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Inspection on 16/03/07 for The Willows Nursing & Residential Home

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

This inspection was carried out on 16th March 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

What has improved since the last inspection?

Residents` admission documents have been reviewed and improved. All are now dated which will make it easier for staff to identify when changes in residents` care needs occur.

What the care home could do better:

Although most residents` files contained photos of the residents in question, a minority do not. The Manager said this issue is in hand and she in the process of having all residents photographed for their files. One visitor to the home said she thought staff should provide more activities to residents on a one-to-one basis. She said this was because not all residents could take part in group activities, particularly those suffering from dementia. Consideration should be given to this suggestion. Not all staff files contained photos of the members of staff in question. It is recommended that the Manager audits the files and ensures that they do.

CARE HOMES FOR OLDER PEOPLE The Willows Nursing & Residential Home 105-107 Coventry Road Market Harborough Leicestershire LE16 9BX Lead Inspector Kim Cowley Key Unannounced Inspection 16 March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Willows Nursing & Residential Home DS0000001934.V329333.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 Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Nursing & Residential Home Address 105-107 Coventry Road Market Harborough Leicestershire LE16 9BX 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) 01858 463177 01858 434772 Mr James Frederick Cooper Mrs Mary Violet Cooper, Mrs Jacqueline Marie Riddett, Mr John Frederick Cooper Mrs Jacqueline Marie Riddett Mrs Mary Violet Cooper Care Home 57 Category(ies) of Dementia (9), Dementia - over 65 years of age registration, with number (9), Mental disorder, excluding learning of places disability or dementia (9), Mental Disorder, excluding learning disability or dementia - over 65 years of age (9), Old age, not falling within any other category (57), Physical disability (36), Physical disability over 65 years of age (57), Sensory impairment (36), Sensory Impairment over 65 years of age (36), Terminally ill (36), Terminally ill over 65 years of age (36) The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling in categories TI(E) & TI to be admitted to the Home when 36 persons of that category/combined categories are already accommodated Service user numbers No person falling within categories MD, MD(E), DE, DE(E) may be admitted to the Home when 9 persons in total in these categories/combined categories are already accommodated within the Home No person falling in categories PD(E) & PD to be admitted to the Home when 57 persons of that category/combined categories are already accommodated in the home No person falling in categories PD may be admitted into the Home where there are 36 persons of category PD already accommodated within the home No person falling in categories SI(E) and SI to be admitted to the home when 36 persons of that category/combined categories are already accommodated No one under the age of 55 falling within categories MD or DE may be admitted to the Home Named person To be able to admit a named person under 55 years of age and falling within category LD named in variation application No. 58114 dated 13/11/03 9th November 2006 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: The Willows Nursing and Residential Home is situated close to the centre of Market Harborough. It provides care for up to 57 older people with a range of needs including physical disabilities, dementia, and sensory impairment. Registered nurses are on duty in the home at all times. The accommodation consists of two older buildings linked by a new wing. Bedrooms are on two floors accessed by both passenger and stair lifts. There are four sitting rooms and one dining room. The home stands within secluded gardens and there is car parking at one side. The fees range from £319 to £700 per week depending on care needs. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included a visit to the home and inspection planning. Prior to the home visit, the two inspectors (Kim Cowley and Lesley Allison-White) spent half a day reviewing information relating to the home. During the course of the inspection, which lasted six hours, the inspectors checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means the inspectors looked at the care provided to four residents living at the home by meeting or observing them (not all residents were able to give their views due to their dementia); talking with the staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home, including health and safety and management issues, were examined. The inspectors also met other residents, relatives, the Registered Manager, and care and ancillary staff. What the service does well: The Willows is a family run home and is jointly managed by a mother and daughter team. Both the managers are nurses. The home has been in the family for over 25 years and the providers are experienced and knowledgeable in the field of care. The premises are decorated and maintained to a good standard and the environment is homely. All areas inspected were clean and fresh. All bedrooms inspected were individually decorated and personalised. There are four lounges available so residents can choose where they sit and socialise. Residents and relatives made many positive comments about the premises including: ‘The home is spotless’ ‘I love my room – it’s my place and I can be private there.’ ‘The home is always clean and tidy.’ ‘All the areas I’ve seen of the home are clean.’ ‘It seems very pleasant in here. The rooms always look nice.’ The home employs nursing, care, and ancillary staff and the rota showed that the staffing hours provided exceed the recommended minimum. During the inspection staff were observed as being professional and caring in their approach to residents. Residents’ and relatives’ comments about the staff The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 6 included: ‘All the staff know their jobs – they’re very good’, ‘The staff are fine and respectful’, and ‘The staff give one hundred percent to their role of caring.’ 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 & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents’ needs are assessed prior to admission to ensure the home is suitable for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All potential residents (or their representatives) are given a copy of the Resident’s Guide to the Home prior to admission. This includes the home’s Statement of Purpose and Service Users’ Guide. Terms and Conditions are drawn up and when a resident is admitted copies of these are kept on file in the home. They state that four weeks notice will be given if fees are altered. The Manager or a senior nurse assesses those residents interested in coming to the home. They visit them in their own homes or in hospital in order to do this. They also talk to relatives and health professionals to get their views on the resident’s needs. These steps help to ensure the home is suitable for the resident and that staff can care for them properly. Once admitted each resident has a trial period of at least four weeks. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 9 Care records were sampled and showed that residents were properly assessed prior to admission. Residents’ admission documents have been reviewed and improved since the last inspection. All are now dated which will make it easier for staff to identify when changes in residents’ care needs occur. Standard 6 was not inspected, as this home does not provide intermediate care. The Willows Nursing & Residential Home DS0000001934.V329333.R01.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): Quality in this outcome area is good. Residents’ health, personal, and social care needs are identified and met by staff at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are in place to ensure that all aspects of health, personal and social needs of the residents are met and assessments take place to monitor the outcomes for residents to ensure that their needs are being met. All residents case tracked had the necessary risk assessments in place. Residents living at the home are all assigned a local doctor and there is evidence in the care notes to explain reasons for visits when seeing residents. Other specialists (for example, options, dentist, chiropodist, etc) also visit and this is recorded in the care records of the residents who were case tracked. Staff confirmed that whenever possible residents (and their relatives/friends where appropriate) are involved in the drawing up of care plans. One resident said she had not yet been involved in her care needs, but the Manager explained this is because she is new and needs to settle in the home first. The The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 11 Manager said that staff aim to review care plans at least once a month, and much more frequently if necessary. Each resident has a ‘social profile’ in their case files containing information about their past lives, hobbies, and interests. This helps staff to get to know residents and interact with them socially. Although most residents’ files contain photos of the residents in question, a minority do not. The Manager said this issue was is in hand and she in the process of having all residents’ photographed for their files. Policies, procedures and practices for the receipt, recording, storage, handling, administration and disposal of medicines were checked. They were found to be satisfactory with regard to all medication kept including controlled drugs. (Controlled drugs fall under the Misuse of Drugs Act 1971 which aims at checking the unlawful use of the drugs liable to produce dependence or cause harm if misused). None of the residents’ case tracked were self-medicating, although the Manager said she would encourage residents to do this if they were able. Discussions were had with the Manager about three specific issues relating to residents’ medication files: the use of photos; the recording of allergies; and the recording of the use of dressings, catheters, etc. It was agreed that the home’s current administrative practices in these areas were acceptable and no recommendations were made. Arrangements for health and personal care ensure that residents’ privacy and dignity are respected at all times. During the inspection staff were observed behaving respectfully to residents and maintaining their dignity by discreetly providing care. One resident said that her clothes sometimes get mixed with other residents’ clothes when they get sent to the laundry. This was reported to the Manager who agreed that this does happen on occasions. She said she is working with the home’s head housekeeper to address this problem. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Daily life and social activities enable residents to lead full lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ hobbies and interests are recorded in their case files. This helps staff to identify which activities they might like to take part in when they are living at the home. An activities organiser is employed from 12.30 – 4pm (Monday to Friday) to provide a programme of leisure and social events. Records showed that recent activities have included: bingo, a clothes sale, visiting entertainers, sing-a-long sessions, and board games. Records were examined and it was evident that residents are able to choose activities and are not forced to take part if they don’t wish. In one file it was it was stated that staff are required to go to a residents’ room regularly and talk to her about the news, her past, or just for a general chat. This is good practice as it demonstrates that staff are able to meet a diversity of needs. All residents who spoke with the inspector stated that they enjoyed the activities on offer and were happy that they could choose whether to join in or not. One visitor to the home said she thought staff should provide more activities to residents on a one-to-one basis. She said this was because not all residents The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 13 could take part in group activities, particularly those suffering from dementia. Consideration should be given to this suggestion. Residents who spoke with the inspectors said that they could receive visitors at any reasonable time and they were assured privacy during visits. One relative said she feels that she is made welcome when she visits and that staff always offer her a drink. The home has a well-equipped kitchen and residents reported that the food is good. A choice of diet is offered and menu sheets indicated that the diet is nutritious and varied. The home also has small kitchens where residents and visitors can prepare drinks and snacks. The Manager was asked about providing every resident with the opportunity of having lunch at the dining table as this would help to stimulate residents’ memories of social dining. The Registered Manager explained that this had already been tried and had not proved to be successful. The inspector spoke to the kitchen staff who were on duty. They were long serving staff (8, 13, and 15 years in post). They had received training for food hygiene in July 2005. A record of the food temperatures taken during and after preparation is recorded. Fridge temperatures were also recorded at regular times of the day along with cleaning rotas. Menus are provided and a member of the care staff was seen later in the afternoon taking residents orders for the meal the next day. Meals seen were varied including an ordinary diet of fishermen’s’ pie or the softer diet option of scrambled egg or the pureed diet for people with chewing or swallowing difficulties. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents feel able to talk to staff about any concerns they might have. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a written complaints procedure, which is given to all residents (or their representatives) prior to admission. A copy of the complaints procedure is also displayed in the home. The Manager said she encourages residents to tell staff if they have any concerns, or to come to her, or approach CSCI, and this advice is also in the residents’ guide. One resident said, ‘If I had a problem there are members of staff I can tell’. A relative said she had once raised a concern informally, and it was dealt with straight away and to her satisfaction. Another relative said that if she was unhappy with her family member’s care she would see the nurse in charge and feel happy to do so. There has been one formal complaint since the last inspection, which is currently being investigated by social services. Staff are trained in safeguarding vulnerable adults during their induction. A record is kept of this training and they sign to say they have understood and completed each section. Ongoing training in safeguarding is provided in-house and via a local college, and the subject is also raised at staff meetings. Ancillary staff also receive basic training in safeguarding with the use of a training pack. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 15 The home has a whistle blowing procedure in place, reporting suspected abuse. The Manager said staff are procedures, which are reviewed annually. During interviewed were able to explain their understanding of what they would do if an incident occurred. and a procedure for made aware of these the inspection staff safeguarding and say The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents live in an environment that is reasonably safe and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are decorated and maintained to a good standard and the environment is homely. All areas inspected were clean and fresh. All bedrooms inspected were individually decorated and personalised. There are four lounges available so residents can choose where they sit and socialise. Residents and relatives made many positive comments about the premises including: ‘The home is spotless’ ‘I love my room – it’s my place and I can be private there.’ ‘The home is always clean and tidy.’ ‘All the areas I’ve seen of the home are clean.’ ‘It seems very pleasant in here. The rooms always look nice.’ The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 17 The home has extensive grounds, which include a woodland walk with benches and a stream which is suitable for residents who are mobile . To the side of the home is wheelchair-accessible patio, which leads off one of the lower ground floor lounges. The Owners are considering fencing this off to provide a secure outdoor area for residents. This would enhance the facilities at the home, as at present residents who wander can only use the patio with staff supervision. The security of the building was inspected and discussed because there have been a number of incidents recently when residents have left the building unaccompanied. The Manager said that although every effort is made to prevent this happening, the home is not a ‘secure unit’, and if a resident is determined to leave they may be able to find a way to do so. All exit doors are kept locked, and all are alarmed but four. These open with a keypad, and the Manager said they cannot be alarmed, as the alarm would go off every time a member of staff or visitor entered or left the building. For a home of this type, the Willows appears to be reasonably safe and secure. The Manager said that if a resident is admitted who is likely to try and leave the premises, detailed risk assessments are put in place, and staff monitor and supervise them as deemed necessary, for example by carrying out half hourly checks on them. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Well-trained and professional staff meets residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs nursing, care, and ancillary staff and the rota showed that the staffing hours provided exceed the recommended minimum. During the inspection staff were observed as being professional and caring in their approach to residents. The following comments were made by residents and relatives about the staff: ‘Staff knock on my door before they come into my bedroom’ ‘The staff are very nice.’ ‘The staff are fine and respectful’ ‘The staff are very polite’ ‘All the staff know their jobs – they’re very good’ ‘The staff give one hundred percent to their role of caring.’ Recruitment procedures and staff files were checked and found to be mostly in good order, with evidence that references and CRB/POVA First checks have been obtained prior to staff members working in the home. Not all staff files contained photos of the members of staff in question, and it was recommended that the Manager audited the files and ensured that they did. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 19 A designated training and personnel officer is employed and staff receive good training opportunities. The ‘Skills for Care’ induction is used, followed by NVQs. At present 68 of staff at the home are trained to NVQ Level 2 or above. Three senior staff at the home are accredited moving and handling trainers and they provide courses and updates in-house. In addition all staff receive an annual appraisal with a team leader or one of the managers. The training and supervision arrangements in the home help to ensure that staff are competent to do their jobs. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. Residents live in a home that is safe and well managed. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Willows is a family run home and is jointly managed by a mother and daughter team. Both the managers are nurses. The home has been in the family for over 25 years and the providers are experienced and knowledgeable in the field of care. Within the home there is a clear management structure in place to help to ensure that staff are properly supervised and supported. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 21 The Managers complete an ongoing quality audit which focuses on the following areas: Care plans Cleaning schedules Kitchens Decoration Polices and procedures Health and safety Staff meetings Residents meetings Complaints Staff and residents and relatives’ surveys are sent out annually so their views can be included in the quality audit. There is also a suggestion box in the home. The Manager said the quality audit was originally set up as part of the home’s Investors in People Award, and the results are analysed annually so the home’s performance can be monitored. An action log is also kept to record how management respond to the results of the audit. There is a range of policies and procedures in place to maintain health and safety in the home. Good records were available to show the home is properly maintained. The Willows Nursing & Residential Home DS0000001934.V329333.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 The Willows Nursing & Residential Home DS0000001934.V329333.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 2 3 Refer to Standard OP7 OP12 OP29 Good Practice Recommendations Residents’ files should be audited to ensure that all contain photographs of the residents in question. The activities programme should be reviewed to see if any further one-to-one activities need to be provided. Staff files should be audited to ensure they all contain photographs of the members of staff in question. The Willows Nursing & Residential Home DS0000001934.V329333.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 & Residential Home DS0000001934.V329333.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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