Inspection on 09/01/07 for Willan House

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willan House 23/06/08

Willan House 21/05/07

Willan House 03/10/06

Willan House 18/08/05

Willan House 18/04/05

Willan House 08/11/04

Willan House 23/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Willan House Willan House Stainfield Market Rasen Lincolnshire LN8 5JL Lead Inspector Elisabeth Pinder Key Unannounced Inspection 9th January 2007 09:30 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 Willan House DS0000059327.V325243.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. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willan House Address Willan House Stainfield Market Rasen Lincolnshire LN8 5JL 01526 398785 01526 399719 willan.house@btconnect.com 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) Mr John Shiers Mrs Christine Shiers Mr John Shiers Care Home 20 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr and Mrs Shiers are registered to provide personal care at Willan House for service users of both sexes whose primary needs fall within the following categories:Old age, not falling within any other category (OP) 20 Dementia DE(E) 10 The category DE(E) applies to service users aged 60 years and over The maximum number of service users to be accommodated at Willan House is 20 15 December 2006 2. 3. Date of last inspection Brief Description of the Service: Willan House cares for older people in a non-smoking environment in a detached property situated in the small village of Stainfield. The home is approximately four miles from the small town of Wragby and ten miles from the historic city of Lincoln. The home stands in its own grounds and gardens with car parking facilities to the front. The home has two floors and a stair lift is fitted to both staircases to the bedrooms on the first floor. There are a variety of aids and adaptations around the building allowing service users to move round the home more independently. Sixteen of the bedrooms are single, six of them have en-suite toilet facilities. There are five communal toilets, two communal bathrooms and a disabled shower room. The current weekly fee range is £335.00 - £425.00. Additional costs are made for hairdressing, chiropody and newspapers. These are all private arrangements and costs are met by individual service users. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken by two inspectors and formed part of a key inspection. There is currently a safeguarding adults investigation being undertaken and this key inspection was carried out to look at some of the issues raised. The visit lasted six and a half hours and took into account previous information held by the Commission for Social Care Inspection (CSCI). The visit consisted of case tracking a sample of five service users’ records, talking to them and assessing their care. A sample of policies and procedures were examined as these had not been looked at during the previous key inspection in October 2006. A period of observation was undertaken watching staff interaction with service users. All care staff on duty and a member of staff working in the laundry were spoken to by one of the inspectors. What the service does well: What has improved since the last inspection? Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 6 Medication has ceased to be ‘potted up’ and is now being administered using correct and safe procedures. 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 Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willan House DS0000059327.V325243.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 Willan House DS0000059327.V325243.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): 1, 3 and 5 standard 6 is not applicable Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This service does not always follow its Statement of Purpose. People considering this home are given information and the opportunity to visit before making the decision to move into the home on a permanent basis. EVIDENCE: The Statement of Purpose and Service User Guide both contain the information required by regulation, although service user views have not been included. The complaints procedure in these documents differ to the one in the home’s policy folder. These should also include up to date details of the Commission’s complaints procedure which was given to the providers at the inspection in October 2006. A number of statements in these documents are not being followed, for example, care plans are not all being evaluated monthly and no information is Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 10 written in care plans regarding whether or not service users wish to follow their religious beliefs. The pre-admission assessments for two new service users were examined, one contained a general assessment and one listed needs on admission. Both service users were very complimentary about the home and confirmed that they had been given information and had been able to visit before making a decision to move in, specific comments were ‘we came to look around and were very impressed’. ‘We were visited at home by the manager and he discussed our needs’. During the previous key inspection the providers agreed to write to service users who are funded by local authority to confirm that after assessment the home can or cannot meet their care needs. There has been no new admissions from local authority since this agreement. Willan House DS0000059327.V325243.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): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is lack of detail written in some care plans and risk assessments putting service users at risk if their care needs have not been identified. Medication management systems must continue to improve to ensure service users are not at risk. EVIDENCE: Most care plans examined contained basic information, for example, personal hygiene gave no preferences regarding hair, bathing or choice of clothes, just referred to as ‘all care’. One care plan highlighted continence, but did not mention wearing continence aids but the daily notes read ‘pad changed’. Another identified the risk of choking but gave no reason why and no risk assessment had been written. A nutritional assessment reviewed in October read ‘no change’, however, the care plan stated that ‘appetite has diminished’. Care plans did not all include information regarding social needs or the social stimulation to meet those needs, however, service users and staff spoken to Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 12 confirmed that activities have continued as at the previous inspection. Care plans must clearly record service users choice regarding intimate care including gender preference. On examining service users files it was noted that information gathered prior to admission is not always used in the current plan of care. For example, one pre-admission assessment identified that a service user took ‘Warfarin’ and was diabetic but there was no information detailed in the care plan. Care records examined during the random inspection undertaken on 15th December 2006 did not give any information to show that service users had consented to care workers giving them medication or that personal preferences were reflected in care plans. Care plans did not include information on medication to allow appropriate management of individual’s conditions. For example admission information did not contain details about medication or on individual health needs for all of the service users traced During the previous key inspection care plans examined did not show that service users or their relatives/representatives were involved in setting up the care plan or subsequent reviews. The manager had agreed to action this, however, during the random inspection on 15th December 2006 this had not been addressed. Care plans examined on this occasion did not evidence that this is being done. The random inspection undertaken on 15th December 2006 was in relation to medication, four immediate requirements were given on the day and an additional nine requirements were made (please refer to requirements section at the end of this report). The provider was required to inform the Commission in writing of action taken to address the immediate requirements by 29th December 2006. This was not done and the provider said she hadn’t noticed the date but will respond immediately. The community pharmacist for this service is due to visit on 10th January 07 and the provider said she would discuss some of the requirements with her as she felt these had previously been acceptable. A telephone call was received on 24th January 2007 from the lead pharmacy inspector confirming that a response from the provider was received on 17th January 2007. During this visit some gaps were noted on medication administration record (MAR) sheets and printed labels were still being stuck on. Also handwritten MAR sheets had not been signed by the person completing the prescription details and the number of tablets given were not always recorded where the prescription identifies ‘one or two tablets’. The medication policy was examined and states that all medication should be dated and signed and variable doses recorded. It also stated that all medication should be recorded on receipt and checked for accuracy. A ‘homely remedy’ policy must be developed. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 13 One service user is self-administering her medication and had signed stating that she accepted and understood her responsibility. This medication was stored appropriately. All service users spoken to said that they are treated with respect and felt their privacy and dignity are respected. Staff members were observed carrying out their duties with kindness and sensitivity towards the service users. One inspector spoke to a visiting district nurse who said that she is always made to feel welcome, ‘staff always seem on the ball, they pick up potential problems well and she had no concerns about people getting the correct medication and on time’. She said that in her opinion ‘care provided to ill people exceeds that which they would receive in hospital’. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to express choices in their daily lives and receive a nutritious, varied diet meeting individual preferences and health requirements. EVIDENCE: Standard 12 was assessed during the key inspection on 3rd October 2006, there has been no evidence to suggest that this has changed although social needs must be included in all care plans. Service users spoken to said that they are given the choice regarding joining in with activity sessions and some said they appreciate staff leaving them alone as they did not want to join in. Prior to the inspection information had been received that service users do not get offered a drink of tea before breakfast when the manager is on night duty. Although the manager has not worked night shifts for a few weeks this was discussed with service users who all said they are being offered drinks each morning before breakfast. Although no visitors were seen during the day, service users said that their visitors can come at any time and they are always made to feel welcome. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 15 Care records identified likes and dislikes although need to include additional information regarding diabetic diets. The midday meal was observed to be nutritious and service users said they had really enjoyed it. During the previous key inspection service user questionnaires identified that not all liked the meals and the provider had explained that she was aware of some issues with a new cook. This person has now left her employment and the provider is cooking six days each week. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are at risk due to inadequate procedures. EVIDENCE: The complaints procedure written in the Statement of Purpose and Service User Guide differ from the one in the home’s policies manual. The home’s policy gives a timescale for response whereas the Statement of Purpose and Service User Guide do not. These must be amended to ensure complaints are acted upon promptly. During the previous key inspection the providers were given information about the Commission’s procedure for reporting complaints and the address and telephone number was given for the Central Registration and Compliance team (CRCT). To date the complaints procedure or Statement of purpose and Service User Guide have not been amended to include this information. No complaints have been made since the previous inspection and service users spoken to during the visit said that they felt confident to raise any concerns with the providers or any member of staff. There is currently a safeguarding adults investigation taking place, Social Services are the lead investigators. The matter which is the subject of the investigation was not referred immediately to Social Services and safeguarding adults procedures were not followed. Failure to make referrals immediately may lead to potential risk to service users. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 17 The Safeguarding adults procedure was examined and this requires more detail regarding reporting allegations as it just reads ‘to the person in charge’. It does not mention other agencies or who to refer to if the allegation concerns the provider. The whistle blowing procedure was examined and this also should include more information as it currently reads ‘staff should raise any concerns with the owners’. It does not give details of how to take it further or if it involves the owner. Six staff completed adult protection training in March 2006. The providers must ensure all staff have completed this training and training should include the reporting process. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users living in this home live in a clean, pleasant and hygienic environment. EVIDENCE: Standard 19 was assessed during the previous key inspection and no information had been gathered to suggest that this had changed. Five service users were spoken to in their own rooms and these were furnished with their own personal items. The radiator in one of the bedrooms was not working but a portable radiator had been provided. The provider is aware of this and action is being taken to address it. Prior to the inspection information had been received that the home is cold at night as the providers do not have the heating on. All service users spoken to during the visit said that the home is warm during the day and Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 19 night and staff confirmed that it is warm during the day but none spoken to work at night. It is recommended that regular checks should be made and records maintained of the temperature in the home at night. During a visit to the home by two social workers as part of the safeguarding adults investigation, they observed one service user sleeping in her recliner chair as her bed was too high and another resident was sitting in an inappropriately low chair. Since the visit this service user has been provided with a specialist bed and there was no evidence that inappropriately low chairs were being used. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate to meet the needs of service users currently living in the home. The recruitment procedure ensures, as far as possible, that residents are protected. Service users are at risk due to shortfalls in staff training. EVIDENCE: Staff spoken to said that there are enough staff on duty to meet the needs of the service users currently living in the home. Service users spoke highly of the staff with specific comments of ‘the staff are all extremely kind’ and ‘the girls will do anything for me’. Duty rotas for the period of 1st – 14th January 2007 were examined in particular with regards to night time. These show two staff on duty each night, with agency staff covering four shifts. Two shifts have not yet been covered and the provider confirmed that agency staff will be used. The provider is currently covering shifts for the manager and is working six days each week. Information supplied in the pre-inspection questionnaire used for the key inspection in October showed that 25 of care staff have achieved, or are working towards, achieving the National Vocational Qualification (NVQ) at Level 2. It is recommended that 50 of staff achieve NVQ training. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 21 Training records examined showed that two staff had undertaken a decontamination course in April 2006, three staff completed moving and handling training, ten staff fire training and four staff commenced NVQ level 2 in dementia care in August 2006 and one member of staff undertook medication training in August. Health and safety training was carried out in July 2005. No training has been received regarding equality and diversity, this had been discussed with the provider during the previous key inspection and it was agreed that in-house discussions would be held on the subject. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The present management structure is inadequate therefore people’s needs are at risk. Service users are potentially at risk as there are no staff with the skills to manage the home if the providers were to become absent. There are no systems in place to ensure that the safety and welfare of service users are promoted in this home. EVIDENCE: One of the providers is currently attempting to manage this home in the absence of the registered manager. She is working long hours and is undertaking the catering six days each week, care shifts and some night duties. As highlighted earlier a response to the immediate requirements given Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 23 during the random inspection was not sent to the Commission by the specific timescale given but has subsequently been received. Medication records examined during the random for the period December 2005 until May 2006 were all signed by the manager indicating that he was on the premises for excessively long hours with no days off. One service user spoken to said that when the manager is here he works ‘morning, noon and night’. Currently there is no effective system in place for managing the home in the absence of the registered manager. There are no staff competent in managing the home Staff supervision is inconsistent, records showed that only four staff received supervision between July and November 2006. During a visit to the home by two social workers as part of the safeguarding adults investigation one service user reported the manager as having a short temper and that he would shout. During this visit one service user said the manager was ‘a very good nurse but could be ‘brusque’ and ‘brash at times’ with other specific comments of ‘he doesn’t suffer fools gladly but nothing is too much trouble for him’. Staff interviews undertaken as part of the safeguarding adults investigation provided information that a female carer had been left alone on duty with a service user who was on the commode at the time and required two carers to transfer her. Policies and procedures have not been reviewed since 2004 and this was discussed with the provider who said that these are currently all being reviewed. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 24 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 2 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 2 17 X 18 1 3 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 2 2 3 Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13[2] Requirement The medication administration record (MAR) must include all medication prescribed and administered including the date administered and the quantity administered. An immediate requirement was given on 15/12/06. This requirement is being addressed. No secondary dispensing should take place. Medication must be directly administered from the original labelled container to residents and signed on the MAR at the time of administration. An immediate requirement was given on 15/12/06. This requirement is being addressed. Dates of opening must be recorded on eye drops, creams, ointments and any liquids that have a reduced expiry date once opened. An immediate requirement was given on 15/12/06. This requirement is being addressed. DS0000059327.V325243.R01.S.doc Timescale for action 31/01/07 2. OP9 13[2] 31/01/07 3. OP9 13[2] 31/01/07 Willan House Version 5.2 Page 26 4. OP9 13[2] 5. OP9 13[2] 6. OP9 13[2] 7. OP9 13[2] 8. OP9 13[2] 9. OP9 13[2] 10. OP9 13[2] Medication must be given according to the prescribed instructions. An immediate requirement was given on 15/12/06. This requirement is being addressed. Accurate records must be kept of all medication received, administered and disposed of to ensure that an audit trail can be followed. Timescale of 15/12/06 not met The records for administration must clearly show the date of administration. Timescale of 15/12/06 not met The construction of medication administration records must be accurate and reflect current good practice guidance in that: If produced by a pharmacy or dispensing doctor the MAR must be typed and labels should not be used. If handwritten the MAR should only be written by trained staff and details should be checked by another trained member of staff. Timescale of 15/12/06 not met A record must be made for all medication that is administered including creams and homely remedies. Timescale of 15/12/06 not met Accurate records must be kept of medication including medication on admission and any changes to medication in service user files. Timescale of 15/12/06 not met Care plans must include details of medication used to manage individual conditions and health DS0000059327.V325243.R01.S.doc 31/01/07 31/01/07 31/01/07 31/01/07 31/01/07 31/01/07 31/01/07 Willan House Version 5.2 Page 27 11. OP9 13[2] needs including pain management, sleep problems and aggression. Timescale of 15/12/06 not met Medication must be reviewed to ensure that records are correct and that all medication is being administered as prescribed, in particular medication that is prescribed regularly but only taken occasionally and medication that is prescribed when required but being taken regularly. The provider said that medication reviews are to be carried out for all service users. There must be a suitable homely remedies policy in place. Timescale of 15/12/06 not met There must be competent staff available to administer medication in the service at all times. This requirement is being actioned The statement of purpose and service user guide must contain full details for dealing with complaints. 31/01/07 12. OP9 13[2] 31/01/07 13. OP9 13[2] 31/01/07 14. OP1 4&5 31/01/07 15. OP3 14[1][c] Pre-admission assessments 31/01/07 should be in enough detail to ensure residents coming into the home will have their needs met. Information should be gathered from all people involved in caring for the resident. Information gathered prior to admission should always be used in the current care plan 16. OP7 15 Care plans must be in more DS0000059327.V325243.R01.S.doc 31/01/07 Version 5.2 Page 28 Willan House detail and show that all risks are identified and clear actions are documented to minimise the risk. Reviews of care plans must be improved to include details of any changes required to the current care given and these should show that residents and/or their representatives have the opportunity to be involved. 17. OP7 Care plans should clearly record service users choice regarding intimate care including gender preference. 13[6] Safeguarding adult procedures must be in more detail to ensure service users are not at risk. These procedures must be complied with. 18[1][c] All staff must be adequately trained to carry out their roles. 12[5][a] The registered manager should always maintain good personal and professional relationships with service users. 13[5] Suitable arrangements must be made for moving and handling service users 38[2][c][d The registered provider shall ] give notice in writing to the Commission, of the absence of the registered manager and the arrangements that have been made for appointing another person to manage the care home during that absence, including the proposed date by which the appointment is to be made. This shall include: The name, address and qualifications of the person who will be responsible for the care home. 12[2, 3 & 4][a][b] 31/01/07 18. OP18 31/01/07 19. 20. OP30 OP32 28/02/07 31/03/07 21. 22. OP38 OP38 31/01/07 31/01/07 Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 29 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. 4. Refer to Standard OP26 OP28 OP36 OP37 Good Practice Recommendations Regular checks should be made and records maintained of the temperature in the home at night. It is recommended that 50 of staff achieve NVQ training level 2. Formal supervision should take place for all care staff at least six times per year. Policies and procedures should all be reviewed and followed. Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Willan House DS0000059327.V325243.R01.S.doc Version 5.2 Page 31 - 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. 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