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Inspection on 06/09/07 for Willow Brook Care Home

Also see our care home review for Willow Brook Care Home for more information

This inspection was carried out on 6th September 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.

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 home is clean and well maintained. The trained staff are good at recognising when residents need help from other Health care professionals to improve their health and well being. Complaints are documented, investigated and complainants are responded to, ensuring that their concerns are addressed. Over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care. Proper checks are done on all staff who come to work at the home to make sure they are suitable to work with vulnerable people. There are good procedures in place to ensure that the home is maintained and managed in the best interests of the residents. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected.

What has improved since the last inspection?

Communal areas have had new carpet laid. Several bedrooms have been redecorated. Improvements in the policy for handling residents` money have been put in place to minimise risk of it going missing.

What the care home could do better:

The initial assessments could include more personal and social history with information about the cultural and religious needs of the residents to help the staff understand and support people better. Care plans should be reviewed regularly to ensure that when care needs change that these are recorded and appropriate changes made to the plan. The arrangements for managing the medication for residents could be much safer to make sure that unnecessary risks are avoided and people get their medication as prescribed by their Doctor.The service could develop the range of activities provided which are appropriate to the needs of less able residents in order to meet their social needs. All staff should be reminded of the whistle blowing policy to ensure that they are aware of their responsibility to protect residents from abuse.

CARE HOMES FOR OLDER PEOPLE Willow Brook Care Home 112 Burton Road Carlton Nottingham Nottinghamshire NG4 3AX Lead Inspector Susan Lewis Unannounced Inspection 6th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Brook Care Home DS0000026427.V344135.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. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Brook Care Home Address 112 Burton Road Carlton Nottingham Nottinghamshire NG4 3AX 0115 961 3399 0115 940 3848 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) BUPA Care Homes (AKW) Ltd Vacant Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (43), Physical disability over 65 years of age of places (3), Terminally ill (3) Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Within the total number of beds a maximum of 3 bed maybe used for the category PD(E) Within the total number of beds a maximum of 3 bed maybe used for the category TI Within the total number of beds a maximum of 1 may be used for PD for a named person Within the Total number of beds, a maximum of 43 may be used for the category OP 21st September 2006 Date of last inspection Brief Description of the Service: The fees for 2007/08 range from £334 to 575. There are separate charges for hairdressing and newspapers. The most recent Inspection report can be found in the entrance hall to the home. Willowbrook Care Home is a purpose built property set on the edge of the city of Nottingham. There are grounds to the front and rear of the building with ample parking facilities. The accommodation comprises 49 single rooms all of which have an en-suite facility. All bedrooms are fitted with an Alarm Call System and suitably furnished. A passenger lift offers access to the first floor and a range of specialist lifting equipment is available for service users with dependent needs. The home has two lounge areas, a quiet room and a designated dining area, providing a variety of comfortable seating and occasional tables. There are six bathrooms, two of which are fitted with an assisted hoist, one with a Parker bath and a shower room. Healthcare professionals will visit the home on request. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 8.5 hours, including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Some of the people who live at this home have a limited ability to understand and communicate. Therefore some judgements in this report are from observation of staff and resident interactions Two members of staff and one set of relatives were spoken with as part of this inspection. In addition the views of three other residents who were not part of the “case tracking” were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. The Registration Certificate was reviewed during the inspection to ensure that it was correct any amendments were discussed with the manager. What the service does well: The home is clean and well maintained. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 6 The trained staff are good at recognising when residents need help from other Health care professionals to improve their health and well being. Complaints are documented, investigated and complainants are responded to, ensuring that their concerns are addressed. Over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care. Proper checks are done on all staff who come to work at the home to make sure they are suitable to work with vulnerable people. There are good procedures in place to ensure that the home is maintained and managed in the best interests of the residents. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected. What has improved since the last inspection? What they could do better: The initial assessments could include more personal and social history with information about the cultural and religious needs of the residents to help the staff understand and support people better. Care plans should be reviewed regularly to ensure that when care needs change that these are recorded and appropriate changes made to the plan. The arrangements for managing the medication for residents could be much safer to make sure that unnecessary risks are avoided and people get their medication as prescribed by their Doctor. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 7 The service could develop the range of activities provided which are appropriate to the needs of less able residents in order to meet their social needs. All staff should be reminded of the whistle blowing policy to ensure that they are aware of their responsibility to protect residents from abuse. 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. Willow Brook Care Home DS0000026427.V344135.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 Willow Brook Care Home DS0000026427.V344135.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): 3 and 6 Quality in this outcome area is adequate. People are assessed before they are admitted to the home to make sure their identified needs can be met, but the assessment is not holistic enough. Information is not always passed on to carers to enable them to understand new residents and help settle them in their new home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed including the most recent people to be admitted to the home and all had an assessment carried out by social services and an assessment done by a senior member of staff at the home. Where possible these were usually carried out prior to the person’s admission at their home or in hospital. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 10 A new style of assessment and care plan has been introduced in the service by BUPA and is called QUEST. This follows a format whereby an assessment is carried out that covers the activities of daily living and this leads on to the creation of the care plan. There is limited information to ensure that cultural and equality needs are met, and some areas such as residents’ life history are either not filled in or provide inadequate information. Staff spoken with confirmed that senior staff carried out assessments and carers spoken with said that they did not receive information from senior staff about new residents regarding their care needs straight away and usually asked the residents or relatives when they moved in what they needed. Relatives spoken with said that they had opportunities to look round the home prior to their loved one moving in and were given information about the home to help them make a choice. Willow Brook Care Home DS0000026427.V344135.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 and 10 Quality in this outcome area is poor. Residents’ health and personal care needs are not addressed in a way, which is consistent, and safe this places them at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans seen were of variable quality, some clearly detailing needs they focussed heavily on function and task rather than the person as an individual. Poor reviewing potentially placed residents at risk particularly in the use of aids and equipment. One care plan identified a person as using a standing aid with support of staff for transfers but in the diary notes it clearly showed on two occasions that this was not safe and staff were stating not to use the aid but the care plan had not been amended. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 12 Others were very basic, especially around the needs of people with short term memory loss and those around cultural and religious needs were particularly poor. This could lead to significant areas of residents’ need being inappropriately responded to by staff. Relatives spoken with said that they were aware of care plans but not their reviews. Other residents spoken with said they left all that to the nurses. There was no evidence of residents or relatives being involved in the development of care plans (other than signatures for the use of bed rails) It is their input which helps to personalise care plans and help staff to understand the needs of residents. Staff spoken with thought care plans were all right and said it was mostly the nurses who talked to residents about their plans. One resident who was spoken with said her health is well looked after and sees the Doctor when she needs to. Staff reported that only trained staff administer medication. A requirement was at the last inspection to ensure that medication records were signed correctly this is not met. Medication was checked and found that on one Medication Administration Record sheets there were three errors. Handwritten notes were signed and countersigned but where numbers had been written incorrectly these had been over written and it was no longer clear what the number was. In counting the medication it was difficult to see if they were correct due to the over writing of the numbers. There was a missing signature on one record with no explanation to say if or why it had not been taken. Controlled Drugs were all accounted for, signed for and countersigned. There was information on drugs policy available including what to do in the event of a drugs error. The fridge and room temperature was taken regularly and air conditioned has been installed to prevent the temperature going above 25°C which potentially harms some prescription medication. A requirement was made at the last inspection to treat residents with privacy and dignity. This requirement is considered met. During the visit all residents appeared clean and well groomed. Staff were observed throughout the day being polite and courteous to residents. Residents spoken with said that staff were lovely and you could have a laugh with them. Relatives spoken with also said that staff were polite and made them feel welcome. Staff spoken with were fully aware of how to ensure that residents privacy and dignity was maintained and supported. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 13 Willow Brook Care Home DS0000026427.V344135.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 and 15 Quality in this outcome area is adequate. Residents’ interests are not always recorded and they are not always aware of what activities are available. Meals are healthy and nutritious with different dietary needs being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A quiz was taking place during the inspection visit, however a number of residents were struggled to hear and the activities organiser had to shout which distorted what she was saying. This was raised with the manager at the time to improve how this was delivered to residents. A record of these activities is not made to show the variety and how much residents get out of it. This would enable staff to know if the activities were successful or they needed to change them in line with residents’ skills and interests. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 15 The manager informed the inspector that two residents were due to go on holiday at the weekend with two care staff. This was confirmed in discussion with the one of the residents involved who was looking forward to it. The manager said this was a trial to see if it worked and then other residents would be asked if they wanted to go. One residents spoken with said that she hasn’t left the home for years since she moved into it, and would like the opportunity to go out for the day somewhere but wasn’t sure if trips were arranged. Care pans did not have much information on the residents past interests, a life history form was in the three plans looked at but only one was filled out. This would, if used correctly, help staff understand the residents and create activities that were suitable for each resident. There was some limited evidence on care plans regarding choice of getting up and going to bed. Residents spoken with said that they felt they could go to bed when they wanted to but often chose to go to bed early, as they wanted to watch TV in their own room. Residents are able to choose where they ate their meal and staff were seen taking trays to those who were in their bedrooms or the lounge. The manager reported that a local minister visited once a month to take a service for residents and if a resident wished to attend church staff would be made available to enable them to attend. Visitors said that they could see their loved one in private if they wished and they could visit when they wanted. There was a side area to the kitchen where residents and their visitors could make a drink if they so wished. Relatives spoken with were unaware of this and the manager should make this better known to relatives particularly people new to the home. The cook was spoken with and said that she was given dietary information about new residents by staff and then she would go and talk to them after few days to check their likes and dislikes and ask what their favourite food was. The midday meal was pork apple sauce and vegetables with a choice available, it smelt and looked appetising and nutritious. The menu was displayed in the reception area and on a notice board in the corridor. Residents spoken with said that the food was good. The cook was knowledgeable about specialist diets including diabetic meals and those who required soft diets. The kitchen was clean and well ordered. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 16 Staff were observed asking residents what they wanted to drink and a wide choice was available including wine for those who wanted it Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Residents’ concerns and complaints are responded to and investigated appropriately, but the lack of awareness amongst staff regarding the whistle blowing policy has the potential to places residents at risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints records were looked at and showed that the organisation (BUPA) has a system where checks are made monthly on complaints and what the outcomes were. The Commission received one concern regarding money going missing, the manager had dealt with the matter and police had been involved. The police could find no evidence of wrong doing amongst staff. However improvements were made in the policy regarding money kept in residents’ personal possessions, to minimise this happening again. A copy of the complaints policy is available in all residents’ bedrooms and relatives spoken with said they were made aware of this when their loved one Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 18 moved to the home. Residents spoken with said that whenever they have raised concerns with staff or the manager they have been dealt with. Staff understood the complaints procedure and knew what their responsibility was to assist people to make complaints, Some staff spoken with had recently had training on Safe Guarding Adults Training but were still unsure as to what the whistle blowing policy was or where it was kept. Staff did however understand what was abuse and were able to say what they would do given various scenarios. Residents spoken with said that they felt safe with staff and that they were never bullied or shouted at and relatives said that they felt that they were leaving their loved ones in a safe place at the end of a visit. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The home is well maintained and residents live in a clean and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the building took place and maintenance records were checked to ensure that the home is safe and well maintained for residents. There was evidence provided by the manager that bedrooms are regularly redecorated to ensure that they are clean and kept to a good standard of repair, new bedroom furniture is also being provided during the redecoration, some areas also had new carpets laid. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 20 Residents spoken with said that they liked their bedrooms and one residents spoken with who is confined to bed due to a disability said that through a discussion with the maintenance person a method of remotely being able to turn the bedroom light on and off had been developed to maintain independence and not rely on staff. The resident was very pleased with this. A new garden was being developed that will enable residents who want to, to get out and garden as the beds were all raised. New pathways were also being made to ensure wheelchair users had access. The manager said that residents had been involved in the development and execution of the garden and an open day was planned shortly to show it to relatives. The laundry was separate to the communal areas and infection control measures were in place to minimise the risk of infection. Staff were observed using gloves and aprons when going to provide personal care to minimise risk of cross infection. Willow Brook Care Home DS0000026427.V344135.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 good. There are sufficient trained staff on duty to meet the needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota was inspected to check to ensure that there are enough staff on duty to meet the dependency needs of the residents. There was conflicting information from staff. They said that there was not enough staff on each shift and said that there was usually only one nurse on each shift. Rotas showed this not to be the case, There was no evidence that care tasks were not taking place or that residents had to routinely wait unacceptable length of time before a carer came. The service has almost achieved the target of 60 of staff trained to NVQ National Vocational Qualification 2 to ensure a suitably qualified workforce. This target should be achieved within the next year. The evidence on staff files indicates that a great deal of training has been provided since the last key inspection The staff files were inspected to make sure that they had all of the information and documentation to ensure that residents are properly protected from people Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 22 who may harm or abuse them. The files were very well kept and contained all of the information and documents needed by Law in order to safeguard vulnerable people. Willow Brook Care Home DS0000026427.V344135.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, 33, 35 and 38 Quality in this outcome area is good. The manager is a caring and approachable person and there are systems in place to ensure the health and safety of both staff and residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a new manager in post since April 2007 and she is currently waiting to be registered as ‘fit’ to manager a care home with the Commission. She has several years of experience of working in the care profession including as a trainer and assessor for National Vocational Qualifications. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 24 Staff spoken with said that the manager was firm but fair and gave a clear lead as to the standard of care expected. BUPA have a thorough quality assurance system where by questionnaires are sent to all residents, families and staff. Results of this survey are published and a copy is available in the reception area of the home. This survey informs the annual plan for the home. Where possible residents remain in control of their finances and written records are maintained for all transactions. Care plans show what personal items residents have brought in. Any monies or valuable items are held securely on behalf of the resident ensuring that personal items do not go missing. The policy regarding has been tightened up following and incident earlier this year when a residents money went missing. This ensures that that where possible residents money and personal belongings are safe. The service has very good maintenance records. Evidence was seen that the maintenance person carries out routine checks such as the fire safety system. Equipment such as the hoist and specialist baths and lift were seen to be well maintained from evidence seen in maintenance records and staff have their mandatory health and safety training including Fire Safety, Moving and Handling and Infection Control. Risk assessments are carried out for safe working practice. Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 X 3 X 3 X X 3 Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(2) Requirement Care plans must be kept under review and where care needs have changed these must be recorded to ensure residents receive the appropriate care. The management of medication must improve as follows: The Medication Administration Record must be fully completed; if any medication is not given there must be an explanation for the omission. This is to ensure that residents get their medication as prescribed by their Doctor. Where hand written entries are made on medication administration records these must not be over written. This is to ensure that they can be read clearly and mistakes are not made. Activities, which are appropriate 31/10/07 to the needs of less able residents, should be developed in order to meet their social needs. DS0000026427.V344135.R01.S.doc Version 5.2 Page 27 Timescale for action 31/10/07 2 OP9 13(2) 31/10/07 3 OP12 15(1) Willow Brook Care Home 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 Initial assessments should complete personal histories; significant life events and cultural and religious needs to enable staff to better understand and support residents on admission. The Registered Person should ensure that residents or representative are involved in reviews. Care plans are in sufficient detail to ensure care is provided in an individual manner. Staff should be made aware of the whistle blowing policy. 2. 3. 4 OP7 OP7 OP18 Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 28 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 Willow Brook Care Home DS0000026427.V344135.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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