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Inspection on 30/07/09 for The Willows Residential Home

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

This inspection was carried out on 30th July 2009.

CQC 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.

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

The Willows provides homely and comfortable accommodation. All the areas we inspected were clean tidy, and fresh. One resident told us, ‘The home is always clean’, and another said, ‘All the rooms are lovely here.’ The atmosphere in the home was warm and friendly. One resident commented, ‘The best thing about this place is that everyone’s so nice.’ On the day we inspected a visiting entertainer was leading a sing-a-long with the residents in the downstairs lounge. In the upstairs lounge residents were watching television, having their nails done, and chatting to staff. A few residents were in their rooms, sleeping, reading, or listening to music. During the inspection we saw that staff treated residents with respect and provided personal care discreetly. Residents are also encouraged to determine their own routines. One resident told us, ‘I can go to bed when I want. The staff help me, they’re the best.’The Willows Residential HomeDS0000001713.V376851.R01.S.docVersion 5.2All the residents we spoke to praised the food. Comments included, ‘The food is brilliant. We get a choice’, and ‘From breakfast through to supper all the food is very, very nice.’ Another resident told us he has a ‘double bacon and egg sandwich’ every morning as this is his favourite. Residents also said they were pleased with the staff team. Comments included, ‘I don’t think you could find nicer staff than we’ve got here’, ‘The staff are friendly and have a chat with me’, and ‘If I ring my call bell they would come quickly.’ We spoke to one staff member who was new to the Willows. She told us the home was ‘a nice friendly place to work’ and described the training she had had since taking up her post. This was thorough and had helped to ensure she had the skills and knowledge she needed to do her job effectively.

What has improved since the last inspection?

Care plans have been re-written to make them more ‘person centred’ and focus on what residents can do rather than what they can’t. Medication systems have improved following an internal audit by the Owning Body. One of the carers has been put in charge of activities and a full programme is in place including monthly trips out and in-house games and entertainment.

What the care home could do better:

Not all care plans were up to standard. There were omissions, particularly concerning health care needs, and some had not been regularly reviewed. One safeguarding investigation remains outstanding and neither Social Services nor the Care Quality Commission have been informed of the outcome of this. The home has had a succession of managers since it was purchased by the Owning Body two years ago. This lack of stability has caused anxiety to some residents and relatives.The Willows Residential HomeDS0000001713.V376851.R01.S.docVersion 5.2

Key inspection report CARE HOMES FOR OLDER PEOPLE The Willows Residential Home 89 London Road Hinckley Leicestershire LE10 1HH Lead Inspector Kim Cowley Key Unannounced Inspection 30th July 2009 12 DS0000001713.V376851.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Residential Home Address 89 London Road Hinckley Leicestershire LE10 1HH 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) 01455 615193 01455 616228 www.schealthcare.co.uk Southern Cross Care Centres Limited Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (10) of places The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only:- Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category: Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is 40. 23rd May 2007 2. Date of last inspection Brief Description of the Service: The Willows Residential Home provides personal care and accommodation for up to forty older people, some of whom have physical disabilities. The home is in Hinckley close to shops, bus stops, and other amenities. The home is a purpose built two-storey building with level entry access and a passenger lift to the first floor. There are two large lounges and a dining room, and 31 single and two double bedrooms, most of which have en-suite facilities. Further information about the home, including the fees, is available from the person in charge. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection that included a visit to the home and inspection planning. Prior to the visit we spent half a day reviewing information relating to the home. During the course of the inspection, which lasted seven hours, we checked the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means we looked at the care provided to three residents living at the home by meeting them; 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. We also met six other residents, the Project Manager, Deputy Manager, Activities Organiser and two care assistants. What the service does well: The Willows provides homely and comfortable accommodation. All the areas we inspected were clean tidy, and fresh. One resident told us, ‘The home is always clean’, and another said, ‘All the rooms are lovely here.’ The atmosphere in the home was warm and friendly. One resident commented, ‘The best thing about this place is that everyone’s so nice.’ On the day we inspected a visiting entertainer was leading a sing-a-long with the residents in the downstairs lounge. In the upstairs lounge residents were watching television, having their nails done, and chatting to staff. A few residents were in their rooms, sleeping, reading, or listening to music. During the inspection we saw that staff treated residents with respect and provided personal care discreetly. Residents are also encouraged to determine their own routines. One resident told us, ‘I can go to bed when I want. The staff help me, they’re the best.’ The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 6 All the residents we spoke to praised the food. Comments included, ‘The food is brilliant. We get a choice’, and ‘From breakfast through to supper all the food is very, very nice.’ Another resident told us he has a ‘double bacon and egg sandwich’ every morning as this is his favourite. Residents also said they were pleased with the staff team. Comments included, ‘I don’t think you could find nicer staff than we’ve got here’, ‘The staff are friendly and have a chat with me’, and ‘If I ring my call bell they would come quickly.’ We spoke to one staff member who was new to the Willows. She told us the home was ‘a nice friendly place to work’ and described the training she had had since taking up her post. This was thorough and had helped to ensure she had the skills and knowledge she needed to do her job effectively. What has improved since the last inspection? What they could do better: Not all care plans were up to standard. There were omissions, particularly concerning health care needs, and some had not been regularly reviewed. One safeguarding investigation remains outstanding and neither Social Services nor the Care Quality Commission have been informed of the outcome of this. The home has had a succession of managers since it was purchased by the Owning Body two years ago. This lack of stability has caused anxiety to some residents and relatives. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Willows Residential Home DS0000001713.V376851.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 Home DS0000001713.V376851.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ needs are assessed prior to admission to ensure the home is suitable for them. EVIDENCE: All prospective residents have an assessment to determine what their needs are. A senior member of staff carries these out, visiting people in their own homes, in hospital, or during a visit to the Willows. The assessment process helps to ensure the home is suitable for those who are considering living there. We talked to some of the residents about how they chose this home. One told us, ‘I looked round before I came and everything impressed me.’ Another said, ‘My daughter heard of this place and she put me in here. I’m glad she did.’ The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 10 Records relating to three recent admissions were examined. They were generally of a good standard, and assessments carried out by health and social services staff had been taken into account. However not all assessments had been signed/dated, so it was unclear which member of staff had carried them out and when. In future all assessments should be signed/dated so it is clear who was responsible for them and when the assessment took place. Standard 6 was not inspected as this home does not provide intermediate care. The Willows Residential Home DS0000001713.V376851.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are not in place for all residents’ social and health care needs and have not been regularly reviewed. EVIDENCE: Since the last inspection all care plans have bee re-written. They are now more ‘person centred’ and focus on what residents can do rather than what they can’t. Staff have received training in completing the new care plans. Those we looked at were clear and easy to follow. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 12 However we found further improvements were needed in a number of areas, for example: • One resident’s assessment stated they needed E45 cream applied daily, but there was no care plan for this and daily records showed staff were not aware of this care need. Another resident’s assessment indicated they had a number of serious health problems, but there were no corresponding care plans for these. A further resident was said to ‘sleep poorly’, but again no care plan had been written to address this. And another resident was identified on assessment as needing ‘thickeners’ in their drinks, but this was not in their care plan. When we discussed this with staff they said the resident in question no longer needed thickeners as their risk of choking had reduced, but there was no documentation to show this. In addition, some care plans had not been regularly reviewed or updated so it was unclear whether needs had changed or not. • • • • We discussed our findings with the Project Manager. She accepted that not all care plans were up to standard, that some had not been regularly reviewed, and that there were omissions, particularly concerning health care needs. She said this was being addressed. To ensure that all residents’ needs are met existing care plans must be reviewed and updated and new ones put in place where necessary. Residents see health professionals, for example General Practitioners and District Nurses, when necessary. The Project Manager told us that she and her Deputy are due to meet with the local District Nursing team to discuss effective ways of working and how to ensure health care needs are proper recorded and met. Medication systems have improved following an internal audit by the Owning Body. During the inspection we saw that staff treated residents with respect and provided personal care discreetly. Residents are also encouraged to determine their own routines. One resident told us, ‘I can go to bed when I want. The staff help me, they’re the best.’ The Willows Residential Home DS0000001713.V376851.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents social and cultural needs are identified and met. EVIDENCE: Regular and varied activities are available to residents who want them. On the day of inspection a visiting entertainer was leading a sing-a-long with the residents in the downstairs lounge. In the upstairs lounge residents were watching television, having their nails done, and chatting to staff. A few residents were in their rooms, sleeping, reading, or listening to music. Since the last inspection one of the carers has been put in charge of activities and a full programme is in place including monthly trips out and in-house games and entertainment. Each resident has an activities book where staff log what they have been doing. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 14 The activities organiser told us that residents who did not wish to take part in group activities were visited in their rooms for one-to-one chats and hand massages. This is good practice as it means that everyone has the opportunity to take part in activities. A summer fete was held on the weekend before the inspection and £200 was raised for the residents’ comfort fund. The Project Manager told us this amount will be matched by the Owning Body. Visiting arrangements are flexible and residents’ told us they can have visitors at any time. Lunch and tea were served during the inspection and the food looked wholesome and appetising. All the residents we spoke to praised the food. One told us, ‘The food is brilliant. We get a choice.’ Another said, ‘From breakfast through to supper all the food is very, very nice.’ Breakfast is available from 7.15 am and residents can choose what they want. One resident told us he has a double bacon and egg sandwich every morning as this is his favourite. Lunchtime is at 12.30 pm when the main meal of the day is served. Tea is from 4.30 pm and is buffet-style, with a platter of food placed on each table for residents to choose from. Snacks are available at any time and a notice in reception reminds residents of this. The Willows Residential Home DS0000001713.V376851.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their representatives are encouraged to talk to staff about any concerns they might have. Some safeguarding information has not been communicated to the relevant authorities. EVIDENCE: In the last few months there have been a series of complaints made directly to the home. We looked at records and saw that investigations had been carried out for each one and action taken where necessary. We saw that when mistakes were made and care had not been up to standard the home accepted responsibility and tried to put things right. Complainants were kept informed of the progress and outcome of their complaints. The Project Manager told us she is encouraging residents, relatives and visiting professionals to speak out immediately if a concern arises so she can address it promptly. She said she has raised this at recent stakeholder meetings and asked everyone to come to her or another member of staff if there is anything they are not happy about. We talked to residents about what they would do if they had a complaint and all said they would tell a member of staff. One The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 16 resident told us, ‘It I wasn’t happy I would tell the staff. That would clear the air.’ There have also been a number of safeguarding referrals. Records showed these have been properly logged and reported to the relevant authorities. There is evidence that action has been taken to reduce risk to residents following a safeguarding incident. For example one resident sustained a skin tear and following this a trainer was sent by the Owning Body to evaluate their moving and handling needs to see if they could be transferred in a safer way. However one safeguarding investigation remains outstanding and neither Social Services nor the Care Quality Commission have been informed of the outcome of this. Safeguarding information must be shared with the relevant authorities in line with the ‘No Secrets’ safeguarding protocol. All staff, including ancillary staff, have had training in safeguarding. This will help to ensure they know what to do if they become concerned about a resident’s well-being. The Willows Residential Home DS0000001713.V376851.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in an environment that is comfortable and clean. EVIDENCE: The premises were homely and comfortable. Decoration was of a reasonable standard, although some rooms would benefit from re-decoration as they looked a bit shabby. Bedrooms were personalised. One resident told us, ‘All the rooms are lovely here.’ The Project Manager said the home is about to be refurbished and areas in need of improvement have been identified. The refurbishment programme was discussed with residents and relatives at a meeting held in the home on the The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 18 day before the inspection (see Standard 33). The Project Manager said residents and relatives will be given the opportunity to become involved in the refurbishment programme and consulted on how they would like the home to look. All the areas we inspected were clean tidy, and fresh. One resident said, ‘The home is always clean.’ One the day of inspection the lift had broken down which meant that some residents who liked to use the downstairs lounge were unable to, and were in the upstairs lounge instead. One resident was unhappy about this but staff reassured them that the problem was only temporary and everything possible was being done to get the lift working again. (See also Standard 38.) The Willows Residential Home DS0000001713.V376851.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Friendly and approachable staff meet residents needs. EVIDENCE: All the residents we talked to praised the staff team. Comments included, ‘I don’t think you could find nicer staff than we’ve got here’, ‘The staff are friendly and have a chat with me’, and ‘If I ring my call bell they would come quickly.’ During the inspection we saw that staff got on well with the residents in the home. There were enough staff on duty to meet residents’ needs and residents did not have to wait too long for staff assistance. We spoke to one staff member who was new to the Willows. She told us the home was ‘a nice friendly place to work’ and described the training she had had since taking up her post. This was thorough and had helped to ensure she had the skills and knowledge she needed to do her job effectively. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 20 Recruitment procedures were discussed with the Project Manager. She confirmed that all staff are subject to CRB and POVA checks, and references are obtained. Staff files were sampled and had the appropriate documentation in place. This helps to ensure residents are safeguarded. Staff receive good training opportunities. All undergo a three months induction followed up by NVQs (National Vocational Qualifications). Additional training courses are ongoing and records showed that staff are encouraged to develop their existing skills and learn new ones. In addition all staff have regular supervision sessions with a senior member of staff. The training and supervision arrangements in the home help to ensure that staff are competent to do their jobs. The Willows Residential Home DS0000001713.V376851.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has had a succession of managers and this has left some residents and relatives feeling anxious. EVIDENCE: The home has had a succession of managers since it was purchased by the Owning Body two years ago. This lack of stability has caused anxiety to some residents and relatives. To address this situation the Owning Body has put an experienced Project Manager in the home to run it until a suitable manager can be found. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 22 To try and address residents’ and relatives’ concerns about the management situation a meeting was held in the home on the day prior to the inspection. Five residents and eight relatives attended and met with the Owning Body’s Managing Director. At the meeting they were given assurances that the Project Manager will stay until the home is stable and a new manager appointed. However one resident who had attended the meeting said they were not reassured by what had been said. ‘We’ve had promises before but they haven’t been kept. I’m fed up with all the changes and I don’t trust the people in charge.’ This lack of confidence in the Owning Body, coupled with ongoing concerns about care planning (see Health and Personal Care), indicates that further action is needed to bring stability to the home and improve standards of care. A competent manager must be appointed and, as soon as practicable, put forward to the Care Quality Commission for registration. This will help to provide continuity for residents, relatives, and staff. The Owning Body oversees health and safety in the home. A facilities manager employed by the Owning Body carried out a fire risk assessment in June 2009. And the Project Manager said a full health and safety assessment is due this summer. On the day of inspection the lift had broken down (see also Standard 19). Staff had immediately called the contractors who sent an engineer to the home. A part had been ordered and the Project Manager said it was hoped the lift would be back in action promptly. Until then, although there was some inconvenience to residents and staff, no-one was being put at risk. The Willows Residential Home DS0000001713.V376851.R01.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 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 2 X 2 X 3 X X 3 The Willows Residential Home DS0000001713.V376851.R01.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 Requirement Care plans must be put in place for all residents’ social and health care needs. This will help to ensure their needs are met. Care plans must be regularly reviewed so they accurately reflect the social and health care needs of residents. Safeguarding information must be communicated to the relevant authorities. Timescale for action 30/09/09 2. OP7 15 30/09/09 3. OP18 13 30/09/09 4. OP31 8 A competent manager must be 30/11/09 put in place and, as soon as is practicable, put forward for registration with the Care Quality Commission. This will help to provide continuity for residents, relatives, and staff. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations All assessments should be signed/dated so it is clear who was responsible for them and when the assessment took place. The Willows Residential Home DS0000001713.V376851.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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