Inspection on 09/03/07 for Willersley House

This inspection was carried out on 9th March 2007.

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

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

Other inspections for this house

Willersley House 14/02/06

Willersley House 27/10/05

Willersley House 08/03/05

Willersley House 16/09/04

Willersley House 04/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Willersley House 85 Main Street Willerby Hull East Yorkshire HU10 6BY Lead Inspector Mr M A Tomlinson Unannounced Inspection 09:45 9 March 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willersley House DS0000019772.V328571.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. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willersley House Address 85 Main Street Willerby Hull East Yorkshire HU10 6BY 01482 653353 01482 659668 home.hul@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged 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) Mrs Gillian Elizabeth Bottomley Care Home 34 Category(ies) of Dementia (34), Old age, not falling within any registration, with number other category (34) of places Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Willersley House is situated in the village of Willerby, the home is operated by Methodist Homes For The Aged; a voluntary organisation specialising in the care of older people. The home is close to amenities and has shops, pubs, banks, hairdressers and the post office all within walking distance. Public transport is accessible. The Home is a Victorian house that provides accommodation for thirty-four older people, and all bedrooms have en-suite facilities. The communal areas include a lounge, an attractive oak panelled quiet room and a large dining room. This care home has retained many of its original features. All areas of the home are accessible to service users via the provision of a passenger lift and ramps. Outside there is a ramp down to a well-maintained garden with numerous trees and bushes, and an enclosed courtyard. There is a small car parking area adjacent to Willersley House. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit formed an integral part of the annual ‘key inspection’ process for the home undertaken by the Commission for Social Care Inspection (CSCI). Information contained in this report was obtained through discussions with the home’s acting manager, the staff on duty at the time of the visit, five service users and the relatives of two service users. Telephone discussions were also held with the relatives of two service users. Reliance was also placed on observation of the staff and the support provided for the less service users. The report also incorporates information provided by the registered manager in the pre-inspection questionnaire and survey comment cards returned by visitors to the home. In addition the report includes relevant information obtained by the CSCI prior to, and subsequent to, the inspection visit. A number of statutory records kept by the home were also examined and an inspection of the premises carried out. Subsequent to the inspection, a telephone discussion was held with the registered manager during which she was provided with feedback from the inspection visit. What the service does well: What has improved since the last inspection? The registered manager continues to place importance on the training of the staff and their personal development. This has produced a cohesive and enthusiastic staff team. In order to standardise the quality and consistency of the service, the home is in the process, along with other Methodist Homes for Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 6 the Aged (M.H.A), of redesigning and redeveloping the service users’ care plans. The M.H.A. have also placed greater emphasis on the ‘person centred’ approach to care planning and the importance of involving the service users in regular activities. To this end the home is required to provide a minimum of two group activities each day. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is excellent. Comprehensive information is obtained on all prospective service users that enable the management team to make a considered decision as to the appropriateness of a proposed placement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service users’ care records were examined as part of the case tracking process. The care records provided documentary evidence that these service users had undergone a comprehensive pre-admission assessment. These assessments had been undertaken in the service users’ own accommodation by the registered manager and/or the deputy manager. From the information obtained on the service users it was apparent that the manager was able to make a considered decision as to the appropriateness of the proposed placement and that the staff were able to meet the prospective service users’ Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 9 assessed needs. The service users, their relatives and the staff of the home confirmed this assessment process. A relative of a service user stated, “When I first visited the home I was taken around by the manager and met a number of the residents and staff. Several weeks before she (service user) was admitted into the home the manager and her deputy came to see her. They encouraged her to visit Willersley House which she did, albeit somewhat reluctantly as she had to travel a considerable distance. The room she chose was the one she got. We thought that it was of a good size particularly as it was en suite. The room was redecorated before she moved in. We looked at several homes before deciding on Willersley House. As soon as we came into the entrance hall we knew that it was the right one”. All prospective service users were sent an Information Pack that included the Service Users Guide. Those service users spoken to felt that they had received sufficient information before being admitted into the home. A number of the service users had previous knowledge of Willersley House and consequently were aware of the standard of service provided. All service users had received and signed a Contract of Residence that included their terms and conditions of residence. The home’s Contracts were in addition to any contract issued by a service user’s placing authority. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is excellent. The needs of the service users are well met through the use of comprehensive care records and multi-agency working. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service users had been provided with a comprehensive plan of care by the home. The home’s care plans were in addition to any care plan provided by a service user’s placing authority. It was evident that the care plans had been based on the initial assessment of the service users. It was also apparent that service users had been encouraged to have direct involvement in the development and implementation of their care plans. This was evident from the fact that several of the service users had written their personal profile and that they, or their representative, had signed the respective care plan in agreement. The more able service users were aware of their care plans and its contents. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 11 The care plans were comprehensive and detailed documents that provided the staff with excellent information on the needs and abilities of the service users and the actions to be taken by the staff to meet those needs. The staff said that they saw the care plans as ‘working documents’ and essential for the continuity and consistency of care. The service users’ ‘key workers’ had the responsibility, with the support of the manager, for the development of the care plans. For ease of use, the care plans were divided into elements of care including personalised risk assessments and weight and nutritional monitoring records. Overall the care records provided a holistic view of each service user. At the time of the inspection visit the care plans were being revised to ensure consistency of approach within the Methodist Homes for the Aged. The care plans had been regularly reviewed and amended as necessary. The service users confirmed that they were encouraged to attend the reviews along with a nominated relative/representative if appropriate. One relative stated, “ My (service user) is reviewed every six months and I attend. She has got a detailed care plan”. If relatives are unable to attend, they are sent a copy of the review. It was evident from the care records examined that the health care needs of the service users had been met. In addition to having good levels of external healthcare support, the staff closely monitored the healthcare needs of the service users. This was evident during a ‘staff handover’ meeting on change of shifts when not only the physical needs of the service users were discussed but also their emotional and nutritional needs. On the day of the inspection visit one service user had been taken to an outpatient’s appointment at the local hospital accompanied by a member of staff. The records provided confirmation that the service users had good access to supporting health services such as chiropody. Some of the home’s activities included appropriate physical exercise for the service users to endeavour to keep them physically active. The home had a dedicated medication room that was kept locked when not in use. Only nominated staff had access to this room. The service users’ ‘in-use’ medication was stored in a lockable drugs trolley that was secured to a wall when not in use. The staff responsible for the administration of medication had been appropriately trained. From a description of the administration process provided by a senior member of staff, it was apparent that it was efficient and safe. The bulk of the medication was administered through the use of a monitored dosage system. Other medication was administered directly from their original containers. A separate controlled drugs procedure was in use that included the use of a dedicated record and the use of two staff in the process. The medication administration records were complete and up to date. Following a recent change in the organisation’s policy, the medication was only administered in the service users’ rooms in order to ensure their privacy and dignity. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 12 From observation of the staff it was evident that they treated the service users with appropriate respect. They spoke to them in a respectful and nonpatronising manner. Emphasis was placed on encouraging the service users to maintain high personal standards. This was evident insofar as the service users were well groomed and dressed in good quality clothing. The relatives of one service user stated, “This place is excellent. They are wonderfully caring about all of the residents. They (staff) treat them (service users) like people”. The registered manager saw the need for special support for service users during the final days of their lives as being of the utmost importance. A number of the staff had received training on this subject. The care records indicated the wishes of the service users after their death. From the description provided by the staff it was evident that service users are provided with positive support during their final days. The home had a guest room so that the relatives of service users could stay if they so wished. Willersley House DS0000019772.V328571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. The service users are provided with an opportunity to live a full and active lifestyle that enables them to retain a good level of independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous activity organiser had retired on grounds of ill health and a replacement had been recruited and was due to take up their post shortly after the inspection visit. In the interim, the staff had maintained a programme of activities albeit on a slightly lesser scale. On the day of the visit, for example, an adult recorder group provided musical entertainment. The majority of the service users attended this session and from their reaction it was apparent that they thoroughly enjoyed it. The social activities were clearly displayed on the notice board. Those service users spoken to were aware of the programme. The Methodist Homes for the Aged had amended their policy regarding social activities to ensure that a minimum of two activities was provided each day of the week including weekends. The service users were encouraged to follow their personal interests and hobbies and several Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 14 examples of this were available. They were also encouraged to actively participate in the planned activities. The best example of this was during the regular church services when several of the service users read lessons and led the prayers. The majority of the service users attended the church services. The service users presented as reasonably stimulated, possessing a sense of humour and having strong personal views on a range of topics. The service users continued to be provided with support by the ‘friends of Willersley House’. This was generally in the form of visiting, fund-raising and the provision of social activities. The volunteers involved in this had been appropriately vetted. The service users had reasonable contact with the local community. A few were able to go out unsupervised whereas others required the support of staff. Their relatives took many of the service users out and as one relative stated, “They can continue to join in family activities”. The visitors to home said that they were invariably made to feel welcome by the staff and could see the respective service user in private if they so wished. They majority of the service users had a telephone installed in their rooms thereby giving them good contact with friends and family. A communal telephone was also available for their use on the ground floor. It was a stated policy of the organisation that staff were not become involved with, or responsible for, the service users personal finances. Three service users handled their own financial affairs whilst the family of others undertook this responsibility. Five service users were subject to Power of Attorney. Those service users spoken to spoke highly with regard to the quality of the meals. They confirmed that there was always a choice of meal and that the meals were varied and cooked to a good standard. They also said that should they want something not on the menu then the cook would endeavour to oblige. The menus indicated that the meals were nutritious and appropriate for the needs of the current service users. The cook, who had previously been a carer, displayed an excellent understanding of the needs of the service users and was completely aware of the importance of good quality meals. It was apparent that a balanced had been achieved between healthy eating and the food preferences of the service users. The records confirmed that the cook had actively sought the views of the service users on the meals and it was observed that she had direct contact with the service users at mealtimes. She took this opportunity to obtain the service users’ choice of meal. Good lines of communication existed between the catering staff and the home’s management to ensure that the service users were monitored with regard to nutrition. Special diets were catered for and efforts were made to make liquidised meals look appetising. The dining room was furnished and decorated to a high standard. The service users ate their meals at round tables with approximately four to a table. The Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 15 dining tables had tablecloths and were enhanced through the use napkins and flowers. The ambience and appearance of the dining room could be best likened to a good quality hotel. The care staff served the meals. This was undertaken in a patient and respectful manner particularly for those service users who required some assistance with their meals. The vegetables were served in tureens thereby enabling the service users to choose the amount they wanted. According to the staff the service users were encouraged to come to the dining room for their meals as it was felt that this minimised the possibility of them becoming isolated in their rooms. The home had several small kitchenettes to enable the service users to make drinks for themselves and their visitors. There was also a small dining area where service users could have visitors for a meal. Willersley House DS0000019772.V328571.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 and 18 Quality in this outcome area is good. The service users are protected from abuse by a good network of internal and external support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a comprehensive complaints policy and procedure that was readily available to the service users and visitors. The registered manager promoted an ‘open door’ policy to encourage service users and visitors to make there views and concerns known so that they could be dealt with before needing to become an official complaint. Prospective service users had received the complaints procedure as part of the Information Pack. From discussions with the service users and some of their relatives, it was evident that they felt confident in discussing concerns directly with the manager and her staff in the knowledge that they would be acted upon. Examples were of this approach were provided by the staff. No complaints had been received by the home since the previous inspection. A relative of a service user said, “The manager and staff are always available for discussions. The manager has encouraged me to discuss any problem (with her)”. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 17 The staff had been provided with training in Adult Protection and the signs and recognition of abuse. The staff demonstrated a good understanding on the subject and were confident that allegation of abuse would be quickly reported and acted upon. As part of the monitoring process any bruising sustained by a service user was discussed by the staff during the formal staff handover. A sound policy and procedure on the subject was available to the staff. Willersley House DS0000019772.V328571.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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is excellent. The service users are provided with a high standard of accommodation that is suitable for their needs and provides them with good levels of comfort. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a Victorian property and whilst it has been extensive modernised it has retained many of its original features particularly in the foyer or entrance hall area. It has good sized grounds that provided reasonable privacy for the service users. Externally it had handrails to assist the service users when walking in the grounds. There was parking facilities available for several vehicles. The garden/handyman had maintained the grounds to a good standard. It was evident that the service users enjoyed sitting in the sun at Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 19 the front of the property. The property had level access that took into account those service users who had mobility problems. The home has several communal lounges that were used for the programme of activities. There were also several secluded sitting areas that enabled the service users to choose where, and with whom, they wished to spend their time. The furniture in the communal areas was appropriate for the needs of the service users and was in keeping with the design and age of the home. Access to the upper floor was by means of a passenger lift or via an elegant staircase. The natural and artificial lighting was adequate throughout the home. All of the service users’ bedrooms had en suite facilities. This further enhanced the standard of privacy and was seen as being particularly important by the service users. Only married couples were sharing a bedroom. Those bedrooms inspected were furnished and decorated to a good standard. It was evident that the service users had been encouraged to furnish their bedrooms with their personal belongings, which further enhanced the feeling of domesticity. The service users presented as having pride in their accommodation. The only negative comment was by a service user who thought that the home had too much in the way of furniture donated by the families of deceased service users. This was not, however, the view of other service users. It was confirmed by the home’s staff and a relative of a service user that rooms are invariably redecorated/refurbished in between occupants of the room. Each service user had access to a call-system that could be conveniently placed for use by the service user. One call-point was tested. Some of the more frail service users who were prone to falling had been provided with a ‘call-pendant’ that was worn around the neck. In addition to the en suite facilities the service users had access to a number of shared bathrooms and toilets. These included special baths and walk-in showers for people who had mobility problems. A number of different types of manual hoists were also available. It was confirmed by the service users that they could have a bath or shower whenever they wished. On the day of the inspection visit the home was clean, warm and totally free from any unpleasant smells. The service users and several visitors to the home confirmed that this standard of cleanliness was the norm. A domestic confirmed that the service users’ bedrooms were dusted and hoovered each day and had a major clean each week. The home’s laundry was well equipped with washers and driers of a commercial standard. The home had a dedicated laundry person who had developed a sound laundry process. She confirmed that the service users’ dirty laundry was collected each day and the clean laundry returned at the end of the day. Precautions had been to minimise errors in the laundry process. The laundry person demonstrated excellent knowledge of the service users Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 20 laundry requirements and had personal contact with the service users thereby enabling them to discuss any personal requirements. Willersley House DS0000019772.V328571.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): 27, 28, 29 and 30 Quality in this outcome area is excellent. The service users are supported by a well trained and competent staff team This judgement has been made using available evidence including a visit to this service. EVIDENCE: From an examination of the staff roster it was evident that there had not been a reduction in the staffing level since the previous inspection visit. The staffing level took into account the number and needs of the service users. The staff confirmed that they had time to spend with the service users on a one-to-one basis especially in their role as ‘key worker’. The staff had been provided with a range of training courses including statutory and professional subjects. This programme of training was provided for all staff regardless of role. The staff training records confirmed that over 50 of the support staff had achieved a National Vocational Qualification at level 2 or above. Methodist Homes for the Aged had recently introduced an ‘on-line’ computer training programme known as ‘E-learning’. All staff had access to this training and for example the maintenance person had recently completed health and safety training using this method. According to the manager this training was verifiable and certificated. Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 22 From discussions with the staff it was evident that they were enthusiastic and knowledgeable as to the needs of the service users. They understood the elements of care, such as independence and choice, which went to provide the service users with a good quality of life. This knowledge was demonstrated during a staff shift handover when the current needs of each service user were discussed. These not only included the formally assessed needs but also those temporary needs observed by the staff such as a service user appearing ‘down and depressed’ or a ‘poor appetite that day’. It was noted that whilst a senior member of staff chaired the handover, all of the staff present made a contribution. The home continued to employ a robust staff recruitment and selection process that ensured that all prospective staff had been fully vetted before taking up their post in the home. The staff displayed considerable empathy with the service users. A relevant comment from a member of staff was, “I love it here. We get great support and training. I like the way that the residents are encouraged to do as much as possible for themselves – it keeps them independent”. Willersley House DS0000019772.V328571.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): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is excellent. The staff and service users are supported by a competent and experienced management team that enables the staff to provide high standards of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A qualified and very competent registered manager who has had a considerable number of years experience in the provision of care for older people managed the home. Two deputy managers supported her. On the day of the inspection visit, however, a senior member of the support staff was managing the home as the manager was on a training course and one of the deputy managers was on holiday. The ‘acting manager’, who was qualified Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 24 and experienced, conducted the inspection in a very professional manner. She was extremely cooperative and was aware of the location of all required documentation. To her credit she did not allow the inspection to take priority over the needs of the service users. It was evident that there were lines of communication between the management team and the staff. The staff confirmed that were provided with good support by the management and were regularly provided with supervision and appraisals. The ethos of the home was one of openness and inclusiveness. The manager had, for example, delegated appropriate tasks to the staff and had consequently provided them with responsibility. The manager demonstrated a pro-active approach to the service to ensure that the service users were provided with high standard of care. The home had a robust quality assurance process in place that was overseen and monitored by staff from the Headquarters of the Methodist Homes for the Aged. It primarily consisted of a process of continual self-monitoring and improvement of the service through consultation and regular review. All elements of the service had been regularly audited. Positive action had also been taken to obtain the views of the service users and visitors to the home on the quality of the service. A number of statutory records were examined. In addition to selected care records these included the accident, fire and medication records. The records were well maintained. The maintenance person explained the records relating to health and safety. It was evident that reasonable steps had been taken, including the development of risk assessments, to ensure that the environment was safe for use by the service users and the staff. Willersley House DS0000019772.V328571.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 4 3 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 4 4 3 3 4 4 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 4 3 3 Willersley House DS0000019772.V328571.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Willersley House DS0000019772.V328571.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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