was seen and inspected, and this showed that there were enough staff on duty to meet the resident’s needs. The evidence seen during the inspection was that there were sufficient staff on duty. The staff team has a structure, which involves different staff taking on different roles. Two residents were asked about the numbers of staff on duty, and both The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 19 said that they thought that there was enough staff, and that they could always find a member of staff if they needed one. The Willows has a National Vocational Qualification (NVQ) training programme, and certificates for those staff who have successfully completed the course are on display. The Commission for Social Care Inspection considers that NVQ level II in care is the basic level of qualification that staff working in care should achieve, with a recommendation that 50 of staff should have achieved this qualification by 2005. The staff training records at the Willows show that this level has been achieved. Staff recruitment records are held centrally at the City Council personnel department, and these will be inspected at a later date. Two members of staff were asked about their recruitment, and this together with evidence seen in staff files suggests that the Willows employs safe recruitment practices, which are put in place to protect the residents. Staff training records showed that there is an ongoing staff training plan in place at the Willows, aimed at training and developing the staff. Discussions with two members of staff together with the training records evidenced that there is a wide range of training opportunities available to staff at the Willows. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38 The quality outcome in this area is good. This judgement has been made using the available evidence including a visit to this service, and meeting with residents. Residents at the Willows 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 responsibilities fully. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 21 The Willows is run in the best interests of its residents. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff at the Willows are promoted and protected. EVIDENCE: A discussion with Stephen Upton, the registered manager and a review of the training records evidenced that he has the skills and experience to run and manage the Willows. The current manager’s qualifications and experience are well in excess of the minimum that would be required by the Commission for Social Care Inspection to take up the position of manager. Currently the Willows do not arrange resident’s meetings. The reason for this being that the residents are short-term, and therefore there is a high turn over. The residents do however complete a questionnaire when they leave, and there is a comments box in the foyer. It’s recommended that resident meetings are introduced, as they are an excellent way of gauging resident’s opinions and views. The City Council operates a small cash needs system in their residential services, and this system is used by the Willows to manage the resident’s cash. The small cash needs records were inspected, and a number of cash balances were checked during the inspection, in each case the records, and cash totals balanced, and receipts supported the expenditure. Two residents were asked about their cash, and both of them said that they could get their money when they wanted it. A number of health & safety records were seen including the fire records, the asbestos log, water testing records, and the Control of Substances Hazardous to Health (COSHH) these were all found to be complete and correct. Two staff members were asked about health & safety issues and training, and the evidence showed that the Willows is training it’s staff in health & safety and carrying out regular health & safety checks. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 22 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 4 2 3 3 4 4 X 5 X 6 4 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 3 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 X 33 2 34 X 35 3 36 X 37 X 38 3 The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations Regular residents meetings should be arranged to allow residents to express their views during their stay at the Willows. The Willows Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Intermediate Care Service DS0000037311.V317304.R01.S.doc Version 5.2 Page 25 - 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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