Inspection on 15/07/08 for The Willows Residential and Nursing Home

This inspection was carried out on 15th July 2008.

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

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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE The Willows Residential and Nursing Home 73 Shakespeare Road Bedford Bedfordshire MK40 2DW Lead Inspector Irene Miller Unannounced Inspection 09:45 15th July 2008 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 Residential and Nursing Home DS0000071839.V366337.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 Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Residential and Nursing Home Address 73 Shakespeare Road Bedford Bedfordshire MK40 2DW 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) 01234 268270 01234 273544 Hestia Healthcare Manager post vacant Care Home 31 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (31), Physical disability (31) of places The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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: Dementia - Code DE, Physical Disability - Code PD Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 31 2. Date of last inspection Brief Description of the Service: The Willows is a care home offering nursing care for up to 31 people The home is an extended town house situated close to Bedford Town centre. Accommodation is provided over three floors that are linked by either stairs or a shaft lift. There are 29 single and one shared bedroom in addition to a variety of communal rooms, including a visitor’s room. Bedrooms are decorated to individual taste and contain appropriate furniture People are encouraged to bring small personal items into the home. Larger pieces of furniture and small pets in cages are accommodated with prior discussion with the home. The weekly fees range from £556 to £663 per week dependent upon need. A copy of the last inspection report is available on the notice board in the front hallway for people using the service and visitors to access and read if they wish. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1star. This means the people who use this service experience adequate quality outcomes. The focus of all inspections undertaken by the Commission for Social Care Inspection (CSCI) are based upon seeking the outcomes for Service Users and their views of the service provided. This visit was unannounced and focused on the ‘key standards’ under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. The care records of three people using the service were sample checked this involved looking through written information available on their care, such as care plans (a care plan sets out how the home aims to meet the individual service users personal, healthcare, social and spiritual needs). Discussions took place with people using the service, staff and visitors and observations of the staff interactions with the people using the service were made, to establish if the needs of people were being met and to establish how people were with the care and services provided by the home. Because people with dementia are not always able to tell us about their experience of the service, we used a formal method of observation called the Short Observational Framework for Inspection (SOFI). This involved spending a period of one hour within one of the communal lounge/diner observing the care of three people. This observation period gave an indication as to how the service supports the needs of people using the service and how the individuality of people living with dementia is maintained. During the visit records in relation to staff recruitment and training, how the home responds to concerns and complaints, the management of medication and the homes general policies and procedures were viewed. Prior to the visit taking place the Commission for Social Care Inspection had sent to the home an Annual Quality Assurance Assessment (AQAA) for completion by the registered provider. This was returned prior to the visit and provided information on how the service self assess their own performance. In addition to the AQAA the Commission for Social Care Inspection also sent out to the home a selection of service users, relatives and staff questionnaires for distribution by the provider. However no completed questionnaires have been received by the Commission for Social Care Inspection prior to this report The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 6 being published, therefore the judgements made about the care provided for people using the service are based upon information from the AQAA, evidence found during the visit through case tracking, and comments received from people using the service, staff and visitors on the day of the site visit. What the service does well: What has improved since the last inspection? What they could do better: Further work on improving the ordering systems of medication would ensure that no people using the service are placed at risk of running out of their prescribed medications. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 7 Work needs to continue on reviewing the details within the care plans as they are transferred onto the new formats, this would ensure that all of the care plans fully reflect the needs of the people using the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (standard 6 is not applicable to this service) Quality in this outcome area is good. People choosing to live at the home can be assured that their needs will be fully assessed This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered provider has submitted an updated copy of the Statement of Purpose and the Service User Guide to the Commission for Social Care Inspection the documents contain all of the details required to inform prospective service users on the management and staffing arrangements at the home and the range of services available. This assists people to make an informed choice as to whether the home can meet their needs. Each bedroom has a copy of the Service User Guide available for quick reference. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 10 Trial visits are encouraged to enable prospective service users to look around the home and meet other people at the home. Within the care plans viewed there was records of pre admission assessments having been carried out prior to admission, the assessments had identified the range of peoples health, personal, spiritual and emotional needs. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 & 10 Quality in this outcome area is adequate. Work is in progress to improve on the quality of the information within the care plans and on improving the medication systems, this work needs to continue to ensure that the needs of people using are fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Work was in progress in transferring the information within the care plans onto a new format, during which the needs of the individual were being reassessed the new formats were more individualised, having greater detail on the current health and personal care needs. It now needs to be addressed as high priority that this work continues to ensure that all care plans are of the same quality. In discussion with the manager she confirmed that the home has introduced a key worker system, this enables each person using the service to have a named member of staff who has the responsibility for ensuring their individual needs are being The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 12 Within the care plans viewed there was records of pressure area care assessments (waterlow scores) that identified the risks of people who are immobile developing pressure ulcers. Based upon the assessment the preventative care and treatment of pressure ulcers was formulated. Pressure relieving equipment was seen to be in use, in line with the information contained within the care plans. Within the bedrooms of people with limited mobility and at risk of developing pressure ulcers there was records available of when people had been turned in bed. There was moving and handling assessments in place which had identified the level of support required and the moving and handling equipment required, during the visit people were observed to be assisted to move using the equipment as outlined in their care plans. There was records of nutritional assessment having been carried out that identified the dietary needs of people using the service such as diabetic and vegetarian diets, there was information on those who have swallowing problems and require foods to be pureed. There was information contained within the care plans to inform staff on the level of support required at meal times. Peoples weight gains and losses were monitored monthly, within one of the care plans viewed the person had lost approximately nine pounds within one month. The home had taken appropriate action in referring this person to the dietic service, there were records available of the outcome of the referral and the action to be taken to meet this person nutritional needs. There was information on how individuals using the service with limited communication skills make their needs and feelings known, this information assists staff in responding to their needs. Within one of the care plans viewed there had been concerns raised by the family, that home had not been meeting the personal hygiene needs of the individual. There was records available within the care plan to demonstrate that the home had acted swiftly in responding to the concerns the care plan had been updated and contained detailed information for staff to follow when assisting with personal care. There were risk assessments in place that identified the specific risks to individuals such as falls, and within the care plans there was records of accidents and incidents to include body charts where injuries had occurred. Where bedside rails (cot sides) were in use risk assessments had been carried out to ensure their use was appropriate for the individual. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 13 There were records of people being seen by their general practitioner and other healthcare professionals to include specialists in the mental health field. A person who had lost weight had been referred to dietician and a person with an eye condition had been referred to see an optician for treatment. Within one of the care plans viewed there was a record that the person had lost their dentures approximately three months prior, the information within the daily notes stated that a relative was to arrange for the person to be seen by a dentist, however there was no further records as to whether this had taken place or what further action was being taken. The medication storage and administration records were sample checked, and actions taken the last inspection visit were discussed with the manager. Within the care plans there is now a medication profile available that lists the medications prescribed for the individual. The manager said that regular medication audits were taking place to ensure that the people using the service receive their medications as prescribed and confirmed that the practice of putting medications into foods had stopped. She confirmed that training for staff in the administration of medications had been provided through the dispensing pharmacy. A member of staff was observed giving medicines over the lunchtime period, the member of staff was observed to attend to each person individually, giving medications and signing the medication administration records (MAR sheet) after the person had received their medicines. The member of staff was heard to ask people who were prescribed pain relieving medication ‘when required’ whether they needed this medication to treat any pain they may have. On checking the MAR charts there is a sample list of staff signatures now available to match the initial of each member of staff who administers medication. There was records of weekly medication audits being carried out, and in discussion with the manager she confirmed that any discrepancies found are brought to the attention of the individual staff member responsible, and that the findings of the audits are discussed within team meetings to raise the profile on the importance of getting the medication systems right. On checking the medications there was records to show that one persons prescribed medications had been recently reviewed by their general practitioner and that there had been an instance when this person had ran out of one of their prescribed medications, and there had been a period of two days between the home obtaining a further supply. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 14 The medications held at the home that come under the controlled drugs category were checked the medication held within the stock matched the balance within the controlled drugs register. The stocks of one persons night medication had ran out the previous night and the home were awaiting a further supply being delivered, of which was received on the afternoon of the visit. In summary efforts had been put into place to improve on the medication administration systems, such as the weekly medication audits and refresher medication training however the systems for the ordering of repeat prescriptions needs to be addressed, to ensure that people using the service are not placed at risk of not receiving their prescribed medications due to medication not being ordered in a timely manner. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 15 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): Standards 12,13,14 & 15 Quality in this outcome area is good. Life within the home in generally matches the expectations of the people that use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit one hour was spent in the company of people using the service within the lounge and dining area of the home. During this time observations were made on the care and support people received, their interactions and level of engagement with staff and other people around them. In discussion with people using the service they expressed satisfaction with the care they received at the home, several people spoken with said that they were ‘happy living the home’, ‘the food was good’, ‘the staff were friendly’. There is a vacancy for an activity coordinator, in the absence of a person to take on this role the staff were endeavouring to ensure that activities continue to take place within the home. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 16 On the day of the visit a clothing company had been arranged to visit the home selling a range of clothing for men and women to purchase if they wished. Within the home there was notices displaying activities such as social events, church services and a forthcoming garden party to include live music. Within the conservatory area there was a range of board games, jigsaws, magazines and books available. People were observed receiving their lunch a small group of people were enjoying a glass of red wine with their meal. Many of the people using the service require full support from staff to eat and drink and staff were observed to provide this support with sensitivity to their needs and at a pace that was right for the individuals. One person was observed to receive support from a family member over the lunchtime the visitor confirmed that this was something they liked doing as it gave the opportunity to do something practical to help their relative. The staff were observed to ensure that individuals that required feeding in recliner chairs were sat upright in a comfortable position, all people were seen to be provided with drinks, and staff were observed to be recording the foods and drink intake. They were seen to offer choice of meals, on the day of the visit there was a choice of chicken with vegetables and mashed potatoes or, sweet and sour chicken with rice, there was also a vegetarian option available. The staff were observed to be patient with individuals the meal was unhurried, and the staff were observed to respond to non verbal communication very well. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 17 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): Standards 16 & 18 Quality in this outcome area is good. People using the service can be assured that any complaints they may have will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection visit two complaints had been received, records were available of the nature of the complaints, the investigations and the outcomes of the investigations. One complaint in relation to the home not fully meeting the personal hygiene needs of one person had a copy of the complaint the investigation and the outcome within the care plan, this served as a reminder to the staff on the importance of following the information in the care plan, and demonstrated that complaint s are taken seriously and acted upon. There was records of meetings having taken place with the complainants to discuss their concerns the outcome of one meeting was to meet every four months to review the care plan. Since the last inspection one safeguarding referral had been investigated the Commission for Social Care Inspection are satisfied that this was fully investigated. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 18 In discussion with the manager and staff it was confirmed that training has taken place on Safeguarding Adults, and from observations made during the visit the staff demonstrated that the rights of people using the service were respected. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 19 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): Standards 18 & 26 Quality in this outcome area is good. People using the service are provided with a warm clean and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A limited tour of the building was conducted which included viewing the communal areas, some of the bedrooms, the main kitchen, laundry and some bathrooms and WC’s. Within the front entrance there was a copy of the last inspection report available and there was information on the homes complaints procedure. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 20 There were notices on display within the front entrance and in the communal areas around the home on up and coming activities. The home appeared clean and homely and there were no offensive odours present. The main kitchen was viewed in discussion with the manager and the cook it was confirmed that this area of the home was soon to benefit from being refurbished. The laundry area was viewed and in discussion with the staff it was confirmed that the washing machines and tumble dryer were all operational. There was hand sanitizer available, however this had been transferred from a 5-litre container into an unlabelled pump bottle. This was brought to the attention of the manager who confirmed that this would be rectified. The bedrooms were clean and personalised with pictures, photographs and small items of personal furniture. Bedside rails were seen to be in place for people who had been identified at risk of falls out of bed. It was noted that within the communal lounge and conservatory no blinds were fitted to the skylights, during the visit a person who had been sitting in a recliner chair had to have their chair moved to a different position due to the sun shining in their eyes. The fitting of blinds would remedy any problems encountered by this. One of the five moving and handling hoists was out of order and during the visit the manager was informed by the engineering company that the hoist was not suitable for repair she confirmed that this would be treated as a high priority to access a replacement hoist as soon as possible. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 21 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): Standards 27,28,29 & 30 Quality in this outcome area is adequate. The staff team have the necessary skill and competency to meet the needs of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the staff recruitment files viewed there was records of pre employment checks having been carried out, which included police checks through the criminal records bureau (CRB) and the protection of vulnerable adults register (POVA first). Professional references had been obtained and for staff employed from overseas and within the European community all checks had been translated into English. The manager confirmed that all new staff employed had received training on Moving and Handling through the company and that all existing staff are to receive refresher M&H training. A member of staff employed at the home is qualified to train staff in moving and handling. Staff were seen during the visit The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 22 to use the appropriate moving and handling equipment when moving people with limited mobility. The manager confirmed that she had recently attended safeguarding adults training and that this was to be rolled out within the staff team. Training is planned to take place to cover Bowel Management, Diabetes, Care Planning, the National Minimum Standards of Care, Bereavement, Catheterisation and Phlebotomy (blood taking). The staff spoken with during the visit said that they liked working at the home, and confirmed that they have been busy transferring the information within the care plans into the new care plan formats. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 23 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): Standards 31,33,35 & 38 Quality in this outcome area is good. The home is run in the best interests of the people using the service, their health, safety and welfare is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In discussion with the manager she confirmed that an application to register with CSCI had been submitted. She is a Registered Nurse with 15 years experience of working with the elderly, and has achieved the Registered Managers Award, an NVQ level 4 in care and a foundation degree in Care Management. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 24 An updated Statement of Purpose & service user guide has been submitted to CSCI, giving details of the management arrangements and the staffing structure, its intended purpose and range of facilities for people using the service. Since the home has been taken over by the new owners there has been a drive to improve on the standard of care provided at the home. Within the care plans and other documentation looked at during the inspection there was evidence to demonstrate that improvements are taking place, to improve on the quality of the information within the care plans, there is still some way to go before all of the care plans have been reviewed and updated with more detail. However the areas of individual risk have been addressed to ensure that no person is placed at risk whilst this process is taking place and there was evidence of the risk assessments being regularly reviewed and updated. During the visit the medication administration practice was seen to have improved, however further work is needed to ensure that people using the service are not placed at risk of not receiving their due stocks not being ordered in a timely manner. The home seeks to hear the views of people using the service and their representatives by carrying out quality assurance surveys, during the visit, visitors were calling into the manager’s office to return their completed questionnaires. The manager was observed to have good relationships with the people using the service, staff and visitors. Visitors spoken with were pleased with the care provided at the home. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 26 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 (2) (b) Requirement Timescale for action 30/09/08 2 OP9 13(2) 3 OP22 23 (2) (n) The registered person must continue with up dating and reviewing the care plans. This will ensure that staff are fully up to date on the current needs of people using the service and that the needs are met. The registered person must 31/08/08 ensure that procedures for the ordering of medicines are followed. This will ensure that people using the service are not placed at risk of not receiving their medications due to lack of stock. The registered person must 30/09/08 ensure that there is sufficient and suitable moving and handling equipment available to meet the needs of the people using the service. The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Willows Residential and Nursing Home DS0000071839.V366337.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!