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Inspection on 12/12/07 for The Willows Nursing Home

Also see our care home review for The Willows Nursing Home for more information

This inspection was carried out on 12th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents of The Willows, their relatives spoken with, and the survey responses, all made positive comments about the home. One relative described the staff as `angels`. The Willows provided a comfortable and safe environment for the people who used the service. Residents and families were encouraged to personalise their rooms with their own possessions. There was a committed and competent staff team who were knowledgeable about the care needs and preferences of residents. The observation showed that the majority of communication with residents demonstrated an understanding of individual needs. There was a range of activities available to suit different tastes and abilities. The meals provided were of a good standard with choices offered at every mealtime. Menus were changed regularly to reflect residents` tastes and preferences. Quality assurance systems formed an integral part of the management of the home and regular audits were used to monitor the quality of the care and services provided.

What has improved since the last inspection?

There was one requirement and five recommendations made at the previous inspection in October 2006. The requirement and two recommendations about medication had been addressed and the lounge and corridors had been redecorated. However, the remaining three recommendations about lighting and quality assurance analysis had yet to be addressed.

What the care home could do better:

Moving and handling practice must improve to ensure that residents are moved safely and with the appropriate equipment. This is essential to prevent accidents to both residents and staff and should be monitored by the home`s management to ensure good practice is maintained. All residents on the dementia unit must have a specific care plan completed for their mental health needs. This will ensure that any specific needs in relation to their dementia are addressed. The lighting in the home, particularly in the lounges and corridors, should be replaced to provide a brighter more pleasant environment for residents. This was recommended at the previous inspection visit in October 2006. The views of residents, relatives and visiting professionals should be obtained through regular surveys and the company should provide a report analysing the findings and what action has been taken to address any issues raised. More individual attention should be given to those residents who are unable to communicate verbally. This will ensure their needs are fully understood and their quality of life is enhanced.

CARE HOMES FOR OLDER PEOPLE The Willows Nursing Home 7 Norbriggs Road Woodthorpe Mastin Moor Chesterfield Derbyshire S43 3BW Lead Inspector Janet Morrow Unannounced Inspection 11:00 12th and 17 December 2007 th 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 Nursing Home DS0000002092.V355346.R02.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 Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Nursing Home Address 7 Norbriggs Road Woodthorpe Mastin Moor Chesterfield Derbyshire S43 3BW 01246 280539 01246 280799 the.willows@craegmoor.co.uk Craegmore.co.uk Parkcare Homes Ltd 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) Post Vacant Care Home 41 Category(ies) of Dementia (19), Dementia - over 65 years of age registration, with number (19), Old age, not falling within any other of places category (22) The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Parkcare Homes Limited may provide the following category of service only: Care Home with Nursing - Code N To service users of the following Gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - code OP (maximum number of places 22) 2. Dementia - Code DE (maximum number of places 19) The maximum number of service users who can be accommodated is 41 25th October 2006 Date of last inspection Brief Description of the Service: The Willows is located in the village of Woodthorpe, near to Staveley where there are amenities including a supermarket, church, post office and library. The home provides accommodation in single rooms, some of which are en suite. There is a dining room, lounge and conservatory on the ground floor and a dining / lounge room on the first floor. There is access to the enclosed garden and car parking space is provided to the front of the building. The fees range from £333.85 to £519.55 per week with additional rates for individuals assessed as having specific needs. The highest fee in January 2008 was £850.00 per week. This information was provided verbally in January 2008. Copies of previous inspection reports were available in the manager’s office. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over two days for a total of 8.5 hours. Two hours were spent observing the care given to residents in the lounge in the dementia unit and the care of two people was looked at in depth when comparisons with the observations were made with the home’s records and the knowledge of the care staff. Care records of residents in the nursing unit were also examined. Staff records were examined. Four members of staff, eight of thirty-six residents currently accommodated, and three relatives were spoken with. A partial tour of the premises was undertaken. One visiting professional was contacted by telephone following the inspection visit. The home had supplied written information in the form of an annual quality assurance assessment that informed the inspection process. What the service does well: Residents of The Willows, their relatives spoken with, and the survey responses, all made positive comments about the home. One relative described the staff as ‘angels’. The Willows provided a comfortable and safe environment for the people who used the service. Residents and families were encouraged to personalise their rooms with their own possessions. There was a committed and competent staff team who were knowledgeable about the care needs and preferences of residents. The observation showed that the majority of communication with residents demonstrated an understanding of individual needs. There was a range of activities available to suit different tastes and abilities. The meals provided were of a good standard with choices offered at every mealtime. Menus were changed regularly to reflect residents’ tastes and preferences. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 6 Quality assurance systems formed an integral part of the management of the home and regular audits were used to monitor the quality of the care and services provided. 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 Nursing Home DS0000002092.V355346.R02.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 Nursing Home DS0000002092.V355346.R02.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): 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was sufficient admission information available to establish that the home was able to meet residents’ needs. EVIDENCE: The care records of four residents were examined, two on each unit. All the records seen included assessment information from the care manager, hospital or funded nursing care team as appropriate. This information included risk assessments for nutrition and pressure sores as well as a general moving and handling assessment. The information available The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 9 established that the home was able to meet residents’ needs and relatives and visiting professionals spoken with also confirmed that needs were well met. In each of the records seen, the assessment information was used to produce a care plan. Residents and their relatives spoken with said that their needs were met at the home. Staff were provided with specific training to ensure that the needs of the resident group were met. One member of staff spoken with confirmed that they had been provided with dementia care training, and felt that they had the necessary skills and knowledge to care for the current resident group. There was always an appropriately qualified nurse on duty in both the dementia unit and the nursing unit. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care needs were met and the care of residents was planned and given in a way that respected individuality. EVIDENCE: Four residents’ care records were examined. All had a care plan in place and these were reviewed on a regular basis, usually monthly. The care plans seen covered all the assessed needs of the residents, including their emotional, social, and spiritual needs. Where a risk was identified, there was a care plan to address the risk. For example, one file showed there was a risk of pressure sores and there was a care plan in place to address this and another showed a nutritional risk and there was an eating and drinking plan in place. However, The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 11 one resident on the dementia unit had not had a care plan completed for their mental health needs. Records showed that residents had appropriate access to health care services. Records were kept of the visits and input of other health care professionals, such as GP, District Nurse, chiropodist, and care manager. There was evidence that residents’ health care needs were promptly and appropriately referred. For example, there was a referral for a physiotherapist on one file examined. Records of blood pressure and weight were also maintained. Residents and relatives said staff respected their privacy and dignity, for example, by knocking on doors before entering and addressing residents by their preferred name. Staff were observed giving assistance with eating and drinking in a sensitive way. The observation carried out looked specifically for indications of residents’ wellbeing and/or distress, level of engagement with activities or objects and type of staff interaction and observed four residents closely. During the period of observation, there was no evidence of residents’ being distressed and some staff were proactive in engaging with residents in a positive manner, such as offering drinks, playing games and having a conversation. Requests for assistance were responded to promptly. However, where residents were unable to verbalise their needs, there was less attention given. Two of the four people observed had no interaction with anyone until the lunchtime meal was served. Discussion with staff, the records and observation supported that staff had a good understanding of how to maintain personal privacy and individuality of the people in their care. Dialogue from staff was polite and respectful, and understanding of individual difficulties with communication and memory loss. During the observation it was also noted that moving and handling practice was not always following proper procedures. Although hoists were available and in use for some residents, one resident was observed being moved bodily by two care staff. Wheelchairs were also not secured with the brake during moving and handling procedures. Both residents’ surveys received stated that they ‘always’ received the care and support needed and that staff listened and acted on what was said. One responded that they ‘sometimes’ received the medical support they needed and the other responded that they ‘always’ did. The medication administration record (MAR) charts of five residents were examined to check the accuracy of the recording. This showed that records were accurate, with signatures in place for medicines dispensed. Two people were signing handwritten medication administration record (MAR) charts to The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 12 ensure they were accurate and the amount of medication received into the home was recorded consistently on all charts. Two residents’ medication administration record (MAR) charts were then examined in more detail and showed that records corresponded accurately with the dispensing system. However, one resident’s medication chart showed they were prescribed Lactulose and Paracetamol but neither of these medicines were available at the time of the medication check. Information that was provided on the second day of the inspection stated that these medicines had run out on the day of the inspection visit but that more were available the following day and no doses had been missed. The nurse spoken with stated that Temazepam was stored and administered under controlled conditions and the records of Temazepam checked for one resident corresponded accurately with the stock held. The controlled drugs currently in stock were also recorded accurately and the stock held corresponded with the record. Secure storage facilities were available. A general check on medicine stocks was carried out and found to be satisfactory with no medicines being past their expiry date. Eye drops were stored in the medication refrigerator and were labelled with date of opening. The refrigerator temperatures were recorded daily and were within safe limits. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 13 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. The home provided a good range of activities and a healthy, varied menu so that the lifestyle in the home met the needs and expectations of residents. EVIDENCE: There were regular activities taking place and a separate activities co-ordinator was employed in each part of the home. The written information supplied by the home stated that there was monthly movement to music and staff spoken with stated that a variety of entertainment was arranged; for example, bingo and church services occurred regularly, a cinema night had been arranged and a pantomime entertainment had also occurred. On the day of the inspection visits, carol singers were present and both activities co-ordinators were involved in individual activities with residents; one was undertaking hand massages and manicures and the other was seen playing games. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 14 The observation in the dementia unit showed that a range of options were available to residents; for example, one member of staff was observed playing a game with a resident and also talked with residents on an individual basis. However, the observation also showed that the more vocal and active residents were the ones who received most attention. Those who appeared withdrawn were not offered any stimulation during the observation period. One residents’ survey received responded that there were ‘always’ activities arranged by the home that they could take part in and one responded that there ‘usually’ were. Visitors spoken with said they were always made welcome by the staff, greeted and offered refreshments. Relatives were encouraged to become involved in social and fund raising events and monthly meetings were held that discussed activities and meals. Residents spoken with said that routines were reasonably flexible and that their choices were respected, such as choosing not to join in with a particular activity. Individual routines of getting up times and use of bedrooms was observed during the inspection visit. Some residents made regular trips out with their relatives. The manager stated that none of the residents had an advocate but he was aware of which organisations to contact should the need arise. The menus were seen and appeared varied and balanced and gave choices at all main meals. The meals served on the day of the inspection visit appeared appetising. Residents and their relatives spoken with and those who responded to the survey were all pleased with the meals. Comments included ‘the food is very good’ and one visitor commented that their relative had put on weight since being at the home. One residents’ survey received responded that they ‘always’ liked the meals at the home and one responded that they ‘usually’ did. Residents requiring assistance with eating and drinking were helped in a sensitive manner and encouraged to eat. The written information supplied by the home stated that it was hoped to provide a sensory room in the dementia unit, to source reminisence therapy and to organise more day trips out. It also stated that there were plans for the cook to access courses to expand her knowledge of different types of diet and provide different formats to present the menu i.e. photographs. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure that complaints and safeguarding issues were responded to appropriately, which ensured that residents were protected and their concerns handled objectively. EVIDENCE: The complaints procedure was examined and this showed that complaints would be responded to within twenty-eight days. The written information supplied by the home stated that eleven complaints had been received in the last twelve months and that two had been upheld. There was a written record of the complaints received and this showed that these were properly investigated and it was clear whether or not the complainant was satisfied with the outcome. One residents’ survey received responded that they knew how to make a complaint but the other stated that they did not know how to. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 16 The home had a comprehensive policy regarding safeguarding vulnerable adults and also a whistle blowing policy. Training records showed that safeguarding training had been organised in March, July and November 2007. Staff spoken with were aware of their responsibilities in reporting potential abuse. The written information supplied by the home stated that there had been three safeguarding referrals made via Local Authority procedures. These were discussed with the manager, which established that they had been satisfactorily resolved. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The home was well equipped and generally well maintained so that residents lived in a safe, clean, comfortable and pleasant environment. EVIDENCE: The Willows was clean and tidy at the time of the inspection visit. All areas of the home were well maintained and decorated, with evidence to support that ongoing maintenance systems were in place. The previous inspection report of October 2006 recommended that the lighting in corridors should be improved but this had not been addressed. The manager The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 18 stated that brighter light bulbs had been sourced and it was hoped to introduce these over the coming months. The written information supplied by the home stated that a progamme of redecoration commenced in January 2007 of bedrooms and communal areas. The corridors and lounges in the dementia unit and the nursing unit had been re-decorated. The laundry area was satisfactory and all equipment was in good working order. Residents’ personal clothing was well washed and ironed, and residents looked well presented. Staff spoken with were aware of how to control the spread of infection and confirmed that there was always a plentiful supply of protective equipment such as gloves and aprons. They confirmed that they had received training in this area and training records seen stated that infection control training had occurred in February and July 2007. During the inspection visit staff were observed to wear disposable gloves and aprons when assisting with personal care, and disposable aprons when assisting with meals. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. There were robust recruitment practices, a good staff training programme and adequate staffing levels so that residents were protected and well supported. EVIDENCE: Staff rotas for the weeks 1st – 28th December 2007 were examined. These showed that there was an appropriately qualified nurse on both the nursing unit and the dementia unit. Additionally, the manager was on duty every day Monday to Friday. The rotas also showed that there were six care staff on each morning and five in the afternoon. Generally, this was sufficient to meet the needs of residents but records of a residents’ meeting in June 2007 indicated that residents wanted more staff. Staff spoken with also indicated that there were times when there were not enough staff. Staffing was discussed with the manager who stated that the home was recruiting for a unit manager in the dementia unit and that currently the home needed to recruit two care staff. Although shifts were covered by existing staff, it was recognised that in the short term until staff were recruited, it was more difficult to cover sickness and holiday absence. The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 20 Both residents’ surveys received stated that there were ‘always’ staff available when needed. Written information supplied by the home stated that nine out of twenty-seven staff had achieved a National Vocational Qualification (NVQ) at level 2 or above and a further three staff were undertaking the training. This meant that the home had not yet achieved the target of having 50 of staff with an NVQ at level 2. The training records showed that mandatory health and safety training was undertaken and that several courses had been run during 2007; for example, fire safety training had been undertaken in February, June and July 2007. There had also been additional training in dementia care, pressure ulcer prevention and challenging behaviour during the year. The manager also stated that training on the Mental Capacity Act was being planned. The written information provided by the home stated that it had recognised specific training needs for staff to work in the dementia unit and had organised this trainnig over the last twelve months. Three staff files were examined and showed evidence of good recruitment processes. All of the documentation required by Schedule 2 of the Care Homes Regulations 2001 was in place, including a Criminal Record Bureau check and Protection of Vulnerable Adults (POVA) check, evidence of identity and qualification and two written references. The Willows Nursing Home DS0000002092.V355346.R02.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 good. This judgement has been made using available evidence including a visit to this service. The home was well organised with good quality assurance procedures, which ensured it was run in residents’ best interests. EVIDENCE: The manager had been in post since September 2007. He was a qualified nurse and had been managing care homes since 2003 and held the Registered Managers Award. Although not yet registered with the Commission for Social Care Inspection, he was in the process of completing his application. He was The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 22 able to demonstrate in discussion that he was familiar with the conditions associated with ageing and with dementia. The quality assurance system included regular surveys of the views of residents and their representatives, monthly visits by the area manager, and in-house audits of the environment and health and safety matters. Records showed that the most recent audit was undertaken in November 2007. However, there had been no survey recently and the company had not carried out the recommendation made at the previous inspection in October 2006 of preparing a report of the analysis of survey findings and what action was to be taken in response to them. Four residents’ accounts were examined and showed that there were secure systems in place for safeguarding residents’ money. The records supported that that all accounts were balanced and all resident money was properly accounted for. Receipts were availbale for individual purchases. The health and safety of those involved with the home was addressed. Staff training in mandatory health and safety areas took place. Staff records confirmed that training in infection control, fire safety, food hygiene and moving and handling had occurred in 2007. However, as stated earlier in the report, staff were not always adhering to safe moving and handling principles. This was discussed with the manager who took steps during the insepction visit to rectify this by issuing a reminder to all staff about proprer procedures. The written information provided by the home stated that regular maintenance of equipment took place that included fire equipment in April 2007, gas safety in June 2007, the emergency call system in July 2007 and hoists in March 2007. A random sample of records at the home showed that fire alarms had been checked in July 2007 and electrical wiring had been checked in July 2003. Information on Control of Substances Hazardous to Health (COSHH) was accessible to staff. The Local Authority Environmental Health Officer had visited in August 2007 and stated that ‘kitchens were being managed to a high standard’. The Willows Nursing Home DS0000002092.V355346.R02.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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement All residents on the dementia unit must have a specific care plan completed for their mental health needs to ensure any needs related to their dementia are met. All staff must adhere to safe moving and handling procedures at all times to ensure their own and residents’ safety and the home’s management must monitor this to ensure good practice is maintained. Timescale for action 01/02/08 2. OP38 13 (4) & (5) 01/02/08 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 OP12 Good Practice Recommendations There should be greater attention paid to residents who are unable to verbalise their needs to ensure meaningful interaction takes place. DS0000002092.V355346.R02.S.doc Version 5.2 Page 25 The Willows Nursing Home 2. 3. 4. OP16 OP19 OP27 The home should ensure that all residents and their representatives are aware of how to make a complaint. The lighting in the corridors should be improved to provide a brighter environment for residents and staff. Staff rotas should be reviewed to ensure there are sufficient numbers available at all times and to identify any specific times and activities when there may be shortfalls. National Vocational Qualification training programmes should be continued to ensure that the minimum target of 50 of care staff with a level 2 qualification is exceeded. The results of service user surveys should be made available and a copy of the report provided to the Commission. Quality assurance surveys should be carried out on a regular basis and include visiting professionals and relatives. 5. OP28 6. OP33 7. OP33 The Willows Nursing Home DS0000002092.V355346.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham 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 Nursing Home DS0000002092.V355346.R02.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. 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